Male catheterisation

Written by Bethany Taylor

Introduction

Wash your hands, introduce yourself with your name and role, and confirm the patient’s name and date of birth. Explain the procedure, check the patient’s understanding and obtain consent. Always call for a chaperone.

Ask the patient if they have any allergies, specifically to latex. Check whether the patient is currently in any pain.

When describing catheterisation to a patient, ascertain what the patient already knows, and use simple phrases such as: “the catheter is a thin, flexible tube that will be inserted into the penis after some local anaesthetic has been applied. It will sit in the bladder and urine will flow through the catheter into the attached bag. It will feel a little uncomfortable but there should not be any pain.”

In the OSCE setting it is usual to state that the examiner will act as the chaperone, but on the wards this may be a doctor, nurse or healthcare assistant. This is an intimate procedure and it is essential to request the presence of a chaperone.

Catheterisation may be short-term or long-term. Indications may include collecting a sterile urine sample, urinary tract obstruction, bladder decompression, urinary retention, urinary incompetence (e.g. patients with spinal cord injury) and to monitor urinary output (e.g. in critically ill patients or post-surgery).

Equipment

Collect a procedure trolley, and clean the top surface using an alcohol surface disinfectant wipe. Next obtain a plastic tray and clean it in a similar manner. You will then need to collect:

Equipment preparation

Check the expiry dates of the catheter, saline, sterile water and anaesthetic lubricating gel. Ensure that a clinical waste bin is nearby.

Wash your hands again and put on the disposable plastic apron. Open the catheter pack on top of the clean procedure trolley. Be sure to maintain sterility by only touching the outer packaging. Using aseptic non-touch technique, empty into the sterile field the catheter and the syringes containing lidocaine and sterile water.

Keep the back of the catheter packet, as the sticky label on the back of the packet will need to be transferred into the patient notes at the end of the procedure.

When selecting a catheter consider patient gender, expected catheter duration period, previous catheter history and any allergies the patient may have (some catheters have a latex coating). In addition, select the appropriate:

Preparation

Patient positioning

Ask the patient to lay supine, with their legs extended and slightly apart. The patient will need to remove their underwear.

Do not uncover the patient at this stage. Place the protective waterproof sheet beneath the patient’s buttocks.

It is important to maintain patient dignity and minimise unnecessary exposure. This can be achieved using the patient’s hospital gown or clean bed sheet

Cleaning the area

Clean your hands and put on the sterile gloves. Place the cotton wool balls into the Gallipot (from the catheter pack) and pour over the 0.9% saline solution.

Expose the patient’s genitalia. Retract the foreskin (if present) and use a sterile swab in your non-dominant hand to hold the penis in place.

Use the cotton wool balls to clean the glans penis with your dominant hand, ensuring that you clean away from the urethral meatus. Once you are satisfied the penis has been cleaned, open the sterile fenestrated drape and place the hole in the drape over the penis so it is surrounded. Dispose of the cotton wool balls in clinical waste. Position a sterile urine collection bowl below the penis, on top of the drape and between the patient’s legs.

Anaesthetic application

Use a fresh sterile gauze swab in your non-dominant hand to hold the penis vertically. Next insert the syringe nozzle of the lubricating anaesthetic gel into the urethral meatus.

Slowly empty the syringe into the urethra. Whilst doing so, ensure that you continue to hold the penis in place to prevent the gel from escaping. Allow time for the anaesthetic to have effect (usually 3-4 minutes) before letting go of the penis.

It is useful to let the patient know that, whilst the anaesthetic may feel uncomfortable initially, the penis will soon go numb, rendering the catheter insertion painless.

Catheter insertion

Dispose of your gloves and don a new pair of sterile gloves.

Ensure that the distal end of the catheter is positioned in the collecting bowl to prevent urine spillage.

Carefully tear the plastic catheter wrapper along the perforated line to expose its tip. Recommence holding the penis vertically with your non-dominant hand using gauze. Warn the patient that you will now put in the catheter, and using your dominant hand, insert the catheter tip into the urethral meatus.

Advance the catheter slowly, whilst gradually retracting the wrapper. Continue until the catheter enters the bladder and urine flows, which, in males, usually occurs near to the catheter bifurcation point.

It can be difficult to retract the wrapper without also retracting the catheter. Ensure that your non-dominant hand has a secure grip behind the glans and that the wrapper is pulled back gently.

To maintain sterility, it is useful to think in terms of having a ‘clean’ dominant hand and an ‘unclean’ non-dominant hand. The dominant hand holding the catheter should remain sterile at all times.

As the catheter reaches the prostate in males, it may become difficult to advance and may cause the patient discomfort. If this occurs, apply gentle pressure on the catheter and ask the patient to strain slightly as they would do to urinate. If you are still unable to advance the catheter and/or the patient is in significant discomfort, remove the catheter. A second attempt or input from urology may be appropriate.

Balloon inflation

At this point you need to secure the catheter inside the bladder by inflating its balloon. Connect the syringe containing 10ml sterile water to the balloon port and gently inflate the catheter balloon. Whilst doing so, observe the patient closely and ask them to let you know if they experience any discomfort, as this may indicate that the catheter is not in the correct position.

After inflation, gently pull on the catheter until resistance is met. This ensures that the balloon is adequately inflated and sits securely at the entrance of the bladder.

Catheter bag attachment

Attach the catheter to a catheter bag, which should be positioned below the level of the bladder to ensure drainage. The bag should be secured in place on a catheter stand to prevent accidental catheter removal.

Completion

If necessary, clean the glans penis. Replace the retracted foreskin to prevent it from becoming trapped behind the glans penis (paraphimosis). Ensure the patient is comfortable and the surrounding area is clean and dry. Remove any equipment, thank the patient, and ask them to inform a member of staff if there is any leakage, pain or dislodgement of the catheter.

Remove your gloves and wash your hands. Record the procedure in the patient’s notes, documenting the date, time, procedure performed, indication for catheterisation, catheter size, local anaesthetic used, the amount and appearance of urine, any complications, the planned removal date and confirmation of consent and chaperone presence.

It is important to observe the appearance and amount of urine collected following catheterisation. Changes to either of these factors may indicate underlying disease.

Appearance

A frothy appearance is typical of proteinuria (glomerulonephritis, diabetes mellitus), a red/pink appearance occurs in haematuria (urinary tract infection (UTI), urinary tract cancers, kidney stones), dark brown urine is typical of post-hepatic jaundice (as a result of gallstones or cancer of the pancreas head) and cloudy urine is also a sign of a UTI. In addition, be aware that urine colour may change with medication and can indicate hydration status.

Amount

In the average adult patient, urine output should be around 0.5-1ml/kg/hr.

List form

Instructions
When assessing each other, please click on each list item as you go along. Doing so will turn the list item green. Make careful note of any steps missed at the end.
We recommend completing any examination or procedure in under 10 minutes, but you can adjust the timer to suit your needs.
:

  1. 1. Introduction: “Hello, I’m SimpleOSCE and I am a medical student. Today I’ve been asked to insert a catheter. Can I confirm your name and DOB? Thank you.”
  2. Explain procedure and gain consent: “This will involve me inserting a thin, flexible tube into the penis after applying some local anaesthetic. It will sit in the bladder and allow urine to flow into an attached bag, so that your urine output can be monitored. It will feel a little uncomfortable but there should not be any pain. Would that be alright?”
  3. Enquire about allergies (latex) and ask if the patient is currently in any pain.
  4. Assemble the correct equipment on a clean procedure trolley.
  5. Check the expiry dates of the catheter, sodium chloride, sterile water and anaesthetic lubricating gel.
  6. Wash your hands and put a disposable plastic apron on.
  7. Using aseptic technique, empty the syringes and catheter from their packets into the sterile field.
  8. Position patient appropriately in supine position, with legs extended and slightly apart.
  9. Apply sterile gloves.
  10. Retract foreskin and clean glans penis away from the urethral meatus, using 0.9% saline.
  11. Hold the penis vertically and insert lubricating anaesthetic gel into the urethral meatus.
  12. Replace gloves.
  13. Expose the tip of the catheter by tearing back the plastic packaging and insert into the urethral meatus, whilst maintaining sterility.
  14. Advance the catheter whilst retracting the plastic packaging, until urine flows into the collecting vessel.
  15. Inflate the catheter balloon using sterile water.
  16. Pull gently on the catheter to position the balloon at the entrance to the bladder.
  17. Attach the catheter to the catheter bag and secure bag on catheter stand.
  18. Clean the glans penis if necessary and replace the foreskin.
  19. Instruct the patient on aftercare, ensure they are comfortable and thank the patient.
  20. Remove gloves and wash hands.
  21. Record the procedure in the patient’s notes, documenting the date, time, procedure performed, indication for catheterisation, catheter size, the local anaesthetic used, the amount and appearance of urine, any complications, the planned removal date and confirmation of consent and chaperone presence.
  22. Overall: 0/28

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