Urinary Catheterisation: Consent, Asepsis and Knowing When Not To

Catheterisation is delegated to interns constantly and questioned rarely. The most useful thing you can bring to the request is the question of whether it is needed at all, because catheter-associated urinary tract infection is among the commonest healthcare-associated infections and the risk accumulates daily.

At a glance

Is it actually indicated?

Reasonable indications include acute urinary retention, bladder outlet obstruction, accurate output measurement in a patient who genuinely requires it, perioperative use for defined procedures, healing of sacral wounds in an incontinent patient, and comfort in end-of-life care.

Incontinence on its own is not an indication. Neither is making nursing observation easier, nor avoiding the effort of assisted toileting. Those are the requests worth politely questioning, and the question is usually welcomed rather than resented.

When you do insert one, record the indication and a review date. A catheter with neither tends to stay in until someone notices it weeks later.

When not to attempt at all

If there is any suspicion of urethral injury — significant pelvic trauma, blood at the urethral meatus, an abnormal prostate position on examination, or extensive perineal bruising — do not attempt catheterisation. Escalate. Passing a catheter through an injured urethra can convert a partial injury into a complete one with long-term consequences.

Also stop and escalate if there is a known urethral stricture, a recent urological operation, or if you meet resistance you cannot overcome gently.

How it is done

1. Explain fully and obtain consent. This is an intimate procedure and consent is not a formality — explain what will happen, that it will be uncomfortable, and that they can ask you to stop.
2. Offer a chaperone and record who was present. This protects the patient and it protects you.
3. Ensure privacy and adequate positioning and lighting before you open anything.
4. Prepare a sterile field and use aseptic technique throughout — this is where infection is prevented or introduced.
5. Clean the meatus and surrounding area according to your local policy.
6. Instil the local anaesthetic lubricant supplied and allow it the contact time on the packaging. Skipping this makes the procedure painful and more traumatic.
7. Advance the catheter gently. In men, expect increased resistance at the prostatic urethra; ask the patient to breathe out and maintain steady gentle pressure rather than force.
8. Wait for urine to drain. Do not inflate the balloon before you see it.
9. In men, advance to the hilt before inflating, because the balloon inflated in the urethra causes serious injury.
10. Inflate with the volume stated on the catheter, using the fluid specified by the manufacturer.
11. Withdraw gently until slight resistance is felt, attach the drainage system, and position the bag below bladder level without letting it touch the floor.
12. In men, reposition the retracted foreskin. Failure to do this causes paraphimosis, and it is a genuinely common omission.
13. Document type, size, batch, balloon volume, residual volume, indication, review date, and who was present.

What can go wrong

What seniors actually ask

• What is the indication, and is it documented?
• When is it due to come out?
• Did you replace the foreskin?
• What was the residual volume?

Last-minute checklist

• Indication documented; review date set
• Chaperone offered and recorded
• Suspected urethral injury means do not attempt — escalate
• Anaesthetic lubricant given its contact time
• Never inflate before urine drains; in men advance to the hilt first
• Foreskin replaced
• Bag below bladder level, off the floor
• Residual volume documented

References

• Your hospital’s catheter insertion and infection prevention policy
• Manufacturer’s instructions for the specific catheter