📋 Catheter Types
| Type | Description | Primary Use | Key Feature |
|---|---|---|---|
| Foley 2-Way | Two lumens — drainage + balloon inflation | Standard continuous urinary drainage | Balloon inflated with sterile water to retain in bladder |
| Foley 3-Way | Three lumens — drainage, balloon, irrigation | Post-TURP haemostasis & continuous bladder irrigation (CBI) | 30 mL balloon for haemostasis; irrigation port for CBI |
| Nelaton / Intermittent | Single lumen, no balloon, straight tip | In-and-out drainage; spinal cord injury (ISC) | No dwelling — removed immediately after drainage |
| Suprapubic | Inserted via percutaneous suprapubic route | Long-term alternative to urethral catheter; urethral obstruction | Inserted surgically above pubic symphysis under sedation/LA |
| Coudé Tip | Curved/angled tip catheter | Benign prostatic hyperplasia (BPH); difficult urethral passage | Curved tip navigates elevated bladder neck; tip rotated upward on insertion |
📏 Size Guide (French / Ch)
PrincipleUse the smallest effective size — minimises trauma and CAUTI risk.
- Women: 14–16 Fr (standard)
- Men: 16–18 Fr (standard)
- Paediatric: 6–10 Fr
- Post-TURP / haemostasis: 20–24 Fr (3-way)
NoteLarger French size = larger diameter. Avoid upsizing without clinical indication.
💧 Balloon Volumes
- Standard 10 mL balloon: Fill with exactly 10 mL sterile water (NOT saline — crystallises)
- Pre-fill note: Balloon labelled "10 mL" = fill with 10 mL to achieve rated size
- 30 mL balloon (3-way): Post-TURP haemostasis; provides tamponade at bladder neck
- Paediatric: 3–5 mL balloons
NeverDo NOT inflate with saline, air, or contrast media. Use only sterile water.
✅ Appropriate Indications — CAUTI Bundle
Catheterise ONLY for the following indications
Accepted Indications
- Acute urinary retention or bladder outlet obstruction
- Critical illness requiring accurate hourly urinary output monitoring
- Perioperative — limited to procedures requiring catheter (not routine)
- Pressure injury management — urinary incontinence contaminating sacral/perineal wound
- Patient comfort in end-of-life / palliative care
- Prolonged immobilisation with spinal instability requiring strict positioning
NOT Acceptable Indications
- Immobility alone (with no wound/monitoring need)
- Urinary incontinence management as routine nursing convenience
- Routine perioperative use for non-urological, non-pelvic surgery
- Patient request without clinical indication
- Physician/nursing workload convenience
ReminderEvery catheter-day = CAUTI risk. Question necessity daily.
🔮 Catheter Materials
| Material | Duration | Use Case |
|---|---|---|
| Latex (standard) | Short-term (<14 days) | Most routine insertions — check latex allergy |
| Silicone (100%) | Long-term (up to 12 weeks) | Latex allergy; less encrustation; silicone-only for suprapubic |
| Silver-alloy coated | Short-term (<14 days) | Reduces CAUTI in short-term catheterisation (evidence-based) |
| Antibiotic-impregnated | Short-term | High-risk patients (immunocompromised, post-transplant) |
| Hydrogel-coated | Long-term | Less friction, improved comfort — ISC and long-term |
Aseptic Non-Touch Technique (ANTT)
Maintain sterile field throughout. Never touch key parts (catheter tip, drainage port, inner connector). Use sterile gloves. If sterility is broken — restart with new equipment.
♀️ Female Catheterisation — Step-by-Step Checklist
Check each step as completed. Progress is saved locally.
♂️ Male Catheterisation — Key Differences
Anatomy ReminderMale urethra is 17–22 cm long (vs 4–6 cm female). Two natural resistances: external sphincter and prostatic urethra. Never force — resistance may indicate stricture or BPH.
- Hold penis at 90° to abdomen (perpendicular) to straighten urethra — then lower to 45° once past external sphincter
- Insert lubricated catheter 17–22 cm until urine flows — advance 3–4 cm further before inflating balloon
- Inflate balloon ONLY after urine flows freely — inflating in urethra causes severe trauma and stricture
- Instill 10 mL anaesthetic gel (Instillagel/lignocaine gel) into urethra — wait 3–5 minutes before catheter insertion
- Retract foreskin before catheterisation — replace (reduce) after procedure to prevent paraphimosis
- Enlarged prostate: use coudé tip catheter with tip rotated upward (12 o'clock position)
🚫 Difficult Insertion
- NEVER force a catheter against resistance
- Try larger/smaller size or coudé tip
- Re-position patient — more lubrication
- Refer to urology if resistance persists
- Suprapubic catheter if urethral route fails
💡 ANTT Principles
- Identify & protect key parts (never touch catheter tip, drainage port)
- Sterile field maintained throughout
- If contamination occurs — replace equipment
- Use single-use sterile equipment only
- Hand hygiene before and after procedure
CAUTI — Most Common Healthcare-Acquired Infection
Catheter-Associated Urinary Tract Infection accounts for ~40% of all healthcare-associated infections. Each additional catheter day significantly increases infection risk. Implement the full bundle.
🛡️ IHI/CDC CAUTI Prevention Bundle Checklist
Complete all bundle elements daily. Progress is saved locally.
📅 Catheter-Days Counter
Enter the catheter insertion date to calculate days in situ and review flag.
Insertion Date
📈 CAUTI Rate Calculation
FormulaCAUTI Rate = (CAUTI Events ÷ Catheter Days) × 1000
Target: <1 CAUTI per 1,000 catheter days (ICU benchmark). Report to infection control for trending and process improvement.
🔴 CAUTI Recognition Criteria
- Fever (>38°C) with no other identified source
- Suprapubic tenderness or costovertebral angle pain
- Cloudy, malodorous urine (not diagnostic alone)
- New-onset confusion in elderly patients
- Positive urine culture ≥10³ CFU/mL with catheter in situ or removed within 48h
NoteCloudy urine or pyuria alone is NOT CAUTI — culture confirmation required.
🔨 Special Catheter Types for CAUTI Reduction
| Catheter Type | Mechanism | Evidence | Indication |
|---|---|---|---|
| Silver-alloy coated | Antimicrobial silver ions inhibit biofilm formation | Reduces CAUTI rate in short-term catheterisation (<14 days) | High-risk units: ICU, post-op |
| Antibiotic-impregnated (minocycline/rifampicin) | Antibiotics leach from catheter surface | Reduces early CAUTI; may select resistant organisms long-term | Immunocompromised, post-transplant |
| Nitrofurazone-impregnated | Nitrofurazone antimicrobial coating | Some evidence for short-term reduction | Short-term high-risk |
General RuleNever force a blocked or resistant catheter. If simple interventions fail, refer to urology. Document all catheter problems and interventions.
Definition: Urine leaking around (not through) the catheter despite it being in situ.
Causes:
- Blocked catheter lumen (sediment, mucus, clots)
- Bladder spasm — most common cause
- Catheter too large (over-distended urethra) or too small
- Constipation compressing urethra
- Catheter not positioned correctly (tip not in bladder)
Management:
- Check for blockage — flush with 50 mL normal saline
- Review catheter size — do NOT upsize to compensate for leakage
- Treat constipation — rectal examination if needed
- Bladder spasm: review medications (antimuscarinic agents e.g. oxybutynin if appropriate)
- If persistent — consider catheter change or specialist review
Do NOTUpsizing the catheter for bypassing worsens urethral trauma and increases CAUTI risk.
Recognition: No urine output for >2 hours in a patient with normal fluid intake — bladder palpable/distended.
Causes: Sediment/mucus plug, blood clots (post-TURP), kinked tubing, catheter tip migration.
Management Steps:
- Check tubing for kinks, loops, dependent pooling — correct positioning
- Ensure drainage bag is below bladder level
- Bladder washout: instill 50 mL normal saline using sterile syringe, aspirate — repeat 2–3 times
- If unsuccessful — change catheter (do not persist with irrigation if clots/blood present)
- Post-TURP haematuria with clots: set up continuous bladder irrigation (CBI) via 3-way catheter
- Refer urology if blockage recurs or cause unclear
Common Causes:
- Post-TURP (most common in urology ward)
- Traumatic catheter insertion
- Urinary tract infection (haemorrhagic cystitis)
- Bladder cancer or renal pathology
- Coagulopathy or anticoagulant therapy
CBI (Continuous Bladder Irrigation) Setup — Post-TURP:
- Ensure 3-way catheter (24 Fr) in situ with 30 mL balloon
- Connect normal saline irrigation bags (3 L) to irrigation port
- Adjust flow rate to keep output a light rosé colour (not red)
- Monitor and document: input (irrigation in), output (drainage bag), net balance
- Traction may be applied to catheter (pull and tape to thigh) for 4–6h post-TURP for haemostasis
- Reduce irrigation rate as haematuria clears — wean off CBI before catheter removal
AlertDark red, frank haematuria with clots requires urgent surgical review — do not increase irrigation rate without surgical instruction.
Causes: Valve defect, balloon channel blocked by debris, catheter kinked at balloon port.
Management (in order):
- Gently aspirate with 10 mL syringe — check valve is fully open
- Try a different syringe or remove valve completely and allow passive deflation
- Inject 2 mL sterile water into balloon port — may dislodge debris — then aspirate
- Pass a wire stylet down inflation channel under urology supervision
- Last resort only: Cut inflation channel distal to balloon port — allows passive collapse
NEVERDo NOT burst the balloon by overfilling — fragments may cause severe bladder injury. Do NOT attempt needle puncture transurethral or transabdominal without urology guidance.
Signs: Bright red bleeding from meatus during or after insertion, catheter resistance that was forced, no urine despite apparent catheter position, pain disproportionate to procedure.
Management:
- Stop the procedure immediately
- Do not inflate balloon if urine has not been confirmed
- Refer immediately to urology — cystoscopy may be required
- Document clearly: resistance encountered, force used, amount of bleeding
- Monitor for urinary retention — suprapubic catheter may be needed as temporary measure
Suspect when: Catheter passes easily to a point then meets resistance; patient has history of urethral trauma, STI, previous catheterisation, or prostate surgery.
Management:
- Try coudé tip catheter with tip directed upward
- Try smaller size (14 Fr instead of 16 Fr)
- If unsuccessful: refer to urology for flexible cystoscopy and guided catheterisation
- Suprapubic catheterisation if urethral route completely fails
- Long-term: urology follow-up for urethral dilatation or urethroplasty
📋 Problem Summary Reference
| Problem | First Action | Escalate If |
|---|---|---|
| No urine >2 h | Check tubing, flush 50 mL NS | Bladder palpable, flush fails |
| Bypassing | Check for blockage, treat constipation | Persists after flush & repositioning |
| Frank haematuria + clots | Set up CBI, monitor closely | Dark red, haemodynamically unstable |
| Balloon won't deflate | Try different syringe, passive deflation | All standard methods fail |
| Traumatic insertion | Stop, no balloon inflation, refer | Immediately — all traumatic insertions |
| Resistance on insertion | More lubrication, coudé tip | Any resistance not resolved — refer urology |
📝 JCI Documentation Requirements
Insertion Record (Minimum)
- Date and time of insertion
- Clinical indication (specific — not "urine monitoring")
- Catheter type, size (Fr), material
- Balloon volume used
- Name/designation of inserting clinician
- Any complications during insertion
- Patient consent and patient education given
Daily Ongoing Record
- Urinary output volumes (every hour if critical; 4-hourly otherwise)
- Character of urine: colour, clarity, odour, sediment
- Catheter hygiene performed (date/time)
- Daily necessity review — continued/removed (reason)
- Catheter site inspection: meatal discharge, inflammation
👤 Patient & Family Education
In-Hospital
- Explanation of catheter purpose and duration
- Importance of not pulling or disconnecting tubing
- Bag should always remain below waist level
- Report: no urine in bag >2 hours
- Report: severe pain, bladder spasm, fever >38°C
Discharge / Home Catheter
- Catheter hygiene: clean meatus with soap and water daily
- Increase fluid intake to 2–2.5 L/day unless restricted
- Leg bag during day, night drainage bag for sleeping
- Activity: walking and light activity encouraged
- Return to ED/clinic: no urine >2h, fever, severe pain, gross haematuria
🔧 Intermittent Self-Catheterisation (ISC) Teaching
IndicationNeurogenic bladder (spinal cord injury, MS, spina bifida), chronic urinary retention where surgical options exhausted, post-void residual >300 mL symptomatic.
ISC Teaching Points
- Frequency: typically 4–6 times/day (based on voiding diary)
- Timing: set schedule, not symptom-driven (neurogenic bladder has no sensation)
- Clean technique (NOT sterile) acceptable for community ISC
- Catheter type: single-use hydrophilic or reusable (cleaned after each use)
- Fluid restriction to 1.5–2 L/day to manage output between catheterisations
Competency Check Before Discharge
- Patient can identify catheter, lubricant, drainage container
- Performs hand hygiene correctly
- Can independently insert and remove catheter
- Documents voiding diary entries
- Knows when to seek help: UTI symptoms, inability to insert
🔎 Quick Reference
14–16 Fr
Standard female catheter
16–18 Fr
Standard male catheter
6–10 Fr
Paediatric sizes
10 mL
Standard balloon fill (sterile water)
30 mL
Post-TURP balloon (haemostasis)
5–7.5 cm
Female insertion depth
17–22 cm
Male insertion depth
≥10³ CFU
CAUTI culture threshold
>7 days
Flag for urgent review
2/3 full
Empty drainage bag when
🏆 Knowledge Assessment — 10 MCQ Quiz
1. Which of the following is an appropriate indication for urinary catheterisation?
2. When inserting a male urethral catheter, the balloon should be inflated:
3. The standard balloon volume for a routine 2-way Foley catheter is:
4. A patient develops urine leaking around the catheter (bypassing). What is the FIRST appropriate action?
5. According to the CAUTI bundle, how should the catheter-meatal junction be cleaned?
6. Which catheter type is indicated for a patient with benign prostatic hyperplasia (BPH) where a standard catheter cannot pass?
7. CAUTI is defined as a positive urine culture with a catheter in situ or removed within 48 hours. The minimum colony count required is:
8. A post-TURP patient has frank haematuria with clots. The drainage bag is full of dark red urine. The MOST appropriate initial action is:
9. During female catheterisation, the urethral meatus should be cleaned using:
10. A nurse encounters resistance while inserting a urethral catheter in a male patient. The CORRECT action is: