Catheters are common. 15-25% of hospital patients will be catheterised. Competence in catheterisation is assessed at medical school and is a requirement for successful completion of foundation training, yet, in spite of this, inserting catheters correctly and looking after patients with catheters can be challenging for junior doctors.
This series aims to take you though the important basics of catheter insertion, what steps the urologists take when you call them for help and finally to share some useful anecdotal advice learned the hard way from years on the wards.
This is the second in a series on catheterisation. It is preceded by Part #1 and followed by Part #3 and Part #4. This series aims to take you though the important basics of catheter insertion, what steps the urologists take when you call them for help and finally to share some useful anecdotal advice learned the hard way from years on the wards.
This, the second in the series, covers the technical basics of catheterisation It’s a great place to start if you haven’t done much before and, if you already feel competent and confident catheterising, you might pick up on some ways to perfect your technique.
1. Proper planning and preparation prevent piss poor performance
You get called to catheterise a patient on another ward while you’re doing a weekend of ward cover. You head over to the ward and can’t find a thing. Or you have asked for a trolley to be prepared before you get there and its missing some essential kit. Worse, still, you get the catheter in, urine starts draining and you realise you haven’t been given a catheter bag.
Before you go to catheterise, go to a familiar store cupboard and get everything you need.
Run through the procedure step-by-step in your head and make sure you have all you need for every step.
Then get extras. Use two pair of sterile gloves? Bring three. Picked up a tube of anaesthetic lube? Grab some more and put them in your pocket. Never assume you’ll be able to find them on another ward and you can guarantee you’ll never regret bringing spare supplies.
2. Give the anaesthetic gel time to work
Tense patients find catheterisation more uncomfortable than relaxed patient. For male patients use an extra tube of gel and give it time to work. This may mean gently squeezing the tip of the urethra so it doesn’t all drip out, perhaps only for a minute whilst making small talk, but it will make a huge difference to the patient and therefore you, too. Proper local anaesthesia will help relax the urinary sphincter which can be clamped tight shut by patients in painful retention.
3. Assume the position
Take time when setting up to position the bed and patient around you. Raise the bed to a height so you don’t put your back out, lower the sides, and lay the patient flat – if possible. For male patients make sure you pull the urethra up and straight, you can afford to be firm when doing this, the straighter the urethra the easier to catheterise. I haven’t seen a degloving injury from catheterisation. Yet.
For female patients the meatus can be a bit harder to find. The best thing to do here is to get the pelvis tilted up towards you. You might do this by asking the patient to put their hands under their hips or getting a pillow underneath them. It’s often helpful to have an extra pair of hands at this stage to help keep the knees apart and don’t forget to get some light on the subject.
4. Firm, but gentle
Constant pressure is your friend. If you get the urethra nice and straight (see point 3) the catheter might actually fall all the way to the level of the sphincter, but at this point you need to apply some pressure, not a large force, but gentle pressure to the catheter to advance it through the sphincter and let it advance through the prostatic urethra. How much pressure is too much? A trick her is that if you feel the catheter bend in the urethra like a bow string stop, its not going to go.
5. Push it good
Do as Salt-N-Pepa advise in their ‘80s hit, and make sure you push the catheter all the way in. This is less important in female patients where the urethra is about 4cm in length, but in men, particularly those with long urethras or big prostates that might extend well into their bladder, its essential to get that balloon into the bladder lumen. So, if it doesn’t go in right up to the hilt, the bifurcation of the catheter tube and valve, then it might not be in. If unsure, if the patient experiences any pain when you inflate the balloon, stop.
Remember! A good way to get a bit of extra knowledge is to go to a flexible cystoscopy list. They run almost every day and by dropping in for just an hour you can see what the urethra looks like as the camera goes in. This helps visualise the passage of the catheter in your minds eye and the above tips should make even more sense.
This is the second in a series on catheterisation. Click here to read Part #3.