Catheterization, Female

Definition
Purpose
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

Urinary catheterization is the insertion of a catheter through the urethra into the urinary bladder for withdrawal of urine. Straight catheters are used for intermittent withdrawals, while indwelling (Foley) catheters are inserted and retained in the bladder for continuous drainage of urine into a closed system.

Purpose

Intermittent catheterization is used for the following reasons:

• Obtaining a sterile urine specimen for diagnostic evaluation.
• Emptying bladder contents when an individual is unable to void (urinate) due to urinary retention, bladder distention, or obstruction.
• Measuring residual urine after urinating.
• Instilling medication for a localized therapeutic effect in the bladder.
• Instilling contrast material (dye) into the bladder for cystourethralgraphy (x-ray study of the bladder and urethra).
• Emptying the bladder for increased space in the pelvic cavity to protect the bladder during labor and delivery or during pelvic and abdominal surgery.
• Monitoring accurately the urinary output and fluid balance of critically ill patients.

Indwelling catheterization is used for the following reasons:

• Providing palliative care for incontinent persons who are terminally ill or severely impaired, and for whom bed and clothing changes are uncomfortable.
• Managing skin ulceration caused or exacerbated by incontinence.
• Maintaining a continuous outflow of urine for persons undergoing surgical procedures that cause a delay in bladder sensation, or for individuals with chronic neurological disorders that cause paralysis or loss of sensation in the perineal area.
• Keeping with standard preoperative preparation for urologic surgery and procedures for bladder outlet obstruction.
• Providing relief for persons with an initial episode of acute urinary retention, allowing the bladder to regain its normal muscle tone.

Description

The female urethral orifice is a vertical, slit-like, or irregularly ovoid (egg-shaped) opening, 0.16-0.2 in (4–5 mm) in diameter, located between the clitoris and the vagina. The urinary meatus (opening) is concealed between the labia minora, which are the small folds of tissue that need to be separated to view the opening and insert a catheter. With proper positioning, good lighting, and gloved hands, these anatomical landmarks can be identified. Perineal care or cleansing may be required to ensure a clean procedural environment.

Catheterization of the female patient is traditionally performed without the use of local anesthetic gel to facilitate catheter insertion. But since there are no lubricating glands in the female urethra (as are found in the male urethra), the risk of trauma from a simple catheter insertion is increased. Therefore, an ample

supply of an anesthetic or antibacterial lubricant should be used.

Once the catheter is inserted, it is secured as appropriate for the catheter type. A straight catheter is typically secured with adhesive tape. An indwelling catheter is secured by inflating a bulb-like device inside of the bladder.

Diagnosis/Preparation

Healthcare practitioners performing the catheterization should have a good understanding of the anatomy and physiology of the urinary system, be trained in antiseptic techniques, and have proficiency in catheter insertion and catheter care.

After determining the primary purpose for the catheterization, practitioners should give the woman to be catheterized and her caregiver a detailed explanation. Women requiring self-catheterization should be instructed and trained in the technique by a qualified health professional.

Sterile disposable catheterization sets are available in clinical settings and for home use. These sets contain most of the items needed for the procedure, such as antiseptic agent, perineal drapes, gloves, lubricant, specimen container, label, and tape. Anesthetic or antibacterial lubricant, catheter, and a drainage system may need to be added.

Catheter choices

TYPES. Silastic catheters have been recommended for short-term catheterization after surgery because they are known to decrease incidence of urethritis

KEY TERMS

Catheter— A tube for evacuating or injecting fluid.

Contaminate— To make an item unsterile or unclean by direct contact.

Foley catheter— A double-channel retention catheter; one channel provides for the inflow and outflow of bladder fluid, the second (smaller) channel is used to fill a balloon that holds the catheter in the bladder.

Incontinence— The inability to retain urine or control one’s urine flow.

Intermittent catheterization— Periodic catheterization to facilitate urine flow.

Perineal area— The genital area between the vulva and anus in a woman.

Urethra— The tube that allows passage of urine out of the urinary bladder.

Urethritis— Inflammation of the urinary bladder.

Urinary retention— The inability to void (urinate) or discharge urine.

Septicemia— An infection in the blood.

(inflammation of the urethra). However, due to lower cost and acceptable outcomes, latex is the catheter of choice for long-term catheterization. Silastic catheters should be reserved for individuals who are allergic to latex products.

Additional types of catheters include:

• PTFE (plastic)-coated latex indwelling (Foley)catheters
• hydrogel-coated latex indwelling catheters
• pure silicone indwelling catheters
• silicone-coated latex indwelling catheters

SIZE. The diameter of a catheter is measured in millimeters. Authorities recommend using the narrowest and softest tube that will serve the purpose. Rarely is a catheter larger than size 18 F(rench) required, and sizes 14 or 16 F are used more often. Catheters greater than size 16 F have been associated with patient discomfort and urine bypassing. A size 12 catheter has been successfully used in children and in female patients with urinary restriction.

DRAINAGE SYSTEM. The healthcare provider should discuss the design, capacity, and emptying mechanism of several urine drainage bags with the patient. For women with normal bladder sensation, a catheter valve for intermittent drainage may be an acceptable option.

PROCEDURE. When inserting a urinary catheter, the healthcare provider will first wash the hands and put on gloves and clean the skin of the area around the urethra. An anesthetic lubricating gel may be used. The catheter is threaded up the urethra and into the bladder until the urine starts to flow. The catheter is taped to the upper thigh and attached to a drainage system.

Aftercare

Women using intermittent catheterization to manage incontinence may require a period of adjustment as they try to establish a catheterization schedule that is adequate for their normal fluid intake.

Antibiotics should not be prescribed as a preventative measure for women at risk for urinary tract infection (UTI). Prophylactic use of antibacterial agents may lead to the development of drug-resistant bacteria. Women who practice intermittent self-catheterization can reduce their risk for UTI by using antiseptic techniques for insertion and catheter care.

The extended portion of the catheter should be washed with a mild soap and warm water to keep it free of accumulated debris.

Risks

Complications that may occur include:

• Trauma or introduction of bacteria into the urinary system, leading to infection and, rarely, septicemia.
• Trauma to the urethra or bladder from incorrect insertion or attempting to remove the catheter with the balloon inflated; repeated trauma may cause scarring or stricture (narrowing) of the urethra.
• Passage of urine around the catheter; inserting a different catheter size can minimize this problem.

Sexual activity and menopause can also compromise the sterility of the urinary tract. Irritation of the urethra during intercourse promotes the migration of perineal bacteria into the urethra and bladder, causing UTIs. Postmenopausal women may experience more UTIs than younger women. The presence of residual urine in the bladder due to incomplete voiding provides an ideal environment for bacterial growth.

Urinary catheterization should be avoided whenever possible. Clean intermittent catheterization, when practical, is preferable to long-term catheterization.

Catheters should not be routinely changed. Before the catheter is changed, each woman should be monitored for indication of obstruction, infection, or

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Urinary catheterization can be performed by healthcare practitioners, by home caregivers, or by women themselves in hospitals, long-term care facilities, or personal homes.

complications. Some women require weekly catheter changes, while others may need one change in several weeks. Fewer catheter changes will reduce trauma to the urethra and reduce the incidence of UTI.

Because the urinary tract is normally a sterile system, catheterization presents the risk of causing a UTI. The catheterization procedure must be sterile, and the catheter must be free from bacteria.

Frequent intermittent catheterization and long-term use of indwelling catheterization predisposes a woman to UTI. Care should be taken to avoid trauma to the urinary meatus or urothelium (urinary lining) with catheters that are too large or inserted with insufficient use of lubricant. Women with an indwelling catheter must be reassessed periodically to determine if alternative treatment will be more effective in treating the problem.

Normal results

A catheterization program that includes correctly inserted catheters and is appropriately maintained will usually control urinary incontinence.

The woman and her caregiver should be taught to use aseptic technique for catheter care. Nursing interventions and patient education can make a difference in the incidence of urinary tract infections in hospitals, nursing homes, and home care settings.

The sexuality of a woman with an indwelling catheter for continuous urinary drainage is seldom considered. If the patient is sexually active, the practitioner must explain that intercourse can take place with the catheter in place. The woman and her partner can be taught to remove the catheter before intercourse and replace it with a new one afterwards.

Morbidity and mortality rates

Injuries resulting from catheterization are infrequent. Deaths are extremely rare. Both complications are usually due to infections that result from improper catheter care.

QUESTIONS TO ASK THE DOCTOR

• Will the catheterization be intermittent or indwelling?
• Who will change the catheter and how long will it remain in place?
• Who will teach me or my caregiver how to insert and remove the catheter, monitor it, and perform routine care?

Alternatives

An alternative to catheterization is to use a pad to absorb voided urine.

Resources

BOOKS

Altman, M. Urinary Care/Catheterization. Albany, NY: Delmar, 2003.

Brenner, B. M., et al. Brenner & Rector’s The Kidney. 7th ed. Philadelphia: Saunders, 2004.

Gearhart, John P. Pediatric Urology. Totawa, NJ: Humana Press, 2003.

Wein, A. J., et al. Campbell-Walsh Urology. 9th ed. Philadelphia: Saunders, 2007.

PERIODICALS

Johnson, J. R. “Safety of Urinary Catheters.” Journal of the American Medical Association 289(3) (2003): 300–301.

Munasinghe, R. L., V. Nagappan, and M. Siddique. “Urinary Catheters: A One-point Restraint?” Annals of Internal Medicine 138(3) (2003): 238–239.

Wilde, M. H., and B. L. Cameron. “Meanings and Practical Knowledge of People with Long-term Urinary Catheters.” Journal of Wound Ostomy Continence Nursing 30(1) (2003): 33–43.

Winder, A. “Intermittent Self-catheterisation.” Nursing Times 98(48) (2002): 50.

ORGANIZATIONS

American Board of Urology. 2216 Ivy Road, Suite 210, Chaarlottesviille, VA 22903. (434) 979-0059. http://www.abu.org (accessed March 10, 2008).

American Foundation for Urologic Disease. 1128 North Charles Street, Baltimore, MD 21201. (800) 242-2383. http://www.afudfoundation.org/ (accessed March 10, 2008).

American Urological Association. 1120 North Charles Street, Baltimore, MD 21201. (410) 727-1100. http://www.auanet.org/ (accessed March 10, 2008).

National Health Service of Great Britain. http://www.nhsdirect.nhs.uk/ (accessed March 10, 2008).

National Kidney and Urologic Diseases Information Clearinghouse. 3 Information Way, Bethesda, MD 20892. (800) 891-5390. http://www.niddk.nih.gov (accessed March 10, 2008).

OTHER

Advance PCS. [cited February 28, 2003] http://www.buildingbetterhealth.com/topic/topic100587629 (accessed March 10, 2008).

Harvard Pilgrim Health Care. [cited February 28, 2003] http://www.intelihealth.com (accessed March 10, 2008).

Wayne State University. [cited February 28, 2003] http://www.dmc.org (accessed March 10, 2008).

L. Fleming Fallon, Jr, MD, DrPH