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Catheterisation #3: Advanced Techniques

Catheters are common. 15-25% of hospital patients will be catheterised. Competence in catheterisation is assessed at medical school and is a requirement for successful completion of foundation training, yet, in spite of this, inserting catheters correctly and looking after patients with catheters can be challenging for junior doctors.

This series aims to take you though the important basics of catheter insertion, what steps the urologists take when you call them for help and finally to share some useful anecdotal advice learned the hard way from years on the wards.

The Essentials

This is the third in a series on catheterisation. It is preceded by Part #1 and Part #2, and followed by Part #4. This series aims to take you though the important basics of catheter insertion, what steps the urologists take when you call them for help and finally to share some useful anecdotal advice learned the hard way from years on the wards.

Catheterisation should be simple. It’s essentially passing a small tube down a well-lubricated pipe. Sometimes, however, it can be difficult.

In this third installation of the series, some of the most common and challenging issues with catheterisation are discussed along with some strategies to try and overcome them.

1. Challenging access in men

Usually the urethral meatus in the male is easy to find, but it can be difficult due to scarring or problems with the foreskin.

In the case of a tight meatus or phimosis too narrow to pass a 12Fr catheter through it’s probably best to call a urologist as the patient may need dilatation under anaesthetic or a dorsal slit. Sometimes, a phimosis leaves just enough space to get the tip of an anaesthetic gel tube in, by instilling some gel, this often dilates the opening and could allow passage of a catheter. If the foreskin looks too tight, don’t force the issue, get urological advice.

Patients in heart failure will often end up with an oedematous foreskin making it difficult to find the glans and meatus for catheterisation. The first thing to do here is to squeeze as much tissue fluid out as possible, until the glans is palpable and you can find or feel some landmarks. Squirting a tube of gel into the foreskin can often open it out, helping you find the meatus. The transparent gel can sometimes act as a lens, magnifying the glans beyond the foreskin, making the meatus easier to see.

For men with large bellies or a big inguinal scrotal hernia and a “buried penis” you need more hands. Get some assistance to lift the belly out of the way; this is often quite heavy, so sometimes a couple of sets of hands are useful. You should also have the rest of your kit at the ready so that your helpers aren’t left holding on while you faff around. With large herniae, you will usually be able to see where the penile skin ends and the scrotal skin begins. You should be able to push down and backwards, towards the patients pelvis to expose enough of the penis to get a catheter in.

2. Challenging access in women

The urethral meatus can be a challenge to find in some women, particularly after the menopause when there might be vaginal atrophy. This can make the tissue contract, pulling the urethral opening up into the front wall of the vagina.

Try positioning the patient as best you can with a raised bed, pillow under the hips to tilt the pelvis up and get a good light source pointed right where you need it. It’s often helpful to have extra pairs of hands to support the patient’s legs.

A final trick when the urethra has retracted back into the front wall of the vagina is to place the catheter against the tip of your index finger and use this as a guide to try and find the urethral opening by feel. This can be tricky, but might get you out of a tight spot. Make sure you warn the patient about what you are going to do before you do this.

3. Navigating BPH

If a patient is known to have a large prostate and you feel the catheter getting stuck at that level, use one or two extra anaesthetic gels and find a curved tip catheter. These are inserted with the tip of the curve facing up towards the patient which aids navigation through the bend in the prostatic urethra. If you don’t feel comfortable doing this, grab all the kit and get someone with more experience to show you how. Consistent pressure should help the catheter navigate the prostatic fossa, but, again if the catheter starts bending in the urethra like a bowstring, it’s not going in.

A note on introducers: these are wire, coat hanger-like contraptions that fit inside the lumen of a catheter and can be bent to produce a curve in the tip. They are best avoided unless you have visualized the urethra with a scope as if there is a urethral stricture. An introducer has the potential to cause significant damage.

4. Kit Urologists might use

Remember! When the basics, positioning, extra gel, and curved tip catheters won’t work then this is really in the hands of a urologist. The first thing they will do is check that a catheter is really indicated, please think about this before you call them!

They are likely to use their experience to try to pass a catheter themselves, this also helps them picture in their minds eye the point of obstruction or where the difficulty lies.

The next options are likely to involve a flexible cystosope or a suprapubic catheter. The equipment for this can sometimes be brought to the patients but often the patient will be taken to theatre for the procedure.

The advantage of a flexible cystoscope is that it allows direct visualization of the urethra and the passage of a guidewire through narrowings or past false passages. Open-ended catheters can then be passed over the wire into the bladder.

Suprapubic cateter are also a very good option for appropriate patients. There are a few contraindications and considerations to suprapubic catheterisation and its not always as easy as “I cant get your catheter in so I’ll call the urologist and they’ll just pop one into your tummy”.

5. Haematuria

Catheterisaton should be a bloodless procedure. However, in men with large vascular prostates there may be some bleeding from even straight forward insertion. This will be seen around the edges of the tubing but usually not within the tube, the urine should drain fairly clear. This does not mean the catheter needs to be changed to a 3-way catheter. Bleeding from the urethra comes around the sides of the catheter and is usually self-limiting, although can look quite dramatic! Blood within the catheter tube means blood coming from the bladder.

If you pass a 2 way and the tube fills with dark blood then it should probably be changed.

Patients who have been catheterised for very large residuals may have decompression haematuria, blood in their urine from small haemorrhages from the overstretch bladder as it empties. This should be self-limiting and as the patient is likely to be admitted to hospital, they can be observed on the ward. As they are likely to diurese, the blood will be washed out of their bladder before it gets the chance to clot and a 2 way catheter should do the trick.

This is the third in a series on catheterisation. Click here to read Part #4.

Words by Dr. Paul Sturch.


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