Bladder Catheterization

Anatomy and Physiology

The urinary system comprising of kidneys, ureter, bladder, and urethra is involved in the production, storage, and excretion of urine. Under normal conditions, in an adult, the kidneys produce approximately 1500 ml of urine in a day. After passing through the ureters, the urine is stored in the bladder. The capacity of the bladder can vary between 350 ml - 500 ml. Three sets of muscles control urinary drainage from the bladder into the urethra. The internal sphincter located at the base of the bladder is an involuntary smooth muscle. The voluntary striated external sphincter muscles encompass the proximal part of the urethra. Lastly, the pelvic floor muscles support and provide additional control.[3]

Indications

The indications for bladder catheterization are:

Therapeutic

• Urinary retention

Urinary retention can be acute or chronic. The causes of urinary retention can be:

1. Obstructive: Urinary obstruction can be intrinsic (within the urinary system) or extrinsic. Benign prostatic hyperplasia (BPH), stones, strictures, stenosis, or a tumor can cause intrinsic obstruction. BPH is the most common cause of urinary retention. If the blockage is from a pathology outside the bladder, it is classified as extrinsic. An enlarged abdominal or pelvic organ can compress on the bladder neck resulting in extrinsic obstruction.[1]
2. Infectious & Inflammatory: Cystitis, urethritis, prostatitis (common infectious etiology in men), and vulvovaginitis in the woman can cause urinary retention.
3. Pharmacologic: Drugs with anticholinergic or alpha-adrenergic agonist properties.
4. Neurologic: Brain or spinal cord injury, cerebrovascular accident, multiple sclerosis, Parkinson disease, and dementia can lead to urinary retention.[4]
5. Others: Trauma, psychogenic, Fowler syndrome in women.[1][5][6]

• Perioperative

Bladder catheterization is performed perioperatively in most abdominopelvic surgeries, such as urological and gynecological procedures. In cases of surgery on structures adjacent to the genitourinary tract, sheath catheters are recommended.[1] Bladder catheterization is also useful in surgical patients who require strict intraoperative urine output. Besides, it is helpful for the management of postoperative urinary retention due to anesthesia, and to achieve better postoperative pain control.[7]

• Neurogenic bladder dysfunction
• Urinary incontinence
• Social and hygiene reasons[1] 
• Acutely ill patients requiring close urinary output measurement[8]
• Chemotherapy drug delivery[8]
• Bladder irrigation[8]

Diagnostic

• Measurement of urodynamics
• Sample collection for urinalysis[8]
• Radiographic studies (cystogram)

Indications for Removal

The need for a bladder catheter should be assessed daily and must be removed when the purpose of the catheter insertion is served.[9] For intraperitoneal colorectal surgeries, the catheter can be removed on postoperative day 1. In the case of mid to low rectal operations, the catheter can be removed between postoperative days 3-6 based on the risk of urinary retention.[10]

Early removal of urinary catheters helps with ambulation and better post-op recovery.[7] For patients with chronic urinary retention and incomplete bladder evacuation, intermittent catheterization is useful.

Contraindications

Contraindications to bladder catheterization include:

• Blood at the meatus. Insertion of the catheter can worsen an underlying injury.
• Gross hematuria 
• Evidence of urethral infection
• Urethral pain or discomfort
• Low bladder volume/compliance
• Patient refusal [11]

Equipment

Bladder catheterization requires the following equipment:

• Sterile gloves
• Sterile water
• Single-use lubricant and anesthetic gel
• Catheter
• Catheter bag
• Waterproof pad (disposable)[9]

Type and Choice of Catheter

The catheters can vary with the composition and coating material.

1. Composition: Silicone, latex, and PVC.
2. Coating: Teflon, hydrogel, and antimicrobial or latex with a silicone elastomer coat.[12]

The selection of a catheter type depends upon the clinical indication, dwell time, and individual patient's risks.[2] A trained physician must perform catheterization with a Coude or suprapubic catheter in cases where standard catheterization is unsuccessful. Silver alloy impregnated catheters are preferred for short term catheterization(≤14 days) as they reduce the incidence of UTI and bacteremia.[13]

Preparation

Preparing for a catheterization involves the following steps:

• Review indications and contraindications for the procedure. A careful history can help to assess the need for urological referral.[14]
• Give clear instructions to the patient about the procedure. Allow appropriate time to respond to the queries of the patient.
• A proper light source should be present.[9]
• Maintain patient's privacy during the procedure.[9]
• The patient should lie down on a firm flat surface with the head resting on a pillow.[15]
• Appropriate positioning of the patient. Supine position for men and frog-leg position for women is recommended.
• Place a disposable pad beneath the patient's buttocks.[9]
• Perform hand hygiene.
• Wear sterile gloves.
• Appropriately drape the patient.
• Prepare the glans penis and the urethral meatus using a sterile technique. In women use the non-dominant hand to expose the urethral meatus by separating the labia and prepare the meatus with an antiseptic solution.[7]

Technique or Treatment

In Men:

Local anesthesia and the lubricant must be generously used. The lubricant gel should be milked proximally with the distal urethra compressed to occlusion.[15] The penis is held using the nondominant hand directed towards the ceiling or the umbilicus. The catheter is inserted into the urethral meatus with the dominant hand until the Y of the catheter is at the urethral meatus.[15] The return of urine in the attached bag is a sign of correct placement into the bladder. The catheter balloon is then inflated using sterile water. The amount of water used for inflation varies with the manufacturer’s recommendations.[7]

In Women:

After exposing the urethral meatus, a lubricated catheter tip is advanced in the meatus until there is a spontaneous return of urine. The catheter balloon is then inflated as per the manufacturer’s recommendations. In morbidly obese patients, exposing the meatus may require help from a second person or placing the patient in a Trendelenburg position. Adequate swabbing with povidone-iodine helps with visualizing the meatus. In the event a catheter is inserted in the vagina, it should be left there until a new sterile catheter is successfully inserted into the meatus.[7] Analgesia is of no proven clinical use in women.[15] Lubrication jelly should be applied to the tip of the catheter. The application of lubricant to the urethral meatus is associated with difficulty in catheter insertion.[15]

Complications

Complications of urethral catheterization include:

• Urinary tract infection (UTI) is the most common complication that occurs as a result of long term catheterization.[7] The normal urinary flow prevents the ascension of microbes from the periurethral skin avoiding the infection. Alteration of the defensive mechanism from the catheter results in an increased risk of UTIs.[3]  Escherichia coil and Klebsiella pneumonia are the most common organisms implicated in UTIs.[3] Recurrent UTIs are associated with increased antibiotic resistance.
• A chronic bladder infection can occur from urinary (10-100 ml) stasis at the base of the bladder, which is obstructed by the balloon of the catheter.[16]
• Pain due to traction on the drainage bag.[8]
• A transitory stinging sensation is common in men that often occurs during lubrication and can be minimized by cooling the gel to 4°C.[8]
• Paraphimosis[8]
• Urethral injury[17]
• Catheter obstruction can occur due to the sediment buildup in patients with subclinical bacteriuria. Flushing can often relieve the blockage. If unsuccessful catheter replacement may be required.[18]
• Urine leakage from the urethral meatus extrinsic to the catheter may occur as a result of bladder spasms. These spasms can be painful and can be alleviated with anticholinergic medications like oxybutynin.
• A negative effect on the quality of life, especially for patients with longterm indwelling catheters.[6]

Due to these complications, indications for the bladder catheterization must be carefully reviewed before the procedure.

Clinical Significance

Bladder catheterization is a commonly performed hospital procedure. Therefore physicians and nurses must be aware of its indications, contraindications, and be familiar with the scenarios where a urology consultation is warranted.[15] The need for a bladder catheter should be evaluated daily. Prompt removal of the catheter decreases the risk of urinary tract infection.[9]

Catheter-associated urinary tract infection (CAUTI) is the most common healthcare-associated infection and accounts for more than $131 million of medical expenditure annually.[19][20] 70% of healthcare-associated UTIs are attributed to catheters. The risk of bacterial colonization of the catheter increases with the duration ranging from 3-10% per day to 100% in long term indwelling catheters. According to the National Healthcare Safety Network (NHSN), a diagnosis of CAUTI is considered in a patient with fever and bacteriuria, who has an indwelling catheter for at least two days.[19] The IDSA (Infectious Diseases Society of America) recommends considering CAUTI as a diagnosis of exclusion in a febrile patient. Antibiotic therapy for asymptomatic bacteriuria is inappropriate and is associated with drug resistance and increased risk of Clostridium difficile infection.[21] When treating a catheter-associated UTI, indwelling catheters for greater than two weeks must be removed.[20] CAUTI prevention is possible by avoiding unnecessary catheter insertion and by frequently assessing the need and aiming for early removal.[20][21]

Acute urinary retention is an emergency that requires urinary catheterization. Urethral strictures are one of the leading causes of urinary retention in patients younger than fifty years. Urethral catheterization can be challenging in the presence of urethral strictures and must be attempted with a 14 French catheter. If an obstruction is encountered, the catheter should not be forced into the urethra.[9] Blood at the meatus can be due to urethral trauma. Repeated attempts of catheter insertion may further increase the risk of injury and the creation of a false passage. Urology must be promptly consulted in challenging cases of urinary catheterization.[15]

Asymptomatic bacteriuria (ASB) is defined by at least ≥ 100,000 colony-forming units [CFU]/mL or ≥100,000,000 CFU/L of a bacteria isolated from a voided urine specimen without any signs or symptoms of UTI. Antimicrobial therapy should not be prescribed for ASB due to an increased risk of antimicrobial resistance and adverse effects. Screening and treatment of asymptomatic bacteriuria are indicated in pregnant women and in patients expected to have a urologic endoscopic procedure that is associated with mucosal trauma.[22]

Enhancing Healthcare Team Outcomes

A myriad of clinical conditions may require bladder catheterization. While a physician or a nurse can place the catheter in most cases, consultation with urology is necessary for specific patients. The nurses are essential members of the interprofessional group, as they will predominantly perform the procedure. They also monitor the catheter and assist with the education of the patient and family as needed. The pharmacist will ensure that the patient is not on any medication that can precipitate urinary retention. The physical therapist also plays a role in early mobilization, voiding exercises, and rehabilitation. Interprofessional communication and care coordination among health professionals are vital to enhancing patient-centered care and improve outcomes.