Difficult Foley Catheterization


Difficult Foley Catheterization

Article Author:
Alexa Bianchi
Article Editor:
Gregory Chesnut
Updated:
10/27/2020 3:22:00 PM
For CME on this topic:
Difficult Foley Catheterization CME
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Difficult Foley Catheterization

Introduction

The placement of a urinary catheter is a common clinical intervention performed to allow for external urinary drainage. Urinary catheterization may be performed to relieve bladder outlet obstruction, such as benign prostatic hyperplasia or strictures in the bladder neck or urethra, or adequately drain a hypotonic neurogenic bladder. Routine urinary drainage in perioperative periods or intensive care settings allows for bladder drainage and urinary evaluation and monitoring. Other times, urinary catheterization may be performed to obtain sterile urine for culture, irrigate clots or blood from the bladder, instill therapeutic agents into the bladder, and evaluate the bladder fluoroscopic or urodynamic studies. While most patients tolerate urinary catheterization with minimal discomfort or complications, some patients experience difficult or traumatic urinary catheterization. These patients experience unnecessary discomfort and may risk injury to the urethra, prostate, or bladder. Improper techniques for addressing difficult urinary catheterization can lead to serious complications and prolonged hospital stays.

Both normal and abnormal anatomic variations can contribute to failed attempts at urinary catheterization. A patient's urologic history can identify prior surgical or radiological interventions that may impact anatomic relationships important to urinary catheterization. Additionally, prior instrumentation, trauma, and sexually transmitted infections can lead to anatomic changes that could pose a challenge for urinary catheterization.

A difficult catheterization can be anticipated and properly addressed with a better understanding of patient-reported symptoms and a detailed genitourinary review of systems and physical examination. Education on available techniques, tools, and instruments to assist in urinary catheterization can improve difficult patients' successful catheterizations. This article aims to educate on the anatomical and physiological basis for difficult urethral catheterizations and outline an approach to catheterization when a difficult catheterization is anticipated or after a necessary catheterization has been unsuccessful.

Anatomy and Physiology

A thorough understanding of normal and abnormal anatomic conditions in both males and females can improve urinary catheterization success. The male and female urethra consists of four layers. From inside out, they are the mucosa, spongy submucosa rich with vasculature, the smooth muscle mucosa, and the outer fibroelastic connective-tissue layer.[1]

Male Urethra

The male urethra is a fibromuscular tube roughly 20 cm long with a 22-24 French meatus.[2] The urethra courses through the corpus spongiosum of the penis, through the prostate gland, and into the bladder. When approached distally, the urethral meatus is first encountered, followed by the navicular fossa, penile urethra, bulbar urethra, membranous urethra, and prostatic urethra. The curvature of the male urethra resembles an S when viewed sagitally. This shape is important to recall during catheterization attempts. To straighten the urethra's curvature and allow for unimpeded passage of a urinary catheter, the penis should be placed on traction.

Areas of narrowing in the male urethra most often occur in the following locations: the fossa navicularis, as a result of strictures caused by instrumentation, infection, or irritation; the bulbar urethra, as a result of urethral strictures caused by trauma, instrumentation, infection, or unknown causes; and the bladder neck, most commonly caused by radiation or prior instrumentation or surgical procedures. Benign prostatic hyperplasia can cause impingement on the prostatic urethra. Hypospadias, duplicated urethras, urethral diverticula, and dorsal pits are other anatomical variations that can lead to difficult catheterization. Urethral duplications exist in several configurations within a sagittal plane and can be complete or incomplete. In a patient with duplicated urethras, the ventral meatus most commonly communicates with the urinary bladder and should be catheterized when necessary. Hypospadias is the most frequent anatomical variant of the penis and occurs during development when hormonal triggers malfunction and the urethra does not properly tubularize. The urethral meatus can be found anywhere along the glans, penile shaft, scrotum, or perineum, leading to a difficult catheterization. Dorsal pits are false urethras that commonly occur in conjunction with urethral duplication and hypospadias. They can appear to be an obstructed urethra upon catheterization when actually they are a blind-ending epithelial-lined false urethra.

When approaching the prostate, the urethra takes a 30-degree ventral turn toward the bladder. This J configuration leaves this portion of the urethra even more susceptible to iatrogenic injury from instruments or surgery, leading to strictures and stenosis. False passages are most commonly created in this location due to forcibly passing a catheter without regard to the changing angle of the urethra. When excessive force is used to place a catheter or introduce instruments, the transition points can be damaged, and the first several layers of the urethra can be perforated. If the provider continues to advance the catheter or instrument, a flap of urothelium can be extended, and a false passage created. The health care provider should take detailed information about prior catheterization attempts; specifically, the type of catheter(s) used, depth of insertion before resistance was encountered, evidence of trauma (e.g., blood on the catheter or at the meatus), and if the catheter balloon was inflated in a portion of the urethra versus the urinary bladder at any point.[3]

The Female Urethra

The female urethra is 4 cm in length and does not have curvature as the male urethra does. Though the distal one-third of the urethra drains to the inguinal lymph nodes and the proximal two-thirds drains to the pelvic lymph nodes, there are no distinct female urethra segments as in the male urethra.

Urethral and vaginal tissue is stimulated by estrogen to increase blood flow and tissue elasticity.[4] Decreased circulating estrogen at menopause can thin out vaginal and urethral tissue, leading to atrophic vaginitis. Thinned vaginal tissue may be tender or inflamed, leading to discomfort in exposing the urethra for catheterization. Similarly, thinning of the tissue may result in the urethral meatus retracting to an anterior position, which is difficult to visualize and intubate with a standard, non-curved catheter from a standard supine frog-legged position.

In women, obesity presents an additional challenge to directly visualizing the urethra for catheterization. To ensure adequate exposure of the urethral meatus in obese women, additional support to retract abdominal pannus and additional lighting may be necessary.

Prolapse

Prolapse of the pelvic organs or urethra can also create difficulty during urinary catheterization. Pelvic organ prolapse, more common in multiparous white and Hispanic women over 50, occurs when the fascial and muscular attachments to the bladder, urethra, rectum, vaginal vault, or uterus become grossly and microscopically weakened by trauma to the neuromuscular structures, hormonal changes, obesity, smoking, connective tissue disorders, and other undetermined environmental and genetic factors. The prolapse of any of these organs can obscure the view of the urethra meatus, compress the urethra leading to retention, and can change the location and look of the expected anatomy. 

Physiology of Difficult Catheterization of the Male

Strictures

Strictures are the most common cause of difficult catheterization. They create narrowing in the lumen, leading to resistance during catheterization that can be anxiety-provoking to both the health care provider and patient. This resistance can be overcome with various instruments and techniques outlined in the following sections. Urethral strictures are caused by infection, inflammation, trauma, and instrumentation. When the urethral lumen is injured, regardless of whether the etiology is inflammation, trauma, or surgery, the epithelial layers are disrupted, and inflammatory changes transform tissue planes. In doing so, the urothelial layer's integrity is broken, and the new cells may be less durable than the original urothelium. Once the urothelium is compromised, urine can extravasate into the spongy tissue surrounding the urethra. The spongy tissue's reaction to inflammation is spongiofibrosis, leading to fibrotic plaques that coalesce over time to form strictures.[5] These strictures can vary in length, depth, and lumen caliber but can all create a difficult catheterization.

Meatal Obstructions Meatal and Fossa Navicularis 

From the tip of the penis, one can begin to encounter anatomy that makes the catheterization difficult. Examples include stenosis, strictures, phimosis, hypospadias, and dorsal pits. In recent reviews, the most common cause of obstruction of the distal urethra was lichen sclerosis. This disease's etiology is still under debate, but studies note autoimmune, skin injury, viral infections, and inflammation in Littre's glands as possible causes.[6] Lichen sclerosis causes a chronic inflammatory state that progresses to thickening, scarring, and obliteration of the prepuce and meatal skin's normal architecture. This inflammation can extend proximally down the penile urethra's length, where it earns itself the name balanitis xerotica obliterans. The phimosis occurs in uncircumcised boys and men when the foreskin is too tight to be retracted down past the glans penis. Phimosis can be pathological, characterized by scarring of the preputial tissue and is generally seen in men, or it can be physiologic, which is more common in young boys and characterized by healthy tissue underlying a tight foreskin.[7] Physiologic phimosis is common and due to the adherence of the glans and preputial tissue. Phimosis generally resolves on its own with gradual, gentle retraction but may require steroid cream or circumcision to fully resolve, especially in the case of pathological phimosis. 

Penile Urethra

The penile urethra is often difficult to traverse with a catheter due to strictures and false passages. Strictures of the penile urethra are most often caused by instrumentation and inflammation and can be seen in men with a history of surgeries, injuries, and infection.

Bulbar Urethra

This is the most common site of strictures, conventionally due to iatrogenic causes like catheterization and trauma such as saddle injuries, which crush the urethra between the pelvic bones. Iatrogenic causes occur due to the anatomy at this location. If you recall the J configuration of the urethra in this region, you can understand how the insertion of instruments or catheters that are not gently guided along the curvature can end up piercing the lumen of the urethra. This injury then follows the pathway to fibrosis outlined for the strictures above.

Prostatic Urethra

The prostatic urethra is surrounded by the prostate's lobes, prone to hyperplasia, especially in older men. Roughly half of men ages 50-60 experience some degree of prostatic hyperplasia where the median lobe eventually compresses the urethra and causes narrowing and resistance during catheterization. The prostatic urethra is also injured during lithotripsy, cystoscopy, and other urologic procedures when the instrument is passed back and forth over this portion of the urethra multiple times, microvascular injuries that lead to fibrosis and strictures.

Bladder Neck

After prostate surgery or radiation, bladder neck contractures are the most common iatrogenic cause for difficult foley catheterization in the proximal urethra.[8] In bladder neck contractures, the bladder neck becomes elevated and poorly compliant. When a urinary catheter or instrument is forcibly pressed into this elevated, contracted, and poorly compliant tissue without angling anteriorly, there is a risk of undermining the bladder.

Physiology of Difficult Catheterization of the Female

Though the female urethra is shorter and pathologic strictures less common, anatomic variations and physiologic changes that occur with menopause and pelvic organ prolapse can make urethral catheterization difficult. In females, lichen sclerosis, atrophy, prolapse, and body habitus contribute to difficult catheterizations.

Menopause and Atrophy of the Anterior Urethra

The female vulvovaginal tissue contains estrogen receptors activated to lubricate and maintain the tissue's architecture. Although the mechanisms are not entirely understood, atrophy occurs during menopause as estrogen levels decline. With decreased estrogenation, the elastic, collagen, and smooth muscle tissues are less stimulated and lose fullness and support. The urethral meatus is commonly retracted superiorly and posteriorly, making direct visualization and catheterization difficult.

Indications

A urinary catheter may be placed to relieve acute or chronic urinary retention, obtain urine for analysis, dilate urethral strictures, splint the urethra after surgery, perform continuous bladder infusion, maintain the hygiene of the immobile patient, and decompress a neurogenic bladder.[3][9] 

Urinary decompression is also indicated in many critical care settings to ensure adequate measurements of outputs and in operative settings during prolonged surgeries for which the bladder needs to be decompressed.

Contraindications

A meticulous clinical history and physical examination for urethral trauma are necessary when evaluating a patient for urinary catheterization. Traumatic injury to the urethra is a contraindication to urinary catheterization without direct visualization. Clinical signs correlating with injuries, such as blood at the urethral meatus and a high riding prostate, are suggestive of urethral injury, and an attempt at foley catheterization should be made under direct visualization with the aid of a cystoscope. The lack of blood or high riding prostate is not enough to rule out urethral injury, and one must use clinical judgment when evaluating the patient's mechanism of injury to determine if a traumatic urethral injury is likely.

Equipment

A prospective analysis for urologic consultations for catheter placement reported that difficult foley catheterization consultations were not required in 41% of cases. A catheter could be placed with a standard foley, coude catheter, or a guidewire in these instances.[10] This finding highlights the significance of understanding the anatomic considerations for the evaluation of difficult urinary catheterizations and the adjunctive tools available to aid in the successful placement of a urinary catheter.

As difficult catheterizations can be encountered in multiple settings, it is recommended to maintain a fully stocked cart with supplies commonly used in the placement of urinary catheters. This cart should include many of the following items to aid in placing the catheter:

Basic Supplies

While many supplies commonly used for foley catheterization can be found sterilely pre-packaged together, it is important to ensure additional supplies are available to allow for safe urinary catheterization using an aseptic technique. Commonly used items include an abundance of sterile lubricant, sterile drapes, sterile preparation solution, sterile gloves, additional sterile water, personal protective equipment, and lidocaine jelly. A variety of urinary catheters should be readily available. As some patients can have allergies to silicone catheters, both silicone and non-silicone catheters in various sizes should be available.

Foley Catheter Kit

Foley catheters are small flexible tubes that are inserted into the urethra to drain urine from the bladder. The circumference of a foley catheter is measured in French, where every French is equal to 0.33 mm. Eyelets on the end of the catheter help drain urine while a balloon can be inflated to keep the foley catheter in place. Foley catheters can be made with latex, plastic, or silicone. Some additional coatings for antimicrobial protection are available as well. Some catheters have wider eyelets or ringed reinforcements to allow for bladder irrigation. The catheter material and design determines the stiffness of the catheter. For example, vinyl and silicone catheters are commonly more rigid than latex catheters. The standard foley catheter is a two-way catheter with two ports: one to drain urine and the other to blow up the balloon. Three-way catheters have an additional port through which sterile fluid can be instilled to flush the bladder. 

Coude Catheter

Coude catheters have a slight bend at the tip, helping to maneuver the catheter beyond obstructions in the bulbar and prostatic urethra. This curve can also help advance the catheter into an anteriorly retracted female urethral meatus. The curvature of the Coude catheter mimics the natural curvature of the male bulbar and prostatic urethra and therefore poses less risk of creating urethral trauma or a false passage than a straight tip catheter.[11] The olive tip Coude is bent with a small bulb, which further aids in bypassing obstacles, while the Tiemann tip is longer, more flexible, and thinner.

Council Tip Foley Catheters 

These catheters feature a hole at the tip of the catheter and are used with a stylet to provide rigidity during catheterization or are passed over a guidewire. A makeshift Council tip can be created through the "Blitz Technique," where an 18 gauge angiocatheter is utilized to punch a hole in the foley's distal end.[12] The catheter is then advanced over a wire until it reaches the bladder.

Ureteric Catheters 

Ureteric catheters are small-caliber, flexible, open-tipped catheters that are designed to pass into ureters. They can also be used in the urethra to traverse narrow strictures. When passed over a wire, a ureteric catheter may bypass a stricture while avoiding additional trauma or false passage creation.

Instruments Used by a Trained Urologist

Urethral Sounds

When urethral strictures are encountered, and there is a need for catheterization per urethra, gentle dilation with sounds or dilators can be performed. Urethral meatal stenosis, fossa navicularis strictures, and urethral strictures require gentle dilation in a controlled manner. To accomplish dilation, metal or disposable urethral sounds or dilators can be used. Sequential dilation with sounds is most commonly indicated for urethral meatal stenosis or strictures in the fossa navicularis.

Multiple sound variations exist, including McCrea, Van Buren (solid metal), and Goodwin (metal with a lumen through which a wire may be passed) sounds. They come in graduated sizes from less than 10 to 32 French diameter. The sounds are curved at one end to follow the J pattern of the prostatic urethra. Sounds for the female are not curved to do the short length and lack of curvature in the urethra.[13] Some common sounds and their characteristics are below.

Hegar: A set of 8 metal sounds with a different size on either end of each sound, totaling 16 graduated sizes. These sounds are slightly curved in an elongated S shape.

Rosebud: Thin, metal, 12" long sounds with a cylindrical tip in varying sizes. 

Pratt 11: 11" long metal sound with an elongated S shape ranges in size from 13-42 French. 

Van Buren: J shaped metal sound with a flat head on one end, indicating the direction of the curved tip. These sounds range from 8-22 Fr and are 10.5" long.

Dilators

Urethral dilators are graduated plastic or metal rods that can be passed over a wire to dilate the urethra sequentially. 

Balloon dilators can be used for short urethral strictures (less than 1.5cm in length). These instruments are flexible tubes with a small balloon that can be inflated at the stricture site to provide radial dilaton and avoid shearing forces of sounds and dilators. 

Filiforms and Followers 

When sounds are too large to be passed, filiforms and followers may be used. Filiforms are small; flexible tubes used to maneuver past strictures and stenosis. They range from 2-6 French and come with straight, coude, or spiral tips. Filiforms are used with a follower, a plastic or metal tube ranging from 10-24 French, offered in straight or coude tip, and used for sequential dilation of the urethra. When the follower reaches the bladder, a hole at the end allows the drainage of urine and confirmation of appropriate positioning within the bladder.

Wires 

Guidewires are useful in assuring access to the bladder. Such wires are most safely used with the aid of cystoscopic visualization to confirm passage into the bladder, though the blind passage of soft wires into the bladder has been described. Multiple guidewire types exist in varying stiffness, coating, tip flexibility or angles, and lubricity. Stiffer wires provide better support for dilation, while more flexible wires or wires with angled tips may be more useful to navigate beyond strictured portions of the urinary tract.[14]

The sensor wire is an example of a commonly used hybrid wire, with a soft, hydrophilic, and rigid shaft wire. Such wires can be customized to a strength that can overcome obstacles while maintaining a flexible tip that minimizes trauma to the urothelium.[14]

Flexible Cystoscope

For bedside urinary catheter placement, flexible cystoscopes can provide direct visualization of the urethra and confirm the source of catheter difficulty. This instrument has a flexible fiberoptic cable with an eyepiece on one end, along with a port through which wires can be passed. It requires a light source and water for visualization and distension of the urinary tract. The flexible cystoscope's tip is controlled by a knob near the eyepiece and can be manipulated to maneuver throughout the external urinary tract.

Percutaneous Urinary Kit

When access to the bladder via the urethra is not able to be safely completed, or when a urethral stricture repair is being considered, a suprapubic tube (SPT) may be placed.

A variety of kits are available for placement of suprapubic catheters at the bedside. Such kits commonly include a procedural tray, the suprapubic tray, a needle introducer (usually 14 Fr) one Fr larger than the foley catheter (usually 12 Fr), a Councill catheter stylet, a collection bag, and a pre-filled catheter inflation syringe.

Personnel

Many providers are trained in the placement of urinary catheters. When a catheter is not easily placed, additional assistance to achieve adequate urethral exposure, aid in positioning, or passing additional instruments is often needed.

Preparation

Preparing for catheterization begins with a thorough clinical and urological history to understand the catheter placement indications and ascertain the cause for difficulty in obtaining urethral access to the bladder.

If appropriate, the patient should be treated with pain medication to minimize discomfort during instrumentation. The bed should be elevated to a height comfortable for the provider, and the patient should be on the same side of the bed as the provider. Additional hospital staff should be available to aid in exposure in obese patients.

Additional attention is required for poorly mobile or recently postoperative patients to ensure safe positioning and adequate urethral exposure. Ensure adequate lighting is available. If space allows, set up a sterile table for instruments and catheter kits to ensure the aseptic technique is maintained. Additional considerations may include using a bed with stirrups to appropriately position the patient's legs or a bed with the ability to allow Trendelenburg positioning to allow for direct visualization. Ensure adequate supplies, such as additional catheters, wires, and instruments, are available when a difficult catheterization is anticipated.

Technique

Techniques to ensure proper urinary catheter placement must account for anatomic variations and differ when approaching male and female patients. In women, the primary difficulty commonly encountered in catheter placement is identifying and cannulating the urethral meatus, which can be retracted or stenosed in cases of atrophic vaginitis or obscured by obesity, pelvic organ prolapse, or from scarring related to prior surgeries or radiation therapy. Similarly, identifying and cannulating the urethral meatus can be difficult in men in the setting of penile edema, buried penis, phimosis, meatal stenosis, and fossa navicularis strictures.[1] When encountering a patient who has just experienced unsuccessful urinary catheter placement, it is important to recognize the discomfort and distress that catheterization and further urinary catheterization attempts have on him or her. Promoting the patient to take slow, deep breaths and providing adequate pain control is important for optimizing the patient's experience.

For female patients, proper positioning and retraction create the best opportunity for direct visualization and intubation of the urethral meatus. The patient should be in a supine, frog-leg position with the head of the bed slightly lower than the feet. If a frog-leg position is not possible due to comorbid conditions or recent surgery, visualization can be improved if one leg is bent at the knees and abducted at the thigh with the heel drawn towards the pelvis. It may be necessary to recruit assistance to retract a large abdominal or suprapubic pannus and provide focused lighting to visualize the urethral meatus. The patient should be prepped, and the aseptic technique maintained. When atrophic vaginitis or vaginal contraction is present, the urethra commonly retracts posteriorly and anteriorly, making it difficult to view directly. If the meatus cannot be visualized, a small catheter, particularly one with a Coude tip, can be slid over a finger placed in the vagina with gentle manual pressure maintained against the anterior vaginal wall.

The urethral meatus can commonly be palpated, if not directly seen, and the catheter gently guided into the urethral meatus. A soft guidewire, often one with an angled tip, can also be placed into an anteriorly retracted urethral meatus if needed. In cases with stenosed and retracted meatus, oftentimes, a firmer, smaller caliber catheter can be more easily placed than larger, softer ones. Anterior prolapse, in addition to obscuring direct visualization of the urethral meatus, can also cause an inferior angulation of the urethra as it joins the bladder neck. This can cause kinking of the catheter. To pass a catheter in such cases, placing a finger into the vagina to elevate the prolapsing bladder or placing a pessary can help align the urethra and bladder neck for direct intubation with a urinary catheter. In some cases where the urethra is retracted anteriorly or when the urethra is obscured by prolapse, the patient may be placed prone for easier catheterization.

Male patients should be positioned in the supine position, and the penis prepped using an aseptic technique. If the urethral meatus is obscured by tight phimosis, gentle downward pressure can be placed on the suprapubic fat and adjacent to the penile shaft, if visible, to expose the urethral meatus. If phimosis remains unrelieved by gentle pressure to retract the foreskin, gently placing a hemostat into the preputial opening and spreading can often allow for adequate exposure to the meatus to allow for catheter introduction. Rarely, in times of tight phimosis, a dorsal slit in the prepuce may be required to expose the meatus. A dorsal penile nerve block will provide satisfactory anesthesia to allow for this instrumentation at the bedside.

In a buried or hidden penis, such as from edema or lymphedema, exposure of the urethral meatus is achieved through downward pressure on the suprapubic fat and along the lateral edges of the penis, if able to be visualized. In some cases, this does not provide sufficient visualization. Blind attempts to pass a catheter or a wire may be successful in such cases. The most reliable method for assuring entry into the urethral meatus is using direct visualization with the assistance of a flexible cystoscope placed into the preputial opening.

The next area of difficulty in catheterization in a male can be encountered at the urethral meatus and fossa navicularis, areas which may be strictured due to prior instrumentation, lichen sclerosis, or chronic irritation. If the meatus is visualized and narrowed, gentle dilation can often allow for introducing the urinary catheter. Dilation of the urethral meatus can be achieved using graduated meatal dilators or with urethral sound or dilators. Liberal use of lubricating jelly with lidocaine provides adequate analgesia for meatal dilation. Starting with the dilator's largest caliber able to fit into the meatus, gently place the dilator into the meatus and the penile urethra. Hold in place for twenty seconds for gentle dilation without tearing the tissue. If placing a dilator is not easy, confirming the urethra's path with a soft guidewire can help direct the dilator intraluminally. Continue gradual dilation with larger dilators until the urethra is calibrated to 2 Fr larger than the anticipated catheter to be placed. A catheter is then placed by placing gentle traction on the penis and advancing the catheter into the bladder. A urologist may be necessary if unable to place a catheter after attempts at gentle dilation, evaluation, and dilation or meatotomy.[15]

Difficulties in placing a urethral catheter, once beyond the fossa navicularis, may arise from urethral stricture disease, benign prostatic hyperplasia, elevated bladder neck, bladder neck contractures, or from anatomic disturbances caused by recent instrumentation, trauma, or surgery. Most obstructions may be bypassed proper technique using either a standard or Coude tip catheter. The penis should be held under gentle traction at a 90-degree angle to the body with the provider's non-dominant hand to straighten the urethra. Using a 4x4 gauze can be used to help maintain a grip on the penis. A well-lubricated catheter can be placed using the dominant hand using gentle pressure. If this does not easily pass, attention should be paid to the point of obstruction, which will most commonly be in the prostatic urethra or bladder neck. A 16-18 Fr Coude catheter should then be gently inserted into the urethra with the curve facing the ceiling anteriorly.[16] 

The catheter should then be advanced with steady, gentle pressure until the bulbar urethra is reached. The traction on the penis should then be directed towards the patient's feet for the catheter to gently pass through the prostatic urethra and over the bladder neck. Placing gentle upward pressure on the perineum can help direct the catheter anteriorly in benign prostatic hyperplasia with an elevated bladder neck. If still unable to pass the catheter, an attempt using a smaller caliber (12 Fr) silicone catheter may be successful due to greater catheter rigidity, which may resist recoil.[1]

Many clinical environments have guidelines for catheter placements and for when urologic consultation is recommended. After the unsuccessful placement of a catheter with the above techniques, a urologic consultation is typically recommended. Successful catheter placement may be achieved after passing a guidewire, either using the direct visual guidance of a flexible cystoscope or with a simple blind passage. Sequential dilation of strictures in the urethra or contracture at the bladder neck may be required.

The initial attempt to passing a soft guidewire directly into the urethra has been described. At the bedside, a hydrophilic guidewire with a soft tip may be placed into the urethra. The soft tip can be passed beyond obstructions and into the bladder. Any obstruction will cause either the guidewire to coil or pass back out through the urethral meatus. If able to pass into the bladder, a catheter or sequential urethral dilators can be passed over this wire.[10][17] If a urinary catheter does not easily pass over a guidewire into the bladder, additional blind attempts may cause additional trauma, and visualization before dilation is recommended.[9]

In cases where this is not successful, direct visualization using a flexible cystoscope is recommended. A false passage can often be visualized and bypassed under direct vision and a guidewire placed into the bladder to allow for catheter placement over a wire. If a urethral stricture is encountered, a guidewire may be directed through the narrowed lumen, which will allow for sequential dilation using urethral dilators or using a balloon dilator. Patients with a known stricture or false passage should be catheterized cautiously and with the use of a guidewire to avoid creating or exacerbating false passages and creating more trauma.[18] 

When using a flexible cystoscope, the patient is prepped sterilely, and the lower extremities are covered with a sterile drape. The cystoscope is assembled and lubricated. With direct vision, the cystoscope is maintained in the center of the urethral lumen to avoid trauma to the urethra. If a false passage is encountered, angling the cystoscope anteriorly towards the ceiling will bypass the damaged urothelium. A guidewire should be placed through the narrowed lumen if a stricture is encountered rather than attempting to force the cystoscope through the stricture area. Once the wire is in place, the cystoscope is removed, and a catheter or dilator is placed over the wire and into the bladder. 

If a wire cannot be passed through the lumen of a urethral stricture or bladder neck contracture, the patient will require suprapubic catheter placement to decompress the bladder.

Finally, if significant instrumentation was required to achieve urinary catheterization, the use of antibiotics should be considered. If a male patient is uncircumcised, returning the foreskin to the anatomic position following catheterization is mandatory to avoid paraphimosis. For male patients, the catheter should be completely inserted before the balloon's inflation, and the balloon should be inflated slowly to ensure it is not inflated in the prostatic urethra.

Complications

Difficult catheterizations and repeat attempts at urinary catheterizations cause patients pain and anxiety. Instrumentation and trauma to the urethra can increase the risk of post-instrumentation infection. If continued pressure is placed when resistance is encountered during urinary catheterization, it is possible for the urinary catheter to cause a false urethral passage, to undermine the bladder neck, or to perforate the urethra or bladder. Trauma to the urethra, prostate, or bladder neck can lead to hematuria. In the setting of prior surgeries or radiation, rectal perforation has also been seen. In poorly mobile patients or immunocompromised patients, trauma from catheterization can contribute to urinary tract infections, Fournier gangrene, or peri-urethral abscess.

In the longer term, urethral trauma from instrumentation may lead to urethral stricture disease.

Clinical Significance

The urinary bladder is designed to hold urine at low pressure and allow for volitional voiding at socially appropriate intervals. When a patient is unable to void effectively or if prompt drainage of urine is required, a urinary catheter is required. While most urinary catheterizations occur without difficulty, complications surrounding urinary catheterizations cause significant distress to the patient and create both short-term and long-term complications for the patient. It is critical to patient care for providers to comfortably assess the difficult catheterization and choose interventions most likely to result in successful urinary catheterization.

Enhancing Healthcare Team Outcomes

 When a difficult catheterization is encountered, clear communication with the patient and treatment team relieves distress and improves outcomes. In 2017, a Journal of Clinical Outcomes Management article outlined an improved process for a two-person indwelling urinary catheterization for decreasing the incidence of catheter-associated urinary tract infections (CAUTIs).[19] 

A team of emergency room leaders, infection prevention members, nursing, and research specialists was created to evaluate a process to indwelling catheterization that would start with a safety time-out, much like a pre-procedural/surgical time-out, to assess pertinent history, physical exam findings, appropriateness of the catheterization, and would include a review of the insertion techniques to educate the entire team. After a time-out, one provider executed the insertion while the other monitored for compromise of sterility. This approach made a significant impact on the rate of CAUTI at this particular institution. This time-out approach can be applied to all patients requiring catheterization, whether it is a formal time-out or a personal checklist that is reviewed before catheterization. This time-out could potentially address 40% of cases when urology consults were unnecessary and help intercept inappropriate techniques, tools, and staff performing the catheterization.

Nursing, Allied Health, and Interprofessional Team Interventions

An approach to care using an interprofessional team will help a patient feel more comfortable and understand the need for catheterization. A foley catheter can be a new and intimidating device for a patient, and if the patient is required to maintain the catheter for longer than their hospital stay, it can be distressing and embarrassing for the patient. With the help of nursing education, patients can fully understand their limitations while the foley catheter is in place and can safely care for their catheter on their own while still living a normal life. Education for catheter care is important for patients who may be overwhelmed by this new piece of equipment, especially if they have to manage the foley and bag at home. The important points should be emphasized by all members of the care team and include the need to maintain a tension-free suspension with the use of a leg strap and to keep the bag below the bladder level, to wash hands before handling or exchanging the catheter, and to exchange the catheter every month if it is to be in place chronically.

To achieve the best care for the patient, every team member must be aware of and invested in the care plan. Communication throughout the catheterization process and in the post-catheterization period will help the patient recover with confidence. The ordering provider should relay both for foley catheter placement and clearly define the anticipated duration of urinary catheterization. There must be no delay in removing a urinary catheter once the decision has been made.

Many members of the care team possess the basic skills required to place a foley catheter. When a difficult foley catheterization is encountered, the team should debrief and take the opportunity to teach team members assessment and catheterization techniques. If members of the care team desire practice with this skill, it should be offered and overseen to identify learning points.

Healthcare professionals may feel negatively toward themselves after a failed urinary catheterization, as urinary catheterization is generally seen as a simple procedure. The truth is that many situations complicate the catheterization. It is everyone's responsibility to understand personal limitations when it comes to catheterization. If a failed attempt occurs, it is best to step back and figure out why before attempting another passage.


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