Tips & Tricks

Male Urethral Catheter Instillation5,6,7

A few points to remember5

  • Choose the easiest side of the bed to catheterize from. If you are right-handed the best place to be is on the patient’s right side. If you are left-handed, then choose the left side.
  • Use lubricating gel. Inject at least 10-20 mL of a 2% lidocaine lubricating gel, or plain urethral lubricating gel into the urethra to distend and facilitate the passage of the catheter and reduce the risk of pain and injury. The average volume of the male urethra is 20 mL so 20 mL may be better.
  • Ask the patient to breathe deep and slowly and try to relax the pelvic to help the catheter pass the urethral sphincter.
  • In men lift the penis up to about a 30° angle by holding the sides so as to not compress the urethra to which will help reduce the angle between the posterior and prostatic urethra and help ease the passage of the catheter through the urethral sphincter. If it is known that there is a vey large prostate, then the angle of the penis may have to be increased from 30° up to as much as 60°.

Tips & Tricks for Male Urethral Catheter Instillation5,6,7

Difficulties in inserting a catheter in a male may arise from a number of conditions: urethral stricture disease, BPH, prostate cancer, bladder neck contractures or elevation, edema, phimosis, obesity or anatomical injuries caused by instrument passage, false passage, surgery or other urological interventions. The severity of injury that can be caused to a patient by a difficult urinary catheterization (DUC) is often underestimated.

Before attempting, take a detailed urological history and physical examination to identify any prior surgical or instrument interventions, trauma or infections that could create a challenge to catheter placement. Studies reported one of the more common tips to minimize urethral trauma and make catheter insertion easier is to ensure sufficient lidocaine gel is used, at least 10-20 mL for a male. Urologists often add more gel before they attempt a repeated insertion

 

Leon-Mata et al, 2018

BPH6,7

Use of a Coudé tip catheter will usually get past the prostate. Using your non-dominant hand, hold the penis at 30° to the body then apply traction to the penis to straighten the urethra. Then instill 20mL of 2% lidocaine jelly into the urethra. This will inflate the urethra and lubricate and anesthetize the lining. The jelly will now be opening the urethra, creating a pathway for the catheter to follow. 

  • Using a 16 French Coudé catheter in the dominant hand, the catheter is gently fed into the bulbous urethra while gently pulling the penis towards the feet to further straighten the urethra. 
  • Sometimes a gentle back-and-forth twisting motion of the catheter may help. Heavy pressure should be avoided since it is more likely to cause bleeding and the formation a false passage.
  • Larger prostates may require holding the penis at an angle greater than 30° up to 60° to provide a straighter angle for entry. Sometimes light upward pressure on the perineum may reduce the angle between bulbar and prostatic urethra.
  • If the first attempt with the 16 French Coudé can’t pass the bulbar urethra, repeat the steps with an 18 French Coudé. Always insert the catheter to the bifurcation of the Y hub to ensure the catheter has reached the bladder

Penile Edema6

To reduce the swelling an elastic compression wrap should be used to apply continuous compression on the penis. Place a gauze pad around the penis before applying the compression wrap. Reduction of the edema should be apparent in 20 minutes. This should now provide visualization of the urethral meatus for catheter insertion.

Phimosis6,7

You only need to get the urethral meatus exposed in order to catheterize. If obscured by a tight foreskin, try placing hands on the fat next to the penile shaft then pressing downward to gently pull open the foreskin and expose the urethral meatus.

  • Another approach is to grasp the foreskin and pull the foreskin from the left and right sides outwards. This should open the foreskin and allow the urethral meatus to be seen and a coude catheter inserted.
  • If this doesn’t work, try passing the coude catheter through the phimosis and enter the meatus by touch knowing the opening in the glans is in the middle just below the midline. If these methods fail, then a dorsal slit in the foreskin may be required.
  • An additional alternative is the use of a vaginal speculum to see through to the meatus.

Obese Males – Buried or Hidden Penis6,7

Have an assistant to press down firmly around the base of the penis with both hands which makes the penis visible so a catheter can be inserted.

  • Try a flexible cystoscope, which is inserted into the opening leading to the penis to allow visualization of the foreskin or glans and meatus. Then a guide wire can be passed into the urethra via the cystoscope followed by a catheter
  • Alternatively, use a laryngoscope to see the glans and urethral meatus which allows direct catheterization with a catheter.

Strictures5,6,7

The urethral meatus and the fossa navicularis just inside the glans are two common sources of strictures. If the meatus is visibly narrowed, gentle dilation may open it so a catheter may be inserted. Dilation is often best managed with metal dilators that are graduated in diameter. This is when a generous amount of 2% lidocaine lubricating jelly should be used since it will help dilate the meatus slowly and gently and provide anesthesia.

  • Using the largest dilator that will fit, slowly advance it into the urethra towards the distant penile urethra. 
  • Hold the dilator in place for at least 20 seconds while the tissue accommodates. 
  • Remove and continue gradual increase in dilator size until the urethra can accommodate a dilator 2 sizes larger than the catheter you want to place.
  • Now using gentle traction on the penis, pulling it towards the feet to help straighten the natural curve, slowly advance the catheter into the bladder. 
  • The patient should be asked to relax the area and take slow deep breaths to help relax the urethra as the catheter travels. 
  • Usually, a 16 or 18 Foley or Coudé Foley works for most men.

High bladder neck position5

Use of a Coudé tipped catheter may enable it to pass the elevated lip located at the 6 o’clock position: keep the curved tip pointing up and insert. If it can’t be passed, pull it back a few cm, rotate it a quarter turn, (3 or 9 o’clock position), then reinsert.

3-Hand Catheterization Technique5

Two people are needed, with one person holding their finger in the rectum and pressing on the prostate to elevate it . Simultaneously you apply traction to the penis to straighten out the urethra and the insert the Coudé.

Click here for Tips & Tricks on Female Urethral Catheter Instillation

References for Tips & Tricks

  1. Carlos Villanueva, George P. Hemstreet III, Difficult Male Urethral Catheterization: A Review of Different Approaches, International Braz J Urol, Vol 34 (4):401;412, July-August, 2008, https://www.scielo.br/j/ibju/a/n6MzhTpdSCWHpJTvc7JWMbb/ 
  2. Bacsu, Chasta et al, A prospective analysis of consultation for difficult urinary catheter insertion at tertiary care centres in Northern Alberta, CUAJ Sept-Oct 2013 Vol 7, issues 9-10,  https://cuaj.ca/index.php/journal/article/view/574
  3. Paul Willette and Scott Coffield, Current Trends in the Management of Difficult Urinary Catheterizations, Western J of Emergency Medicine, vol XIII, no 6 Dec 2012 p 472-478  doi: 10.5811/westjem.2011.11.6810    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3555603/
  4. Mario Gardi et al, The Challenge of Difficult Catheterization in Men: A Novel Technique and Review of the Literature, UroToday Int J. 2013 August;6(4):art 53. http://dx.doi.org/10.3834/uij.1944-5784.2013.08.12
  5. Leon-Mata et al. Tips and Tricks for Difficult Urethral Catheterization. International Annals of Medicine. 2018;2(1). https://doi.org/10.24087/IAM.2018.2.1.396
  6. Cameron Ghaffary, et al, A Practical Approach to Difficult Urinary Catherizations, Curr Urol Rep (2013) 12:565-579 DOI 10.1007/s11934-013-0364-3
  7. Alexa Bianchi; Stephen W. Leslie; Gregory T. Chesnut., Difficult Foley Catheterization, Oct 5, 2022, https://www.ncbi.nlm.nih.gov/books/NBK564404/