urinary catheterization in male and female patients

2. Introduction
• Insertion of an indwelling urethral catheter (IDC) is an invasive
procedure that should only be carried out using aseptic technique,
Insertion of an indwelling urethral catheter (IDC) is an invasive
procedure that should only be carried using aseptic technique, either
by a nurse, or doctor if complications or difficulties with insertion are
anticipated. Catheterisation of the urinary tract should only be done
when there is a specific and adequate clinical indication, as it carries a
risk of infection.

3. Definition of terms
• Indwelling Urinary Catheter (IDC): A catheter which is inserted into
the bladder, via the urethra and remains in situ to drain urine.
• Oliguric: a reduction in urine output.
• Paraphimosis: occurs when the foreskin is left in a retracted position.
The pain and swelling may make it difficult to return the foreskin to
the non-retracted position, this may reduce blood flow to the tip of
the penis which if left untreated could lead to necrosis of the glans
penis.

4. Indications
• To drain the bladder prior to, during, or after surgery
• For investigations
• To accurately measure the urine output
• To relieve retention of urine
• To relieve urinary incontinence when no other means is practical

5. Preparation of the child and family
• Preparation
• Preparation of the child and family
• Gain patient/primary care givers consent for procedure
• Families/primary care givers should be given a thorough explanation of the
procedure. Involve the parents where possible when providing an age
appropriate explanation of the procedure to the patient.
• Consider the need for a referral to play therapy to assist in explaining and
preparing the patient for the procedure. Play therapists are also able to empower
the child to identify distraction techniques, as well as provide support and
distraction throughout the procedure.
• Nursing staff should discuss and plan procedural pain management with the child
and family prior to the procedure. This may include non pharmalogical (including
distraction techniques) and pharmalogical considerations including Nitrous Oxide
or sedation if necessary.

6. Preparation of Environment and Equipment
• Ensure the patient’s privacy is maintained throughout the procedure and that
they are kept warm. Ensure there is adequate light to perform the procedure.
• Prepare the following equipment:
• Dressing trolley
• Catheterization pack and drapes
• Sterile gloves
• Appropriate size catheter
• Sterile Lubricant and/or Xylocaine jelly syringe (plain sterile lubricant for infants)

7. Preparation of Environment and Equipment
• Sterile water to inflate balloon (normal saline can crystallise and render the
balloon porous, causing its deflation and the risk of catheter loss)
• 5ml/10ml Syringe
• Specimen jar
• Sterile normal saline
• Straps/tape to secure catheter to leg
• Drainage bag
• Waterproof sheet

8. Catheter size
Use an appropriate size catheter depending on the age of the child. Catheters that are too big or small are at risk
of urethral trauma or leakage. The rational for IDC insertion should also be considered when selecting catheter, for
example a patient requiring an IDC post kidney trauma may require a larger size to provide adequate drainage of
potential blood clots. Consider silicone catheter if for long term use.
Age Weight Foley
Neonate <1200g 3.5 Fr umbilical catheter
Neonate 1200-1500g 5 Fr umbilical catheter
Neonate 1500-2500g 5 Fr umbilical catheter or size
6 Nelaton
0-6 months 3.5-7kg 6
1 year 10kg 6 – 8, preferably 8
2 years 12kg 8
3 years 14kg 8-10
5 years 18kg 10
6 years 21kg 10
8 years 27kg 10-12
12 years varies 12-14

9. Procedure for insertion of urinary catheter
Female child
• Perform hand hygiene
• Place child in supine position with knees bent and hips flexed
• If soiling evident, clean genital area with soap and water first
• Perform hand hygiene
• Open dressing pack (aseptic field) and prepare equipment needed using aseptic
technique
• Pour sterile normal saline onto tray
• Perform aseptic hand wash and don sterile gloves
• Apply sterile drapes/towel
• Separate labia with one hand and expose urethral opening. In neonates, the
urethral meatus is immediately above the hymeneal fringes.
• Using swabs held in forceps in the other hand clean the labial folds and the
urethral opening. Move swab from above the urethral opening down towards the
rectum. Discard swab after each urethral stroke into waste bag or designated
waste area.
• Lubricate catheter

10. •Insert catheter into the urethral opening, upward at approximately 30 degree angle until urine
begins to flow.
•Inflate the balloon slowly using sterile water to the volume recommended on the catheter.
Check that child feels no pain. If there is pain, it could indicate the catheter is not in the bladder.
Deflate the balloon and insert the catheter further into the bladder. ALWAYS ensure urine is
flowing before inflating the balloon.
•Withdraw the catheter slightly until resistance is felt and attach to drainage system
•Remove gloves and perform hand hygiene
•Secure the catheter to the thigh with either a catheter securement device or tape
•Clean trolley and dispose of used articles into yellow biohazard bag
•Perform hand hygiene

11. Male child
•Perform hand hygiene
•Place child in supine position
•If soiling evident, clean genital area with soap and water first
•Perform hand hygiene
•Open catheter pack (aseptic field) and prepare equipment needed using
aseptic technique
•Pour sterile saline onto tray
•Perform aseptic hand wash and don sterile gloves
•Lift the penis and retract the foreskin if non-circumcised. Do not force the
foreskin back, especially in infants. A sterile gauze swab can be used to hold
the penis.
•Using other hand, clean the urethral opening with swabs held in forceps. Use a
circular motion from the urethral opening to the base of the penis. Discard
swab into waste bag or designated waste area.

12. •For boys older than 3 years insert the Xylocaine gel into the urethra. Gently hold the urethra
opening closed and wait 2 - 3 minutes to give the gel time to work. For infants apply sterile
lubricant to catheter before insertion.
•Remove the wire if using a 6Fr catheter
•Hold the penis with slight upward tension and perpendicular to the child's body. Insert the
catheter.
•When the first sphincter is reached (at level of pelvic floor muscles) gently bring the penis down
to face the child's toes, apply constant gentle pressure.
•If resistance is felt the following strategies should be considered:
• Remove the catheter and utilise a 2nd tube of lubricant
• Increase traction on penis and apply gentle pressure on the catheter
• Ask the child to take a deep breath
• Ask the child to cough and bear down e.g. try to pass urine
• Gently rotate the catheter.

13. Nursing Management
•Measure urine output as indicated 1 – 4 hourly, assessing the colour and concentration
of urine output.
•Unless otherwise specified by the treating team, normal paediatric urine output is 1-
2ml/kg/hr. Report any variation from this to the treating medical team.
• Certain drugs will increase diuresis, such as diuretics and ACE inhibitors.
• If oliguric ensure catheter is not blocked (see trouble shooting below).
• Record fluid balance. A fluid balance which keeps the urine dilute will lessen the
risk of infection. This may not be possible due to the clinical condition of the child.

14. • IDC insertion site and securement should be assessed at least once a
shift, to ensure the IDC is not pulling on the genitals and not twisted.
•IDC drainage bags should be emptied once a shift at a minimum.
•Position drainage bag to prevent backflow of urine or contact with the floor.
Gravity is important for drainage and prevention of urine backflow. Ensure
the drainage bag is below the level of the bladder, is not kinked or twisted
and is secured.

15. Drainage system
Adherence to a sterile continuously closed method of urinary drainage has been
shown to markedly reduce the risk of acquiring a catheter associated infection.
Therefore breaches to the closed system should be avoided.
Consider changing the catheter tube and/or bag based on clinical indicators including
infection, contamination, obstruction or if system disconnects. If the equipment is
damaged or leaks, replace system and/or catheter using aseptic technique and sterile
equipment.

16. Hygiene
•Routine hygiene should be maintained with routine bathing/showering, including daily clean IDC insertion
site with warm soapy water and more frequently if build-up of secretions is evident
•Uncircumcised boys should have the foreskin gently eased down over the catheter after cleaning.
•Always check the strapping of the catheter is secure after hygiene is performed.
Infection surveillance
•Consider daily the need for the IDC to remain in situ. Remove as soon as no longer required to reduce
risk of Urinary Tract Infection (UTI).
•Cloudy, offensive smelling or unexplained blood stained urine is not normal and needs further
investigation.

17. Specimen collection
•Urine for for urinalysis or culture should be collected fresh from the needleless sampling
port of catheter tubing (not drainage bag), this should be completed in line with
the Aseptic Technique Procedure.
• Clamp below the sampling point.
• Scrub sampling point vigorously with 70% alcohol and chlorhexidine (0.5% or 2%)
soaked gauze or swabs for at least 15 seconds and allow to air dry
• Access port with a 10ml syringe to collect sample
• Unclamp catheter
•Large volumes e.g. 24hr collection, can be collected from drainage bag.

18. Troubleshooting
•Catheter not draining/ blocked/patient oliguric
•Check catheter/tubing not kinked
•Check catheter is still secured to patient leg and that it hasn't migrated out of bladder
•Assess patient’s hydration status to ensure they are not dehydrated. Consider the need
to perform a bladder scan to assess bladder volume. Escalate to medical team if
concerned.
•The patency of a catheter can be checked via the sampling port or catheter tubing. A
blocked catheter should be flushed via the catheter tubing, this is of particular
importance in case of blood clots or mucus (for example after a bladder augment).