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Fluids - Urinary catheter (female)

Indications

Urinary retention

Urine output measurement (any critically ill or injured patient)

Urine collection for diagnostic purposes (if unable to voluntarily void)

Preservation of skin integrity

Patient comfort (as part of end of life care)

Contraindications (absolute in bold)

Trauma patient with suspected urethral injury

Recent urological surgery

Alternatives

Management without a catheter (measure voided urine, midstream urine collection, skin care)

Suprapubic catheter

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Pain

Failure (including creation of a false passage)

Allergy

Urethral trauma and haemorrhage

Pressure injury around insertion site

Urinary tract infection

Urethral stricture

Procedural hygiene

Standard precautions

Aseptic non-touch technique

PPE: sterile gloves, aprons, protective eyewear or shield

Maintaining an aseptic field throughout catheterisation requires practice and good technique

The urethral meatus (‘key site’) requires preparation not covered in our procedural hygiene overview

We explicitly describe the equipment and steps required for asepsis in this procedure

Area

Any adequately private bed space with good lighting

Staff

Proceduralist and assistant

Equipment (prepared catheterisation trolley preferred)

Extra sheet or towel placed under patient

Sterile tray, gauze squares and cotton balls (cleaning tray)

0.9% sodium chloride (for cleaning) and forceps for application

Extra sterile tray (drainage tray)

Fenestrated drape

Lubricant (lignocaine gel)

12-16g urethral catheters (non-latex)

Luer lock syringe (10ml or larger depending on catheter balloon size)

Sterile water for injection

Catheter drainage bag

Catheter securing device

Positioning

Supine position with the knees flexed and separated and feet flat on the bed, about 60cm apart

If uncomfortable flex only one knee and keep the other leg flat on the bed

If unable to maintain this position aim for legs as far apart as possible or left lateral position

Medication

5ml of 2% lignocaine gel (lubricant)

Sequence

Place the cleaning tray with saline and gauze between patient’s legs

Use gauze squares to separate labia minora to identify the urethral meatus (using non-dominant hand)

Clean labia minora and urethral orifice with gauze soaked with 0.9% sodium chloride (forceps in dominant hand)

Discard cleaning gauze after one downwards wipe, and once cleaning complete, discard cleaning tray

Place tray for drainage between patient’s legs

Remove 14g catheter from plastic sleeve, maintaining sterility of the catheter (non-touch technique)

Lubricate the sterile catheter (with lignocaine gel) and pass it through the meatus towards the bladder

Pass the catheter until flashback of urine obtained, then insert a further 2-3cm (collect sample if required)

Inflate the balloon with 10ml of water (or balloon volume as marked on catheter)

If resistance or discomfort, deflate the balloon and reposition with further insertion

After passage and inflation, withdraw the catheter until resistance is met (confirming bladder position)

Connect the catheter drainage bag and secure catheter

If unable to insert catheter, reattempt changing to 12g or 16g catheter size

If unable to insert after two attempts, seek assistance from a senior clinician

A new catheter should be used for each attempt

Post-procedure care

Document procedure (completion, size of catheter, residual volumes, number of attempts, immediate complications)

Document management plan for catheter

Tips

Catheters should be removed as soon as the clinical need has been resolved

Discard any catheter that inadvertently enters the vaginal (breaching aseptic field)

Routine antibiotic prophylaxis for high-risk patients only (trauma, prosthetic heart valves, immunosuppression) Catheterising spinal patients involves risk of autonomic dysreflexia (monitor BP, drain only 250ml every 15 minutes)

Discussion

Clinicians should select the smallest sized catheter that will enable adequate access and drainage. For females this will usually be a 14-16g catheter, however the heavier the sediment, haematuria or clots, the larger the catheter required to reduce the chance of obstruction. Large clots and haematuria will require a 18-24g three-way catheter to facilitating irrigation. Three-way catheters are generally placed after discussion with urology.

Urethral disruption is associated with pelvic trauma. Blood at the meatus is the classical sign of urethral trauma. In most trauma settings, a gentle, single passage of a urethral catheter by an experienced clinician may be attempted with minimal risk of exacerbating an underlying urethral injury. Any difficulty would suggest that urology advice and suprapubic catheterisation are required.

Meatal cleaning for catheterisation can be completed with saline or antiseptic solution. We suggest saline cleaning to reduce the chance of reducing the bacterial growth of urine samples sent for culture. The available evidence does not suggest this leads to higher levels of contamination.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

NSW Ministry of Health. Adult urethral catheterisation for acute care settings. Sydney: NSW Health; 2015. GL2015_16. Available from: https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2015_016.pdf

NSW Agency for Clinical Innovation. Female indwelling urinary catheterisation (IUC) – adult. Sydney: ACI; 2014. Available from: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0019/256132/ACI_Female_IUCv2.pdf

Geng V, Cobussen-Boekhorst H, Farrell J, Gea-Sánchez M, Pearce I, Schwennesen I, Vahr S, Vandewinkel C.

Catheterisation: indwelling catheters in adults - urethral and suprapubic. 2012. Arnhem: European Association of Urology Nurses; 2012. Available from: https://nurses.uroweb.org/guideline/catheterisation-indwelling-catheters-in-adults-urethral-and-suprapubic/

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Schaeffer AJ. Placement and management of urinary bladder catheters in adults. In: UpToDate. Waltham (MA): UpToDate. 2019 July 2. Available from: https://www.uptodate.com/contents/placement-and-management-of-urinary-bladder-catheters-in-adults

Sliwinski A, D'Arcy FT, Sultana R, Lawrentschuk N. Acute urinary retention and the difficult catheterization: current emergency management. Eur J Emerg Med. 2016;23(2):80-88. doi:10.1097/MEJ.0000000000000334

Chung C, Chu M, Paoloni R, O'Brien MJ, Demel T. Comparison of lignocaine and water-based lubricating gels for female urethral catheterization: a randomized controlled trial. Emerg Med Australas. 2007;19(4):315-319. doi:10.1111/j.1742-6723.2007.00961.x

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