Chapter 25 · Acute lower urinary tract conditions
Bladder catheterization and difficult catheterization
General principles
Catheterization is the most common urological procedure. In an emergency, key considerations are:
- appropriate catheter selection;
- insertion technique;
- recognition of difficult cases.
Catheter selection
| Catheter type | Indication |
|---|---|
| Nelaton (straight) | Short-term catheterization in men |
| Foley (balloon) | Long-term drainage, hemostasis |
| Three-way Foley | Irrigation for clot retention |
| Tiemann (curved tip) | BPH, prostatic obstruction; not a universal solution for strictures |
| Coudé (angled tip) | BPH, prostatic obstruction, difficult anatomy |
Catheterization technique
- Hand hygiene, aseptic technique, sterile equipment, and maintenance of a closed drainage system.
- Generous lubrication.
- Incremental advancement.
- Immediately stop a blind attempt if there is marked resistance, sharp pain, urethral bleeding, or a suspected false passage.
- After failure, involve an experienced operator; use guidewire-assisted or visually controlled access, or suprapubic drainage as indicated.
Difficult catheterization
Situations:
- urethral stricture;
- BPH;
- false passage;
- traumatic injury.
Management:
- guidewire-assisted access by an experienced specialist, preferably under endoscopic guidance;
- urethrocystoscopy with catheter placement under direct vision;
- suprapubic cystostomy when safe transurethral access is impossible and no contraindications are present.
Complications of catheterization
- Infection.
- Urethral trauma.
- False passage.
- Bladder perforation.
- Balloon injury (inflation of the balloon in the urethra).
Algorithm
| Step | Action |
|---|---|
| 1 | Assess for BPH, stricture, previous surgery, and signs of urethral trauma |
| 2 | Select a catheter and make one gentle attempt without force |
| 3 | Stop blind attempts if there is pain, blood, marked resistance, or a suspected false passage |
| 4 | Involve an experienced operator; use guidewire-assisted or endoscopic access |
| 5 | Consider suprapubic cystostomy if safe transurethral access is impossible |
| 6 | Connect a closed system; document the device, urine output, and follow-up plan |
Cross-references: Chapters 11, 44, 54, and 57.
Infection control
- Insert a catheter only for a justified indication and remove it as soon as it is no longer needed.
- Obtain urine for culture aseptically from the designated sampling port after disinfection, not from the collection bag.
- If the system is breached, obstruction develops, or symptomatic infection occurs, assess the need for device replacement and obtain a culture before antibiotics, provided this does not delay treatment.
- Record the insertion date, indication, size, complications, and removal plan in the medical record and device register.