Urinary Catheterisation Nursing Guide

Indications & Contraindications

Indications (ABCDE)

Acute urinary retention
Bladder monitoring (strict UO in ICU/post-op)
Continence management (pressure ulcers, comfort care)
Drainage pre/intra/post surgery
Exact measurement in haemodynamically unstable patients
Instillation of bladder medications
Bladder irrigation after TURP

Contraindications

Absolute: Suspected urethral injury (trauma — blood at meatus, perineal bruising, high-riding prostate)
Relative: Urethral stricture (use Coudé catheter or seek urology)
Urethral surgery (consult surgeon before catheterisation)
Acute prostatitis (relative)

If blood at urethral meatus after trauma — DO NOT catheterise. Request urgent urology/surgical review. Risk of converting partial urethral tear into complete transection.

Catheter Types & Sizes

Type	Design	Use
Foley (2-way)	Drainage lumen + balloon lumen	Standard indwelling catheter — most common
3-way Foley	Drainage + balloon + irrigation lumen	Post-TURP, haematuria requiring continuous bladder irrigation (CBI)
Coudé (curved tip)	Angled tip	Urethral stricture, BPH — helps navigate past obstruction
Intermittent (Nelson/Nelaton)	No balloon — in/out	Clean intermittent self-catheterisation (CISC); neurogenic bladder
Suprapubic catheter	Inserted through abdominal wall into bladder	When urethral route not possible; long-term drainage

Catheter Size (French/Charrière — Fr)

Patient	Catheter Size	Note
Adult female	12–14 Fr	Larger size not needed; smaller = less discomfort
Adult male	12–14 Fr standard; 16–18 Fr if haematuria	Larger bore for clot drainage
Post-TURP / haematuria	20–24 Fr (3-way)	Large bore required for CBI
Paediatric	6–10 Fr	Age-dependent

Rule: Use the smallest catheter that achieves adequate drainage. Larger catheters cause more urethral trauma, urethritis, and bypassing. Size 12–14 Fr is adequate for most indwelling catheters.

Balloon Volume

Standard adult balloon: 10 mL sterile water (NOT saline — crystals can block deflation valve)
Post-TURP: 20–30 mL balloon for haemostasis
Paediatric: 3–5 mL

Aseptic Catheterisation Technique — Male

Explain procedure, obtain consent. Maintain dignity — ensure privacy, screen/curtains.

Wash hands. Prepare sterile field: catheterisation pack, catheter, 10 mL sterile water for balloon, lubricant (instillagel — anaesthetic/lubricating gel for male).

Don sterile gloves. Clean around urethral meatus with sterile gauze and 0.9% NaCl — cleaning from tip outward (distal to proximal).

Apply sterile drape with hole. Retract foreskin if present (document; replace foreskin after — paraphimosis risk).

Instil 6–11 mL instillagel into urethra. Wait 3–5 minutes for anaesthetic effect.

Hold penis at 90° (perpendicular to body) to straighten urethra. Advance catheter slowly, using non-dominant hand to hold penis through sterile drape.

When urine flows, advance catheter further 2–3 cm (ensure balloon is IN the bladder, not urethra).

Inflate balloon with 10 mL sterile water. Gently withdraw until resistance felt.

Attach drainage bag below bladder level. Secure catheter to inner thigh (prevents traction). Replace foreskin.

Document: time, catheter size/type, balloon volume, urine output obtained, patient tolerance.

NEVER inflate balloon if urine not draining freely — balloon may be in the urethra → urethral rupture. If resistance felt advancing catheter, STOP, withdraw, and seek senior/urology advice.

Female Catheterisation Key Points

Position: dorsal recumbent (supine with knees bent and apart — "frog-leg position")
Identify urethral meatus — above vaginal orifice, below clitoris. May be difficult in obese/elderly patients — use good lighting
Clean labia minora, then urethral meatus with downward strokes (front to back)
Use water-based lubricant (gel). Smaller urethra = less instillagel needed (5 mL)
Advance catheter 4–6 cm until urine flows
If catheter inadvertently enters vagina — leave it in place as a landmark, insert new catheter, then remove the first

CAUTI — Catheter-Associated Urinary Tract Infection

CAUTI is the most common healthcare-associated infection (HAI) globally, accounting for ~30–40% of all HAIs. Most are preventable. In GCC hospitals, CAUTI reduction is a key patient safety indicator.

Definition: CAUTI = UTI in a patient who had a urinary catheter within 48 hours before symptom onset. Symptoms include: fever >38°C, suprapubic tenderness, urinary frequency/urgency (in catheter-free patients), and positive urine culture ≥10⁵ CFU/mL.

CAUTI Prevention Bundle (7 Evidence-Based Measures)

Insert catheter only when indicated — challenge every catheter order; avoid for convenience/incontinence management alone
Maintain strict aseptic technique at insertion
Maintain closed drainage system — never disconnect without clinical reason; no routine irrigation
Keep drainage bag below bladder level at all times — prevents backflow
Avoid kinking/obstruction of tubing — check at every assessment
Daily review of catheter necessity — document indication; remove when no longer required (CAUTI risk increases ~5% per day)
Meatal hygiene — clean with soap and water during bathing; avoid antiseptic ointments (no evidence of benefit; may select resistant organisms)

CAUTI Bundle Goal: The single most effective CAUTI reduction strategy is early catheter removal when no longer indicated. Every day without an unnecessary catheter = reduced infection risk.

Catheter Bag Management

Practice	Recommendation
Bag position	Always below bladder (gravity drainage); never on floor
Emptying frequency	When 2/3 full or routinely 6–8 hourly; use clean technique
Tap cleaning	Wipe with 2% chlorhexidine wipe before and after emptying
Bag changing	Only when clinically necessary (closed system integrity broken, leaking, end of manufacturer recommendation)
Urine sampling	Use needleless sampling port — never break junction between catheter and bag

Complications of Catheterisation

Complication	Signs	Management
CAUTI	Fever, cloudy/offensive urine, suprapubic pain	Urine MC&S; antibiotics; consider removal/change
Blocked catheter	No urine output, bladder palpable/painful	Flush with 50 mL 0.9% NaCl; if persistent, change catheter
Bypassing	Urine leaking around catheter	Check/clear blockage; bladder spasm → antispasmodics; do NOT upsize catheter
Haematuria	Blood in urine on/after insertion	Ensure balloon in bladder; if trauma suspected, seek urology; monitor; increase fluid intake
Urethral trauma	Bleeding, pain, difficulty passing	Stop if resistance felt; senior/urology review; CXR if false passage suspected
Paraphimosis	Foreskin retracted, oedematous, cannot be replaced	Emergency — manual reduction or surgical dorsal slit; apply cold compress; ice pack; penile block
Bladder spasm	Intermittent cramping pain, bypassing	Check position; anticholinergics (oxybutynin); reassure patient
Urethral stricture (long-term)	Difficulty voiding after catheter removal	Urology referral; dilatation; optical urethrotomy

Post-obstruction diuresis: After relieving acute urinary retention (especially chronic), patients may produce large volumes of urine (polyuria >200 mL/hr). Monitor electrolytes and fluid balance closely. Avoid draining more than 500 mL at first catheterisation (some guidelines suggest clamp after 500 mL and release after 15–30 min) — though evidence is limited, it prevents haematuria ex vacuo in some patients.

GCC-Specific Catheterisation Considerations

Dignity & Cultural Sensitivity in GCC ▼

Urinary catheterisation involves intimate exposure and is particularly sensitive for GCC patients given Islamic cultural values of modesty (haya). Key considerations: same-gender catheterisation is strongly preferred — female nurse should catheterise female patients; male nurse/doctor for male patients (unless emergency). Explain the procedure fully in the patient's language. Maintain maximal privacy with screens/curtains. Minimise exposure time. For Muslim patients who may be conscious of ritual cleanliness (tahara), explain that the catheter does not affect Islamic prayer obligations — this is a medical necessity (darura).

BPH & Acute Retention in GCC Male Patients ▼

Benign prostatic hyperplasia (BPH) is extremely common in GCC men over 50. Acute urinary retention is a common emergency presentation. The enlarged prostate makes catheterisation more difficult — use generous instillagel, Coudé catheter if standard fails, and have urology available if difficulty encountered. A 16–18 Fr catheter may pass more easily than 14 Fr when navigating around an enlarged prostate.

CAUTI as a Quality Indicator in GCC Hospitals ▼

JCI-accredited hospitals in the GCC (a large proportion of major GCC hospitals hold JCI accreditation) track CAUTI rates as a core quality and patient safety indicator. Many GCC institutions participate in national infection surveillance programmes (e.g., Saudi MOH HAI Surveillance, DHA infection control reporting). Nurses are accountable for documenting catheter indication daily and challenging unnecessary catheters at ward rounds.

Hajj Medical Centres & Catheter Management ▼

During Hajj, hundreds of thousands of pilgrims with serious medical conditions — including post-stroke neurogenic bladder, BPH, and spinal cord disease — require catheter management in field hospitals. Nurses must be competent in catheterisation in resource-limited environments. Clean technique may be necessary when strict sterile conditions are not available; CAUTI prevention remains paramount.

MCQ Practice — Urinary Catheterisation

Q1. You are catheterising a male patient and meet resistance advancing the catheter. The correct action is:

A) Apply more force to advance past the obstruction

B) Inflate the balloon with 5 mL to check position

C) Stop advancing, withdraw the catheter, and seek senior/urology advice

D) Use a larger catheter to dilate the stricture

✅ C — Resistance indicates possible urethral stricture, enlarged prostate, or false passage. Forcing the catheter risks urethral rupture. Stop, withdraw, and seek urology. A Coudé catheter or flexible cystoscopy may be needed.

Q2. Which single action has the greatest impact on reducing CAUTI rates?

A) Daily antiseptic meatal cleaning

B) Using silver-coated catheters for all patients

C) Removing the catheter as soon as it is no longer clinically indicated

D) Routine catheter bag changes every 48 hours

✅ C — The most effective CAUTI prevention strategy is early removal of unnecessary catheters. Every day a catheter remains increases infection risk by ~5%. Daily review of catheter necessity is mandatory. Antiseptic cleaning has no evidence of benefit.

Q3. After inserting an indwelling urethral catheter in a male patient, the balloon is inflated before urine drains. The patient cries out in severe pain. What has likely occurred?

A) Urinary tract infection

B) Bladder spasm — normal finding

C) Balloon inflated in the urethra causing urethral trauma/rupture

D) Paraphimosis

✅ C — The balloon must NEVER be inflated until urine is draining freely, confirming the catheter tip is in the bladder. Inflating in the urethra causes severe pain and urethral injury/rupture. Deflate immediately and seek urgent urology review.

Q4. What fluid is used to inflate the catheter balloon, and why NOT saline?

A) 10 mL tap water — saline is too hypertonic

B) 10 mL sterile water — saline can crystallise and block the deflation valve

C) 10 mL 0.9% NaCl — preferred to reduce osmotic damage

D) 10 mL air — reduces pressure on the bladder wall

✅ B — Sterile water (not saline) is used to inflate catheter balloons. Saline can form crystals inside the balloon valve, making deflation impossible and requiring catheter cutting/cystoscopy for removal. Never use air — risk of balloon rupture.

Urinary Catheterisation — Nursing Guide