How to catheterise a male.

How to catheterise a male:

  1. Find the penis.
  2. Stick it in.

Actually, it is a little more complicated that that.

The normal male urethra leaves the bladder at the trigone. It then passes through the prostate, burrows its way down the length of the penis and emerges at the tip of the glans.

Note: insertion of a catheter is contraindicated in the presence of urethral injuries. Look for blood at the meatus, presence of scrotal haematoma or suspected pelvic fractures. If these are present do not proceed.

Equipment selection:

Assemble catheterisation equipment as per your hospital policy.
Usually this will include:

  • a catheterisation pack
  • a 14 – 18 Fr  Foley catheter
  • a catheter bag
  • saline solution
  • sterile gloves
  • lignocaine gel
  • a 10ml sterile water-filled syringe
  • drainage bag

How do I select the best catheter size?
The best way to do this is to inspect the patients urinary meatus prior to beginning the procedure.

Too big and you risk causing erosion of the bladder neck and urethral mucosa. This can also lead to stricture formation and restrict drainage of the peri-urethral gland secretions. Take care with selecting sizes 18fr or bigger.

Too small and you may find urine will simply flow around the catheter resulting in a wet bed.

You also need to consider type of drainage bag. If you patient is clinically unwell an ‘hourly measure’ bag should be used.

“As catheterisation is an intimate procedure, the psychsocial effects should always be considered. I would advise all nurses to explain the procedure well to all patients, then assess if a second nurse should be present. Our patients have diverse feelings about what’s appropriate. Transcultural nursing should encompass these differences” — @DamianHurrell (Nurse)

Take time to prepare the patient and equipment.
Allow plenty of time (3min) for Lignocaine gel to work before inserting catheter.
Hold penis at 90 deg when inserting catheter.
Do not insert if blood at meatus, scrotal haematoma or trauma to pelvis.
Seek guidance if recent urological surgery.

Positioning the patient:

Position the patient laying comfortably on his back with legs slightly apart.

Perform a thorough hand wash and then don sterile gloves.

Most catheterisation kits contain a second pair of sterile gloves to place over the first pair. You can then remove the outer pair once you have swabbed the site.

Swab the shaft of the penis with saline soaked gauze.
Take the penis in your non-dominant hand and gently retract the foreskin if they have one (around 1 in 6 males worldwide are circumcised).
Swab the glans… and swab around the urethral meatus.

Discard used swabs into the bin you have placed close by.

Carefully remove your outer gloves.
Pick up the sterile fenestrated towel or drape.
Rather than having the penis poking through the hole in the towel, I prefer to fold it in half ( the towel, not the penis ) forming a slot that can then be slid toward the penis from below. The penis then flops down onto the sterile field.

Catheter insertion:

OK. Let us proceed.

Grasp the penis just below the glans with the thumb and first finger of your non-dominant hand.
Lift it upwards, perpendicular to the abdomen.
This straightens out the urethra, which normally follows a sort of ‘S’ trajectory in a flaccid penis.

Inform the patient that this next bit is going to feel a little weird. And a little cold.
Using the applicator syringe, slowly squirt the entire contents of Xylocaine jelly (around 10 mls) into the urethra.

Tip: Do not pick up the syringe and say, “I am just going to inject some local anaesthetic into your penis!” Your patient may think you are about to stick a giant needle into their willy and have a cardiac arrest.

Once the urethra has been filled with anaesthetic jelly, squeeze it closed by applying pressure just below the glans with your thumb and finger (to stop the gel oozing out).

The big mistake here is to attempt to pass the catheter before the anaesthetic gel has had time to take effect. This is painful, causing the patient to tense-up and increase resistance to the passage of the catheter.
Local takes around 3 minutes to work properly, although that may seem like a long time making polite conversation with your patient whilst holding his penis in your hand. So at least wait a bit.

Now, lift across the catheter in its tray, and lay it on the sterile field.
Pick up the catheter with your dominant hand while your other hand re-applies gentle traction, lifting the penis back to attention (90 degrees).
Insert the tip of the catheter into the urethral meatus and advance it cautiously down the urethra, feeding it from the tray so as not to contaminate it.

There are 2 potential roadblocks to a smooth catheterisation.
The first is the external sphincter and the second is the prostate.
If resistance is felt, ask the patient to try and relax and take a few deep breaths. Try to advance gently with a rotation movement as the patient exhales. Or you could try asking him to give a few coughs.

If there is still resistance, you can gently apply a little more traction to the penis and push a little more firmly….but that’s about it.
If the catheter will still not advance you should remove it, try again with a slightly smaller (or larger) size or notify the medical officer.

Once the catheter advances smoothly, continue to feed it in.
I usually pass it all the way up to just below the ballon port. You want to make sure that you are not about to blow the balloon up in your patients urethra.

No urine flow?

Do not be alarmed if there is not an immediate flow of urine from the catheter. All that anaesthetic jelly tends to clog the end of the catheter and it may take a minute or so before it ‘melts’.

To encourage flow, you can perform what is known as Crede’s Manoeuvre by applying gentle pressure with the palm of your hand just below the navel.
Alternatively you can use a sterile bladder syringe to gently aspirate on the catheter.
Do not inflate the catheter balloon until you are confident that it is within the bladder.

Once urine flows.

Keep the sterile dish that you had the catheter in close by to catch the initial flow of urine (you may want to perform a urinalysis on this).

Inflate the balloon with 10mls of sterile water and connect the catheter to the drainage bag. Once the balloon is inflated, you can gently pull the catheter back until resistance is felt. Place the drainage bag below the level of the bladder.

Catheter security and clean-up.

Secure the catheter to the patient as per your hospital policy and clean up.
Where should you secure the catheter?

Be sure you roll the foreskin back over the glans if you pulled it back during swabbing, to prevent a swelling and constriction known as paraphimosis which could, if left untreated, lead to gangrene of the penis.

Remove drapes. Take care to clean up all the anaesthetic gel that usually spills around the penis. Cover your patient and make them comfortable.

Documentation:

Clean up the whole area, and document your procedure in the nursing notes including:

  • Date and time.
  • confirmation that consent was obtained.
  • size and type of catheter
  • Volume of water in balloon.
  • indication for inserting the catheter.
  • residual amount of urine drained.
  • appearance of the urine (e.g. straw coloured, dark, haematuria)

References:

  1. Urethral Catheterisation (Male) OSCE Station Guide. (n.d.). Retrieved June 16, 2015, from http://www.osceskills.com/e-learning/subjects/urethral-catheterisation-male/
  2. Urinary Catheter Insertion. (n.d.). Retrieved June 16, 2015, from http://www.med.uottawa.ca/procedures/ucath/

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