Clinical medicine from the New England Journal of medicine

urethral catheterization from its direct drainage of the urinary bladder and is often performed in
pediatric practice it may be used for diagnostic purposes such as collection of an uncontaminated urine
specimen for culture and urinalysis when it is essential to obtain a urine specimen from a young child
who can avoid on command urethral catheterization also may be performed to carry out voiding sister
ography or to monitor urine output in certain postoperative patients or very ill patients therapeutic
indications include decompression of acute urinary retention intermittent catheterization of neurogenic
bladder continuous bladder irrigation for the removal of blood and clots and Drug Administration this
video shows a diagnostic urethral catheterization in a male infant using a catheter without a balloon
urethral catheterization should be avoided in patients with suspected traumatic injury to the lower
urinary tract suspect this type of injury in patients with pelvic oh straddle type injury hearing Neil
hemant oma or blood at the meatus should increase your suspicion that such an injury might be present
avoid urinary catheterization in patients With no major anatomic malformations of the lower urinary
tract or recent urethral or bladder neck reconstruction in addition be certain that there is no history of
latex allergy as many gloves and catheters are manufactured from latex there are two types of catheters
straight catheters and balloon are Foley catheters straight catheters are soft single lumen catheters that
are most often made of polyvinyl chloride or PVC they are used in the collection of uncontaminated
urine for diagnostic purposes and in patients with neurogenic bladder who need intermittent
catheterization a balloon catheter consists of a double or triple lumen tube with an expandable balloon
at the distal end when expanded the balloon secures the catheter in the bladder balloon catheters are
often made of latex or silicone and are generally used when the catheter must remain in the bladder As
for close monitoring of urine output for prevention or relief of an obstruction for continuous irrigation of
the bladder or occasionally when complete filling of the bladder is necessary As for imaging of the
urinary tract the choice of the catheter depends on the size of the urethra and generally on the age of
the child appropriate sizes range from four to six French in newborns 6 to 8 French in infants 10 to 12
French in prepubertal children end up to 14 French in adolescents although some clinicians substitute
appropriately sized feeding tubes for urethral catheterization and infants feeding tubes should not be
used if the length of insertion is excessive there is a risk that intravesical knotting of the feeding tube
may occur this complication impedes catheter removal the anatomy of the male infant or child is similar
to that of the male adult except for the obvious differences in size and lack of secondary sexual
characteristics the male urethra has an S shaped curve behind the synthesis pubis after it crosses the
external sphincter the urethra enters the bladder the urethra meatus is easier to locate when the
glances visible it may be more difficult to locate in uncircumcised newborns or young boys with a tight
foreskin gentle retraction of the foreskin can help to visualize the meatus gather the necessary
equipment you will need sterile water or saline and so sterile gauze pads and towels and absorbent
underpad sterile and non sterile gloves you will also need a 10ML prefilled syringe with sterile lubricant
gel with or without 2% lidocaine antiseptic solution containing chloro hexagon or providone iodine and
appropriately sized urethral catheter and a sterile urethral catheterization kit the kit contains at least
one sterile fenestrated drape swaps for cleansing 2 specimen collection cups one for collecting the urine
and one for holding the equipment two additional four steps may be used one for holding a swab to
disinfect the genitalia and one for manipulating the catheter you will also need appropriate containers
for urinalysis or culture before you begin describe the anatomy in the procedure and its benefits risks
and complications to the parents or caregivers and to patients old enough to understand ask about any
latex allergies and about iodine allergies if you are using providone iodine also determine whether
urethral catheterization has been performed or attempted previously place the patient in the supine
frog leg position with knees flexed ask an assistant to hold the legs firmly in this position which permits
adequate stabilization of the pelvis and complete visualization of the external genitalia wearing non
sterile gloves place the absorbent underpad with the plastic side down and meets the patients buttocks
watch the external genitalia with soap and water using the gauze rinse with clean water and dry the skin
with a hand towel dispose of the non sterile gloves wash and disinfect your hands place the sterile
urethral catheterization kit on a tray open the inner paper wrapping to form a sterile field remove two
of the sterile swabs from the cup one will be used for the application of the lubricant gel on the catheter
and the other will serve to hold the penis during the procedure open the Chlorhexidine or iodine
disinfectant solution and pour it over the sterile swabs open a sterile 10ML syringe prefilled with
lubricant gel and open a sterile catheter placed them on the sterile field disinfect your hands and put on
sterile gloves lubricate the distal end of the catheter with sterile gel using a sterile swab prepare the
entire genital area by cleansing three times going from the center to the periphery using an antiseptic
agent then place the sterile fenestrated drape over the patient so that the penises accessible through
the opening remove your gloves and put on another pair of sterile gloves use your non dominant hand
to hold the penis at a 90 degree angle to the patients legs gently retract the foreskin if present a
physiologic phimosis is frequently present during childhood and the foreskin should never be forced to
retract use the non dominant hand to hold the penis throughout the procedure it is considered non
sterile with your dominant hand watch the urethral meatus three times using antiseptic soap cotton
swabs at many pediatric centers lubricant gel is placed on the catheter before the procedure is
performed at some centres clinicians also insert lubricant into the urethra place the catheter in the
sterile container within the sterile field between the patients legs the entire procedure can be done
using your fingers or four steps with your dominant hand first we will demonstrate the procedure when
using four steps while holding the penis in a vertical position slowly and gently insert the tip of the
catheter into the urethra meatus slowly advance it into the bladder the other end of the catheter should
remain in the container you may encounter resistance near the base of the penis because of the
anatomic curving of the urethra gently pulled the penus rust early to overcome the resistance you may
feel resistance again because of the contraction of the external bladder sphincter you can overcome this
by maintaining traction on the penis while applying gentle but continuous pressure with a catheter
never force the catheter through the urethra as this may cause trauma or even perforation after the
catheter has entered the bladder urine should drain through it into the container when urine flow has
ceased remove the catheter and sending urine for culture and urinalysis if a foreskin is present gently
pulled it back over the glans to prevent the development of a paraphimosis we will now show the
insertion technique without the use of forceps after finishing a sterile prep in positioning the child hold
the lubricated catheter with the fingers of your dominant hand inserted through the urethra and into
the bladder using the same technique as previously demonstrated if catheterization via the urethra
meatus is unsuccessful in an uncircumcised boy and if you and must be obtained directly from the
bladder consider suprapubic aspiration provided that the bladder is full and you are experienced in
performing the procedure this procedure will not be demonstrated here it should not be attempted
without previous instruction if there is insufficient return of urine massage the suprapubic region with
gentle pressure to increase urine flow if there is no urine return remove the catheter and describe
properly consider whether the procedure should be attempted with a catheter that is different in size or
flexibility if the catheterization was down to verify that a child has an area and no urine is obtained be
sure to consider whether and how much hydration is indicated before reattempting the procedure
although rare complications of urethral characterization may occur immediate complications may
include gross or microscopic material creation of false passages or offering fistula with urethral
perforation long term complications such as urethral strictures may also occur a paraphimosis may be
caused by failure to replace the foreskin in its normal position after catheterization in addition yatra
genic confection may occur if aseptic conditions are not adequate