Comprehensive Guide to Male Catheterization for Medical Students

Catheterization is a common procedure in medical practice, particularly in urology. It involves the insertion of a catheter into the bladder to drain urine. While the procedure may seem straightforward, it requires a thorough understanding of anatomy, sterile technique, and patient care to avoid complications. This guide aims to provide a detailed, step-by-step approach to performing male catheterization, with a focus on best practices, patient comfort, and safety.

Anatomy and Indications

Understanding male urinary anatomy is crucial for successful catheterization. The male urethra is approximately 20 cm long and runs from the bladder, through the prostate, and down the length of the penis to the urethral meatus. The urethra has three sections:

1. Prostatic urethra: Passes through the prostate gland.
2. Membranous urethra: The shortest and narrowest part, passing through the urogenital diaphragm.
3. Penile (spongy) urethra: Runs the length of the penis.

Indications for Catheterization:

• Acute urinary retention: Often due to benign prostatic hyperplasia (BPH) or urethral stricture.
• Chronic urinary retention: As part of long-term management in cases where voiding is inadequate.
• Monitoring urine output: In critically ill patients or during surgery.
• Obtaining a sterile urine sample: When non-invasive methods are not possible.
• Bladder irrigation: To manage hematuria or post-surgery blood clots.
• Administration of intravesical medications: Such as chemotherapy for bladder cancer.

Types of Catheters

There are different types of catheters used in male catheterization, and choosing the right one depends on the indication and the duration of catheterization.

1. Intermittent Catheter (Robinson or Nelaton catheter): A single-use catheter used for short-term catheterization.
2. Indwelling Catheter (Foley catheter): A catheter that remains in place, with a balloon inflated to keep it secure in the bladder.
3. Coude Catheter: A catheter with a curved tip, used in patients with enlarged prostates or other obstructions.

Materials:

• Latex: Flexible and soft, but not suitable for patients with latex allergies.
• Silicone: Less reactive and better for long-term use.
• Hydrogel-coated: Provides more comfort and reduces friction.

Pre-procedure Preparation

Patient Assessment and Consent:

• Review the patient’s medical history, focusing on urinary symptoms, previous catheterizations, and any history of urethral strictures or surgery.
• Discuss the procedure with the patient, explaining the reason for catheterization, potential risks, and benefits.
• Obtain informed consent.

Equipment Preparation:

• Sterile catheterization tray, including:
  • Sterile gloves
  • Drapes
  • Antiseptic solution (e.g., chlorhexidine or povidone-iodine)
  • Lubricant jelly (preferably with local anesthetic, such as lidocaine)
  • Sterile gauze
  • Urinary catheter (appropriate size)
  • Syringe with sterile water (for inflating the Foley catheter balloon)
  • Drainage bag
  • Adhesive tape
• Ensure all equipment is within reach and that the environment is conducive to maintaining sterility.

Patient Positioning:

• Position the patient supine with legs extended and slightly apart. If the patient is unable to lie flat, adjustments can be made to ensure comfort and accessibility.
• Drape the patient, exposing only the genital area to maintain privacy and reduce contamination risk.

Step-by-Step Catheterization Procedure

1. Hand Hygiene:
   • Perform thorough handwashing with soap and water or use an alcohol-based hand sanitizer.
   • Wear sterile gloves.
2. Sterile Field Setup:
   • Open the catheterization tray and arrange the equipment on a sterile field.
   • Place sterile drapes around the genital area.
3. Cleansing the Urethral Meatus:
   • Retract the foreskin (if present) and hold the penis with non-dominant hand, maintaining sterility.
   • Use sterile gauze soaked in antiseptic solution to clean the urethral meatus in a circular motion from the center outward.
   • Repeat this step 2-3 times using new gauze each time.
4. Lubrication:
   • Apply a generous amount of sterile lubricant jelly to the catheter. If using lidocaine gel, insert it into the urethra and wait 2-3 minutes for the anesthetic effect.
   • Lubrication is essential to minimize discomfort and reduce the risk of urethral trauma.
5. Catheter Insertion:
   • Hold the penis at a 60-90 degree angle to straighten the urethra and reduce resistance.
   • Gently insert the catheter into the urethra, advancing it slowly but steadily. Instruct the patient to take deep breaths and relax, which can help ease the passage of the catheter.
   • If resistance is encountered at the membranous urethra (around the level of the urogenital diaphragm), ask the patient to cough or bear down as if to urinate. This can help the catheter pass through.
   • Continue advancing the catheter until urine begins to flow, indicating that the catheter is in the bladder.
   • If inserting a Foley catheter, advance the catheter another 1-2 inches to ensure the balloon is within the bladder.
6. Balloon Inflation (For Indwelling Catheter):
   • Once urine flows, inflate the balloon with the pre-filled syringe of sterile water (usually 10 ml).
   • Gently tug the catheter to ensure the balloon is properly seated at the bladder neck.
7. Connecting to Drainage Bag:
   • Connect the catheter to the drainage bag, ensuring that the connection is secure and that there are no kinks in the tubing.
   • Tape the catheter to the patient’s thigh or lower abdomen to prevent traction on the bladder neck.
8. Post-procedure Care:
   • Clean the area, replace the foreskin if retracted, and cover the patient.
   • Ensure the drainage bag is positioned below the level of the bladder to prevent backflow of urine.
   • Document the procedure, including the size and type of catheter used, the volume of water in the balloon, and any complications encountered.

Potential Complications and How to Manage Them

Urethral Trauma:

• Symptoms: Bleeding, resistance during insertion, or patient discomfort.
• Management: Stop the procedure, assess the extent of trauma, and consult a urologist if needed. For mild cases, rest, hydration, and analgesics may suffice.

Urinary Tract Infection (UTI):

• Prevention: Strict aseptic technique, proper catheter care, and limiting catheterization duration.
• Management: If a UTI is suspected, obtain a urine sample for culture and sensitivity, and start empirical antibiotics.

False Passage:

• A false passage occurs when the catheter is forced into the urethral wall, usually at the level of the membranous urethra.
• Management: Stop the procedure immediately. Remove the catheter and consult a specialist for further management.

Balloon Inflation in the Urethra:

• This can cause significant urethral trauma.
• Management: Deflate the balloon immediately, remove the catheter, and monitor the patient. Urological consultation may be necessary.

Paraphimosis:

• Paraphimosis can occur if the foreskin is not replaced after catheterization.
• Management: Reduce the paraphimosis manually by compressing the glans and pulling the foreskin forward. In severe cases, surgical intervention may be required.

Post-Catheterization Care and Patient Education

• Monitoring: Regularly check the catheter site for signs of infection, irritation, or blockage. Ensure that the catheter remains patent and the drainage bag is emptied regularly.
• Patient Education: Instruct the patient on proper catheter care, signs of complications (e.g., fever, pain, foul-smelling urine), and when to seek medical attention.
• Catheter Removal: For indwelling catheters, ensure that the balloon is completely deflated before removal. Withdrawal should be slow and steady to avoid trauma.

Special Considerations in Different Patient Populations

Patients with Prostate Enlargement:

• Use a coude catheter for easier navigation past the enlarged prostate.
• Consider ultrasound-guided catheterization in cases of significant difficulty.

Patients with Urethral Strictures:

• Strictures can complicate catheterization. Consider using a smaller catheter size or consulting a urologist.
• In cases where catheterization is not possible, suprapubic catheterization may be necessary.

Pediatric Patients:

• Use age-appropriate catheter sizes (typically 6-12 French).
• Engage the child and parents in the procedure to reduce anxiety.

Elderly Patients:

• Be mindful of comorbidities and increased risk of infection.
• Use silicone catheters, as they are less likely to cause urethral irritation.

Conclusion

Male catheterization is a vital skill for healthcare professionals, requiring meticulous attention to detail, an understanding of anatomy, and patient-centered care. By following the steps outlined in this guide, medical students and healthcare professionals can perform catheterization with confidence, minimizing discomfort and complications for their patients. As with all medical procedures, continuous learning and adherence to best practices are essential for success.