Continuing Education Activity

Urinary catheterization is a common clinical intervention to ensure adequate urinary drainage when patients cannot void effectively. When a urinary catheter cannot easily be placed, a thorough understanding of anatomic considerations that may impact catheter placement and fundamental working knowledge of various Foley catheterization techniques can aid physicians and other healthcare professionals in successfully enabling urinary bladder decompression. This activity reviews anatomic and clinical considerations when encountering difficult catheterizations and highlights the role of the interprofessional team in evaluating and managing difficult urinary catheterizations to improve the care for men and women undergoing Foley placement.

Objectives:

• Identify the contraindications to urinary instrumentation in difficult foley catheterization.
• Describe the equipment, personnel, preparation, and technique regarding difficult foley catheterization.
• Review the techniques to assess and treat patients who are difficult to catheterize.
• Summarize interprofessional team strategies for improving care coordination and communication to improve care for difficult foley catheterization and improve outcomes.

Introduction

The placement of a Foley catheter is a common clinical intervention performed to allow for external urinary drainage. It is estimated that over 100 million urinary catheters are sold globally every year, with about 30 million used just in the United States.[1]

Urinary catheterization may be performed to relieve bladder outlet obstruction, such as benign prostatic hyperplasia, strictures of the bladder neck or urethra, to treat acute urinary retention, or to adequately drain a hypotonic neurogenic bladder. Routine urinary drainage in perioperative periods or intensive care settings allows for improved bladder drainage, urine chemistry evaluations, and fluid monitoring. Urinary catheterization may be performed to obtain an uncontaminated specimen for culture, irrigate clots or blood from the bladder, instill therapeutic agents intravesically, and evaluate the bladder fluoroscopically or during urodynamic studies.

While most patients tolerate urinary catheterization with minimal discomfort or complications, some patients will endure difficult, painful, or traumatic insertions. Such discomfort is often unnecessary, and multiple attempts at catheter insertion risk significant injury to the urethra, prostate, or bladder. Improper and sub-optimal techniques for addressing difficult urinary catheterizations can lead to bladder distension, reflux, patient discomfort, detrusor damage, unnecessary therapeutic delays, serious urological complications, avoidable urinary infections, permanent scarring, and prolonged hospital stays.[2]

Both normal and abnormal anatomic variations can contribute to failed attempts at urinary catheterization. A patient's urologic history will identify prior surgical or radiological interventions that may impact anatomic relationships important to urinary catheterization. Prior instrumentation, trauma, and sexually transmitted infections can also lead to anatomic changes that could pose a challenge for Foley placement.

A difficult catheterization can be anticipated and properly addressed with a better understanding of patient-reported symptoms, a detailed genitourinary review of systems, obtaining a good urological history, and a thorough physical examination. A risk prediction model to estimate the likelihood of difficult Foley urethral catheterization that will likely require extensive urologic instrumentation has been developed, although it lacks validation.[3] It is also unclear how useful it would be in actual clinical practice.[3]

Education on available techniques, tools, and instruments to assist in performing urinary catheterization can improve successful Foley placements even in difficult patients, minimize preventable urethral trauma, reduce the rate of catheter-related urinary tract infections (CAUTIs), and avoid unnecessary urological consultations. This review article aims to educate and empower readers on the anatomical and physiological basis for difficult urethral catheterizations and outline a practical, reasonable approach to Foley placement when difficulty is anticipated, or several attempts have already been unsuccessful.[2]

Anatomy and Physiology

A thorough understanding of normal and abnormal anatomic conditions in both males and females can improve urinary catheterization success. The male and female urethra consists of four layers. From the inside out, they are:[2]

• Mucosa (inner epithelial lining)
• Spongy submucosa (rich with vasculature)
• Smooth muscle layer
• Outer fibroelastic connective tissue layer

The Female Urethra

The female urethra is usually about 5 cm in length and does not normally have any natural curvature, as does the male urethra.[4] The distal one-third of the urethral drains to the inguinal lymph nodes and is lined with stratified squamous epithelium. The proximal two-thirds drains to the pelvic lymph nodes and is lined with transitional epithelium (urothelium).[4] There are no distinct anatomical urethral segments in females comparable to those in the male urethra.

Urethral and vaginal tissue will increase blood flow and tissue elasticity when stimulated by estrogen.[5] Decreased circulating estrogen at menopause can thin out vaginal and urethral tissue, leading to atrophic vaginitis. Thinned vaginal tissue may be tender or inflamed, leading to discomfort in exposing the urethra for catheterization. Similarly, atrophic vaginitis may result in the urethral meatus retracting inwards to an anterior position, which is difficult to visualize and intubate with a standard, non-curved catheter from a standard supine frog-legged position.[2]

In women, obesity presents an additional challenge to directly visualizing the urethra for catheterization. To ensure adequate exposure of the urethral meatus in obese women, additional support to retract the abdominal pannus and additional lighting may be necessary.

Prolapse

Prolapse of the pelvic organs or urethra can create difficulty during urinary catheterization procedures. Pelvic organ prolapse, more common in multiparous white and Hispanic women over 50, occurs when the fascial and muscular attachments to the bladder, urethra, rectum, vaginal vault, or uterus become grossly and microscopically weakened by trauma to the neuromuscular structures, hormonal changes, obesity, smoking, connective tissue disorders, and other undetermined environmental and genetic factors. The prolapse of any of these organs can obscure the view of the urethra meatus, compress the urethra leading to retention, and can change the location and look of the expected anatomy. 

The Male Urethra

The male urethra is a fibromuscular tube roughly 20 cm long with a 22-24 French meatus.[6] The urethra courses through the corpus spongiosum of the penis, through the prostate gland, and into the bladder. When approached distally, the urethral meatus is first encountered, followed by the navicular fossa, penile urethra, bulbar urethra, membranous urethra, and prostatic urethra. The curvature of the male urethra resembles an S when viewed sagitally. This shape is important to recall during catheterization attempts. To straighten the urethra's curvature and allow for unimpeded passage of a urinary catheter, the penis should be placed on mild traction.

Areas of narrowing in the male urethra most often occur in the following locations: the fossa navicularis, as a result of strictures caused by instrumentation, infection, or irritation; the bulbar urethra, as a result of urethral strictures caused by trauma, instrumentation, infection, or unknown causes; and the bladder neck, most commonly caused by radiation or prior instrumentation or surgical procedures. Benign prostatic hyperplasia can cause impingement on the prostatic urethra. Hypospadias, duplicated urethras, urethral diverticula, and dorsal pits are other anatomical variations that can lead to difficult catheterization. Urethral duplications exist in several configurations within a sagittal plane and can be complete or incomplete. In a patient with duplicated urethras, the ventral meatus most commonly communicates with the urinary bladder and should be catheterized when necessary.

Hypospadias is the most frequent anatomical variant of the penis and occurs during development when hormonal triggers malfunction and the urethra does not properly tubularize. The urethral meatus can be found anywhere along the glans, penile shaft, scrotum, or perineum, leading to a difficult catheterization. Dorsal pits or neuroectodermal dimples are false urethras that commonly occur in conjunction with urethral duplication and hypospadias. They can appear to be an obstructed urethra upon catheterization when actually they are a blind-ending epithelial-lined false urethra.

When approaching the prostate, the urethra takes a 30-degree ventral turn toward the bladder. This J configuration leaves this portion of the urethra even more susceptible to iatrogenic injury from instruments or surgery, leading to strictures, bleeding, and stenosis. False passages are most commonly created in this location due to forcibly passing a catheter without regard to the changing angle of the urethra. When excessive force is used to place a catheter or introduce instruments, the transition points can be damaged, and the first several layers of the urethra can be perforated. If the catheter or instrument continues to be advanced, a flap of urothelium can be extended, and a false passage is created. Nurses and physicians should take detailed information about prior catheterization attempts; specifically, the type and size of the catheter(s) used, depth of insertion before resistance was encountered, evidence of trauma (e.g., blood on the catheter or at the meatus), and if the catheter balloon may have been inflated in a portion of the urethra versus the urinary bladder at any point.[7]

Physiology of Difficult Catheterizations of Males

Phimosis

Phimosis occurs in uncircumcised boys and men when the foreskin is too tight to be retracted below the glans penis. Phimosis can be pathological, characterized by scarring of the preputial tissue due to chronic inflammation generally seen in diabetic men, or it can be physiologic, which is more common in young boys and characterized by healthy tissue underlying a tight foreskin.[8] Physiologic phimosis is common due to the adherence of the glans and preputial tissue. It generally resolves on its own with gradual, gentle retraction but may require steroid cream applications. If it fails to resolve or if the phimosis is pathological and causing problems or symptoms, a dorsal slit procedure or circumcision will fully resolve the problem.

Buried Penis

It can be challenging to find the meatus in patients with a buried penis, especially if they also have phimosis. The buried penis only needs to be managed sufficiently to expose enough of the glans to visualize the urethral meatus which can often be accomplished by firm pressure around the base of the penis. Further details of dealing with a buried penis are described below under "Technique".

Meatal Stenosis and Fossa Navicularis Strictures

From the tip of the penis, one can begin to encounter anatomy that makes catheterization difficult. Examples include stenosis, strictures, phimosis, hypospadias, and dorsal pits. In recent reviews, the most common cause of obstruction of the distal urethra was lichen sclerosis. This disease's etiology is still under debate, but studies note autoimmune, skin injury, viral infections, and inflammation in Littre's glands as possible causes.[9] Lichen sclerosis causes a chronic inflammatory state that progresses to thickening, scarring, and obliteration of the prepuce and meatal skin's normal architecture. This inflammation can extend proximally down the penile urethra's length, where it is called balanitis xerotica obliterans.

Strictures

Strictures are the most common cause of difficult catheterization. They create narrowing in the lumen, leading to resistance during catheterization that can be anxiety-provoking to both the health care provider and the patient. This resistance can be overcome with various instruments and techniques outlined in the following sections. Urethral strictures are caused by infection, inflammation, trauma, and instrumentation. When the urethral lumen is injured, regardless of whether the etiology is inflammation, trauma, or surgery, the epithelial layers are disrupted, and inflammatory changes transform tissue planes. In doing so, the urothelial layer's integrity is broken, and the new cells may be less durable than the original urothelium. Once the urothelium is compromised, urine can extravasate into the spongy tissue surrounding the urethra. The spongy tissue's reaction to inflammation is spongiofibrosis, leading to fibrotic plaques that coalesce over time to form strictures.[10] These strictures can vary in length, depth, location, lumen caliber, and toughness but can all create a difficult catheterization.

• The Penile (Pendulous) Urethra makes up the majority of the urethral length. It can become difficult to traverse with a catheter due to strictures and false passages. Strictures of the penile urethra are most often caused by overly aggressive instrumentation and inflammation. They can be seen in men with a history of surgeries, injuries, sexually transmitted diseases, urological instrumentation, and urinary infections.
• The Bulbar Urethra is the most common site of strictures, generally due primarily to iatrogenic causes like catheterization and trauma such as saddle injuries which crush the urethra between the pelvic bones. Iatrogenic causes occur due to the anatomy at this location. The J configuration of the deep bulbous urethra just distal to the external male sphincter makes it very easy for the unguided insertion of instruments or catheters to proceed straight at that point which would damage or even pierce the posterior wall lumen of the urethra, creating a false passage. This injury then follows the pathway to fibrosis outlined for the strictures discussed above.
• The Membranous Urethra represents the external sphincter. Overly aggressive treatment of strictures in this location can easily result in incontinence that can be difficult to treat. Causes include trauma, pelvic radiation therapy, and instrumentation such as transurethral resection of the prostate.

The Prostatic Urethra

The prostatic urethra is surrounded by the prostate's lobes, which are prone to hyperplasia, especially in older men. Roughly half of men ages 50 to 60 experience some degree of prostatic hyperplasia, where the median lobe eventually compresses the urethra and causes narrowing and resistance during catheterization. The prostatic urethra is also injured during lithotripsy, cystoscopy, and other urologic procedures when the instrument is passed back and forth over this portion of the urethra multiple times, microvascular injuries that lead to fibrosis and strictures.

The Bladder Neck

After prostate surgery or radiation, bladder neck contractures are the most common iatrogenic cause of difficult Foley catheterization in the proximal urethra.[11] In bladder neck contractures, the bladder neck becomes elevated and poorly compliant. When a urinary catheter or instrument is forcibly pressed into this elevated, contracted, and poorly compliant tissue without angling anteriorly, there is a risk of undermining the bladder.

Physiology of Difficult Catheterization of the Female

Though the female urethra is short and pathological strictures are less common, anatomic variations and physiologic changes that occur with menopause and pelvic organ prolapse can make urethral catheterization difficult. In females, lichen sclerosis, atrophy, prolapse, and body habitus contribute to difficult catheterizations.

Menopause and Atrophy of the Anterior Urethra

The female vulvovaginal tissue contains estrogen receptors activated to lubricate and maintain the tissue's architecture. Although the mechanisms are not entirely understood, atrophy occurs during menopause as estrogen levels decline. With decreased estrogenization, the elastic, collagen, and smooth muscle tissues lose fullness, elasticity, and support. The urethral meatus is commonly retracted superiorly and inwards, making direct visualization and catheterization more difficult.

Indications

The first step in confronting a difficult Foley catheterization situation is to review the indications for the catheter.[2]

A urinary catheter may be placed to relieve acute or chronic urinary retention, obtain urine for analysis, dilate urethral strictures, splint the urethra after surgery, perform continuous bladder infusions, manage hematuria, drain the bladder after an injury, maintain the hygiene of the immobile patient, and decompress a neurogenic bladder.[7][12] 

Urinary decompression is also indicated in many critical care settings to ensure adequate measurements of urinary outputs and during prolonged surgeries for which the bladder needs to be emptied.

Foley catheters are possibly appropriate for measuring and collecting urine only when fluid status or urinary output cannot be determined by other means. Just being in an ICU does not automatically require the placement of a Foley. Patients who are able to void with acceptable post-void residual volumes and are not being treated for urinary tract-based sepsis or infection probably do not need catheters.[12] 

In difficult situations, it may be prudent to avoid extensive urological instrumentation to place a Foley catheter unless absolutely necessary.[2]

Contraindications

A meticulous clinical history and physical examination for urethral trauma are necessary when evaluating a patient for urinary catheterization. Traumatic injury to the urethra is a contraindication to urinary catheterization without direct visualization. Clinical signs correlating with injuries, such as blood at the urethral meatus and a high-riding prostate, suggest urethral injury, and an attempt at Foley catheterization should only be made under direct visualization with the aid of a cystoscope. The lack of blood or high-riding prostate is insufficient to rule out urethral injury. One must use clinical judgment when evaluating the patient's mechanism of injury to determine if a traumatic urethral injury is likely. If in doubt, a retrograde urethrogram should be performed.

Equipment

Reviewing the patient's urological history and understanding the anatomic considerations for the evaluation of difficult urinary catheterizations will lead to the optimal selection of the adjunctive, specialized tools available to aid in the successful placement of a urinary catheter.

As difficult catheterizations can be encountered in multiple settings, it is recommended to maintain at least one fully stocked, mobile urological emergency cart with supplies commonly used to place urinary catheters under various circumstances. Since there is no guarantee that only one urological emergency will occur at a time, two separate, fully stocked carts are recommended. Each cart should include many of the following items:

Basic Supplies

While many supplies commonly used for Foley catheterization can be found sterilely pre-packaged together, it is important to ensure additional supplies are available to allow for safe urinary catheterization using an aseptic technique. Commonly used items include an abundance of sterile lubricant, sterile drapes, sterile preparation solutions (at least two different types in case of allergies), sterile gloves, additional sterile water for irrigation, personal protective equipment, irrigation sets, Toomey syringes, and lidocaine jelly. A variety of urinary catheters in different sizes should be readily available. As some patients can have allergies to silicone or latex, both silicone and non-silicone catheters in various sizes should be available. Guide wires (0.035") and 18 gauge angiocaths should also be supplied. 

Foley Catheter Kit

Foley catheters are small flexible tubes inserted into the urethra to drain urine from the bladder. The circumference of a Foley catheter in cm. is measured in French, where every French is equal to 0.33 mm. Eyelets near the end of the catheter drain the urine while a balloon located just distal to the eyelets is inflated to keep the Foley in place. Foley catheters can be made with latex, plastic, or silicone. Some additional coatings for antimicrobial protection are available as well but have limited proven efficacy.[13] Some catheters have wider eyelets or ringed reinforcements to allow for bladder irrigation of clots and debris. The catheter material and design determine the overall stiffness of the Foley. For example, vinyl and silicone catheters are generally more rigid than latex products. The standard Foley catheter is a two-way catheter with two ports: one larger passage to drain urine and the other passage to inflate the balloon. Three-way catheters are generally larger (at least 20 French) and have an additional small caliber port through which sterile fluid can be instilled to flush the bladder continuously. They are typically used for control of significant hematuria.

Coude Catheter

Coude catheters have a slight bend just before the tip, helping to maneuver the catheter beyond obstructions in the bulbar and prostatic urethra. This curve can also help advance the catheter into an anteriorly retracted female urethral meatus. The curvature of the Coude catheter mimics the natural curvature of the male bulbar and prostatic urethra, posing less risk of creating urethral trauma or a false passage than a straight tip catheter.[14] The olive tip Coude is bent with a small bulb, which further aids in bypassing obstacles, while the Tiemann tip is similar but slightly longer, more flexible, and thinner.

Council Tip Foley Catheters and the "Blitz" Technique

These catheters feature a hole at the tip of the catheter. They are either used with a stylet to provide rigidity during catheterization with filiforms or are passed over a guide wire. A makeshift Council tip equivalent can be created through the "Blitz Technique," where an 18 gauge angiocatheter is utilized to punch a hole in the Foley's distal end.[2][15] When the needle is removed, it leaves behind the plastic sleeve from the angiocath, which has punctured the tip of the catheter and will readily accept an 0.035" guide wire (but not an 0.038"). With the plastic sleeve removed, the catheter is then advanced over the 0.035" guide wire until it reaches the bladder. (An 0.035" guide wire will fit easily through an 18 gauge angiocath sleeve.)[2][15]

Ureteric Catheters 

Ureteric catheters are small-caliber, flexible, open-tipped catheters designed to pass into the ureters up to the kidneys. They can also be used in the urethra to traverse narrow strictures. A ureteric catheter may bypass a stricture while avoiding additional trauma or false passage creation. Some are designed to pass over guide wires. Their primary disadvantage is that they lack stiffness by themselves for easy insertion and are generally too small to drain bladders effectively.

Instruments Used by Urologists:

Filiforms and Followers 

When sounds are too large to be passed, filiforms and followers may be used. Filiforms are small, flexible tubes used to maneuver past strictures and stenosis. They range from 2-6 French and come with straight, coude, or spiral tips. Filiforms are used with a follower, a plastic tube ranging from 10-24 French with a "male" screw tip, offered in straight or coude (curved) tip, and used for sequential dilation of the urethra. With a filiform in place, the tip of the follower can be screwed into the distal "female" end of the filiform and then advanced into the bladder. When the follower reaches the bladder, a hole at the end allows the drainage of urine and confirmation of appropriate positioning within the bladder. The instrument is then removed until the end of the filiform is visualized externally, the follower is unscrewed, and the next larger-sized follower is selected. The procedure is repeated until adequate dilation is achieved. 

Filiforms and followers are generally reusable, but some sets are disposable. They have largely been supplanted by guide wire-based urethral sounds, which are generally preferred. Urologists should nevertheless be familiar with their use. 

A "male" screw tip catheter guide can be passed through a council tip catheter and then screwed into the distal "female" end of the filiform to facilitate passage. This is somewhat awkward but effective. Be sure that the catheter guide can be easily extracted from the Foley along with the filiform once the catheter is positioned in the bladder. Blowing up the Foley balloon once the catheter is in the bladder can help prevent inadvertent removal of the Foley during this process. The internal lumen of the catheter should be well lubricated to facilitate easy removal of the catheter guide once the catheter is in place.

A few additional tips:

• Filiforms come in different lengths and stiffness with various tips. If the first filiform won't pass, try another.
• Ensure the filiform used isn't too short for the expected urethral length.
• If multiple filiforms won't pass, leave several in place and try another. The initial filiforms may fill any false passages allowing subsequent filiforms to pass.
• Avoid pressing or pushing too hard. This will only cause a new false passage and additional bleeding.
• While usually passed blindly, they can be introduced around a flexible cystoscope if necessary.

Guide Wires 

Guide wires are useful in assuring access to the bladder. Such wires are optimally used with the aid of cystoscopic visualization to confirm passage into the bladder, though the blind passage of soft guide wires into the bladder can also be done. Passing a guide wire blindly is actually quite safe as, generally, the guide wire will either pass into the bladder or hit an obstruction and reverse direction, eventually protruding from the urethral meatus. If this occurs, a repeat attempt at blind passage can be done. While cystoscopic passage is optimal, the blind passage technique can be done safely even by non-urologists with minimal equipment without waiting for a cystoscope and light source or even a urologist to be available at the bedside.[2]

Multiple guide wire types exist in varying stiffness, coatings, tip flexibility or angles, and lubricity. Stiffer wires provide better support for dilation, while more flexible wires or wires with angled tips may be more useful to navigate beyond strictured portions of the urinary tract.[16]

Urological guide wires often have hydrophilic coatings and are available with variable stiffness characteristics. They are designed to overcome or bypass obstacles while maintaining a flexible tip that minimizes trauma to the urothelium.[16] An 0.035" wire size is usually recommended to allow the "Blitz" technique (described above) to be easily employed.

Urethral Sounds and Dilators

When urethral strictures are encountered and there is a significant need for catheterization per urethra, gentle dilation with sounds or dilators can be performed. While they can be used interchangeably, sounds are intended for use in the urethra, while dilators were designed for cervical and uterine dilatation. Dilators have no holes or openings and are not designed to pass over guide wires. They are most commonly used for strictures in the fossa navicularis, urethral meatal stenosis, and female urethral strictures.

Urethral sounds are graduated straight or curved plastic or metal rods with tapered tips that can be passed blindly or over a guide wire to dilate the urethra in a sequential fashion. In difficult situations, the use of a guide wire along with a sound (Heyman or Goodwin) designed to pass over such wires is generally recommended to avoid false passages, minimize urethral trauma, facilitate safe stricture dilatation, and enable Foley placement.

General Dilation Technique with Sounds: The use of dilators or sounds to treat urethral strictures is relatively simple. A tight, scarred, narrowed urethral segment is identified. A lubricious 0.035" guide wire may be passed through the tightened lumen into the bladder. A small French well-lubricated sound is then passed over the guide wire and into the bladder. (While the use of a guide wire is optional, it is highly recommended) The passage of the instrument beyond the stricture can be verified by gently turning the curved sound to either side, as this is only permissible if the tip is actually inside the bladder. On removal of the sound, the tip will leak a few drops of urine. The next larger French size sound is then used, and the process is repeated. The luminal diameter of the strictured segment gradually increases due to radial expansion from the increasing larger sounds. Each sound should be left in place for at least 20 seconds to allow time for optimal radial dilation of the urethra. The dilation continues until the desired French size is reached.[17] This is typically two French sizes larger than the intended catheter. For a standard 16 French catheter, dilation should be at least 18 French and sometimes 20 French. Keeping the guide wire in place allows easier catheter placement by using a Council tip or similar catheter that can pass directly over the wire.

While the described technique is relatively simple, it is often painful for the patient and can easily cause significant injuries if not performed correctly and gently. Small French-size sounds without guide wires are particularly dangerous as they can easily penetrate the urethral wall causing false passages and bleeding. 

Multiple sound variations exist, including McCrea, Van Buren (solid metal), and Goodwin (metal with a lumen through which a wire may be passed) sounds. They come in graduated sizes from 8 up to 32 or even 40 French sizes. Many sounds are curved at one end to follow the J pattern of the prostatic urethra. Female dilators are generally straight due to the short length and lack of curvature of the female urethra.[18] Some common sounds and their characteristics are described below.

• Bougie-a-boules or "Bougies": These instruments are slim metal rods with an olive-shaped, slightly tapered tip or head and a slightly flattened handle. They come in sizes from 8 to 40 French and are about 10" long. They are most often used for measurement or calibration of the urethral lumen as well as dilation. For active dilation, other instruments are usually preferred as the effective tip is quite short and the slim metal rod can bend.
• Dittel Sounds: Solid metal straight sounds with a slightly tapered tip. The back end or handle is wide and flat, like the Van Buren sounds.
• Goodwin Sounds: Very similar to the standard Van Buren dilators with a gentle curve; Goodwin sounds have a small hole running from the very tapered tip to the end of the handle. They are designed to be passed over a guide wire and should never be used alone as their narrow tip could easily create false passages. However, when used over a guidewire placed in the bladder, they can easily and effectively open even tough strictures as they are superior dilators. Being metal, they are reusable but can be challenging to clean and sterilize due to the small, long hole through their center.
• Guyon  Sounds: Solid, reusable metal sounds with a flattened handle area and a continuous curve at the tip. The curve starts posteriorly and immediately begins a gradual, continuous turn anterior to the tip, roughly 90 degrees from the original shaft.
• Hegar Dilators: A set of 8 metal sounds with a different size on either end of each sound, totaling 16 graduated sizes. These sounds are hollow steel without any holes or openings. They are slightly curved in an elongated S shape and about 8" long. Being short, they are typically used only for meatal and fossa navicularis strictures as well as female urethral strictures. They are sized in mm, not French size. One end is 1 mm larger than the other.
• Heyman Sounds: A set of 4 to 8 curved sounds with a small central hole designed to fit over a guide wire or similar guide. Very similar to the Goodwin sounds described above, except Heyman sounds are usually disposable and have a wider proximal tip while Goodwin Sounds are metal, reusable, and have a smaller, tighter tip with a more gradual taper making them better dilators. Heyman sounds are usually disposable, while Goodwins are metal and reusable. Disposable sets of Heyman sounds are commercially available, but they tend to be expensive.
• McCrea Dilators: Very similar to the Van Buren sounds, these dilators are shorter with a gentle curve at the tip. They are intended for female patients and children.
• Pratt Dilators: These solid metal dilators are 11" long with an elongated S shape. There is a 15-degree angle at about 1" from each tip. They are longer and heavier than Hegar dilators. Pratt dilators are double-ended, with one end being 2 French sizes larger than the other. Size ranges from 13-43 French. 
• Rosebud Sounds: Thin, metal, 12" long sounds with a cylindrical tip in varying sizes.
• Van Buren Sounds: J-shaped solid metal sounds with a flat head on one end, indicating the direction of the curved tip. The curve is about 70 degrees and located 1.5" from the tip. These sounds range from 8-30 French in size and are 10.5" to 12" long. They are reusable and represent the classic "blind" metal urethral sound.

Urethral Balloon Dilators

Balloon dilators can be used for short urethral strictures (less than 1.5 cm in length). These instruments are flexible tubes with very strong balloons of varying lengths (usually 4 cm or 10 cm) that can be inflated slowly under pressure at the stricture site to provide effective radial dilatation without the tearing and shearing forces produced by sounds and dilators. Each balloon dilator is disposable and has a maximum pressure recommendation, often up to 20 atmospheres. Many are designed to pass over a guide wire. Positioning the balloon exactly at the stricture site can be challenging, and the maximum balloon pressure is limited. They can be used for both male and female urethral strictures. The balloons and inflation mechanism are disposable but can be expensive to use. Some strictures may be too tough and fail to dilate even with maximum allowable pressure. 

Flexible Cystoscope

For bedside urinary catheter placement, flexible cystoscopes can provide direct visualization of the urethra and confirm the location, source, and nature of the catheterization problem. Cystoscopy also allows visualization of the correct urethral lumen, which can then be traversed by a guide wire. The flexible cystoscope has a flexible fiberoptic cable with an eyepiece on one end, along with a port through which irrigation and guide wires can be passed. It may optionally have a video camera and monitor. The cystoscope requires a light source and irrigation fluid to distend the urethra and provide optimal visualization. The flexible cystoscope's tip is controlled by a knob or lever near the eyepiece and can be manipulated to maneuver the instrument throughout the lower urinary tract.

Suprapubic Percutaneous Urinary Kits

When access to the bladder via the urethra cannot be safely completed, or when a urethral stricture repair is being considered, a suprapubic tube (SPT) may be placed.

A variety of kits are available for the placement of suprapubic catheters at the bedside. Such kits commonly include a procedural tray, the suprapubic tray, a needle introducer (usually 14 Fr), some plastic dilators, a guide wire, a Council catheter stylet, a collection bag, and a pre-filled catheter balloon inflation syringe. Sutures to secure the catheter, different catheter sizes and types (Council tip is preferred), longer guide wires, spinal needles (18 gauge or larger), and local anesthetic may be included but are often omitted and will possibly be needed. Image guidance is suggested.

Personnel

Many physicians and nurses are trained in the placement of urinary catheters. When a catheter is not easily placed, additional assistance to achieve optimal urethral exposure, aid in positioning, obtaining supplies, or passing additional instruments, is often needed.

Preparation

Preparing for catheterization begins with a thorough clinical and urological history to understand the catheter placement indications and ascertain the cause for difficulty obtaining urethral access to the bladder. The location of any urethral obstruction (fossa navicularis, meatus, bulbous urethra) can be estimated from the prior failed catheterization attempts. The physician should review the indications for the urinary catheter to ascertain if it is absolutely necessary. (A Foley catheter can often be avoided in patients who can void spontaneously, empty their bladders well, and are being catheterized only to monitor fluid output.)

If appropriate, the patient should be treated with pain medication to minimize discomfort during instrumentation. The bed should be elevated to a height comfortable for the physician, and the patient should be on the same side of the bed as the provider. Additional hospital staff should be available to aid in exposure in obese patients, and adequate light should be available. A Trendelenberg position can sometimes be helpful, especially in morbidly obese females.

Additional attention is required for poorly mobile or recently postoperative patients to ensure safe positioning and adequate urethral exposure. Ensure adequate lighting is available. If space allows, set up a sterile table for instruments and catheter kits to ensure the aseptic technique is maintained. Additional considerations may include using a bed with stirrups to appropriately position the patient's legs or a bed with the ability to allow Trendelenburg positioning for easier direct visualization. Ensure adequate supplies, such as additional catheters, wires, angiocaths, sterile drapes, lubricant, and instruments, are available when a difficult catheterization is anticipated.

Technique or Treatment

Techniques to ensure proper urinary catheter placement must account for anatomic variations and differ when approaching male and female patients.

In women, the primary difficulty commonly encountered in catheter placement is identifying and cannulating the urethral meatus, which can be retracted or stenosed in cases of atrophic vaginitis or obscured by obesity, pelvic organ prolapse, or from scarring related to prior surgeries or radiation therapy. Similarly, identifying and cannulating the urethral meatus can be difficult in men in the setting of penile edema, buried penis, phimosis, meatal stenosis, and fossa navicularis strictures.[2] When encountering a patient who has just experienced unsuccessful Foley placement, it is important to recognize the discomfort and distress that further urinary catheterization attempts will have on them. Recognizing the patient's discomfort, explaining the reasons and necessity for the catheter, reviewing the procedure, answering any questions, and reassuring them that adequate analgesia will be provided before further instrumentation are all critically important steps to minimize further pain and discomfort.

Some patients will need to be positioned with special care. For example, in patients with significant congestive heart failure (CHF), a reverse Trendelenberg position (lying flat but bed tilted 15 to 30 degrees with the head up) is preferred to minimize CHF exacerbations.

Females

For female patients, proper positioning and retraction create the best opportunity for direct visualization and intubation of the urethral meatus. The patient should be in a supine, frog-leg position with the head of the bed slightly lower than the feet. If a frog-leg position is impossible due to comorbid conditions or recent surgery, visualization can be improved by an alternative technique. One leg is bent at the knees and abducted at the thigh, with the heel drawn towards the pelvis. It may be necessary to recruit assistance to retract a large abdominal or suprapubic pannus and provide focused lighting to visualize the urethral meatus. When atrophic vaginitis or vaginal contraction is present, the urethra commonly retracts posteriorly and anteriorly, making it difficult to view directly. If the meatus cannot be visualized, a small catheter, particularly one with a coude tip, can be slid over a finger placed in the vagina with gentle manual pressure maintained against the anterior vaginal wall. The urethral meatus will feel like a buttonhole on the anterior midline surface of the vagina which will allow for catheter introduction. In rare cases, access to the vagina and urethral meatus may actually be easier from behind, with the patient lying on her back or side.[2]

A soft guidewire, often one with an angled tip, can be placed into an anteriorly retracted urethral meatus if needed. In cases with a stenosed and retracted meatus, a firmer, smaller caliber catheter (usually silicone or vinyl) can often be more easily placed than larger, softer ones. A coude tip catheter is recommended for this purpose. The use of a catheter guide to stiffen the Foley is sometimes helpful as well. 

In addition to obscuring direct visualization of the urethral meatus, anterior prolapse can also cause an inferior angulation of the urethra as it joins the bladder neck. This can cause kinking of the catheter. To pass a catheter in such cases, placing a finger into the vagina to elevate the prolapsing bladder or placing a pessary can help align the urethra and bladder neck for direct intubation with a urinary catheter. In some cases where the urethra is retracted anteriorly or when the urethra is obscured by prolapse, the patient may need to be placed prone for easier access.

Males

Male patients should be placed in the supine position, and the penis prepped using an aseptic technique. 

Phimosis: If the urethral meatus is obscured by tight phimosis, gentle downward pressure can be placed on the suprapubic fat adjacent to the base of the penile shaft to expose the urethral meatus. If the phimosis remains unrelieved by gentle pressure to retract the foreskin, carefully placing a hemostat into the preputial opening and gently spreading it can often allow for adequate exposure of the meatus sufficient to allow for catheter introduction. The entire glans of the penis does not need to be exposed; just enough so the meatus can be visualized.

An alternate technique involves grasping the foreskin on the right and left sides and then pulling them outwards. This will tend to extend and separate the lips of the phimotic foreskin, which may allow visualization of the urethral meatus. A coude-tipped catheter can sometimes be introduced into the distal urethra through the phimosis and enter the meatus just by touch, as the anatomical location of the opening in the glans is known to be slightly below the midline. Rarely, when all of these techniques fail, and the phimosis is particularly tight, a dorsal slit procedure in the prepuce may be required under local anesthesia at the bedside to expose the meatus. A dorsal penile nerve block will provide satisfactory anesthesia to allow for this instrumentation at the bedside.

Buried or Hidden Penis: In a buried or hidden penis, such as from edema, anasarca, or lymphedema, exposure of the urethral meatus can often be achieved through downward pressure along the lateral edges of the base of the penile shaft with one hand on either side. If this allows visualization of the urethral meatus, an assistant can introduce the Foley catheter. In those cases where this does not provide sufficient visualization, a blind attempt to pass a catheter or a guide wire may be successful.

The most reliable method for assuring entry of a g guide wire or catheter into the urethral meatus is using direct visualization. This can be done with the assistance of a flexible cystoscope or ureteroscope placed into the preputial opening. Once the meatal opening is found, it can be catheterized with an 0.035" guide wire after which the cystoscope or ureteroscope is removed. A council tip Foley catheter is then passed over the wire and into the bladder.

Another technique utilizes a laryngoscope to directly visualize the glans. This has the advantage of allowing direct catheterization of the urethral meatus with a Foley catheter under vision rather than having to use a guide wire.[19]

Meatal Stenosis and Fossa Navicularis Strictures: The next area of possible difficulty in catheterization in a male will be encountered at the urethral meatus and fossa navicularis, areas which may be strictured due to prior instrumentation, lichen sclerosis, or chronic irritation. If the meatus is visualized and narrowed, gentle dilation can often allow for the introduction of the urinary catheter. Dilation of the urethral meatus can be achieved using graduated meatal dilators, male urethral sounds, or even female dilators. Liberal use of lubricating jelly with lidocaine provides adequate analgesia for meatal dilation if performed slowly and gently.

Starting with the dilator's largest caliber that will fit, place the dilator carefully into the meatus and gently advance into the fossa navicularis and distal penile urethra. Hold in place for twenty seconds for gentle dilation without tearing the tissue. If placing a dilator is not easy, confirming the urethra's path with a soft guidewire or a pediatric dilator can help direct the instrument intraluminally. Sometimes a tear duct probe or similarly small-sized dilator is needed to initiate the process.

Continue gradual dilation with sequentially larger dilators until the urethra is calibrated to 2 French sizes larger than the desired catheter to be placed. The Foley catheter is then placed using gentle traction on the penis and slowly advancing the catheter into the bladder. Urology consultation may be necessary if unable to place a catheter after reasonable attempts at gentle meatal or fossa navicularis dilation have been attempted.[20]

Standard Placement Technique: Difficulties in placing a urethral catheter once beyond the fossa navicularis may arise from urethral stricture disease, prostate cancer, an elevated bladder neck, bladder neck contractures, or anatomic disturbances caused by recent instrumentation, false passages, radiation therapy, trauma, or surgery. Benign prostatic hyperplasia is not generally a cause for difficult catheterization, as the enlarged prostatic lobes are easily bypassed by catheters. Proper technique using either a standard or a Coude tip catheter will generally bypass most obstructions.

The penis should be held under gentle traction at a 90-degree angle to the body with the provider's non-dominant hand to straighten the urethra. A 4 x 4 gauze pad can help maintain a firm grip on the penis. A Toomey syringe filled with 20 mL of sterile lubricant, 2% lidocaine jelly, or a mixture of the two can optionally be injected directly into the male urethra. This will help separate the walls of the urethra as well as provide generous lubrication and possibly some additional analgesia. A well-lubricated 16 French catheter is then placed using the dominant hand and gentle pressure. As the catheter advances into the bulbous urethra, the penis should be gently pulled inferiorly towards the feet to straighten the passage as much as possible. A gentle twisting back-and-forth motion on the catheter will sometimes help, but extreme pressure should be avoided as it will only cause false passage formation and bleeding. Placing gentle upward pressure on the perineum can help direct the catheter anteriorly in cases where there may be an elevated bladder neck. If the catheter still does not easily pass, attention should be paid to identifying the point of obstruction, which will most commonly be in the pendulous urethra or at the bladder neck, and the Foley should be removed. If the catheter passes into the bladder, it should be advanced all the way to the hub before trying to inflate the balloon. This minimizes the risk of inadvertent balloon inflation inside the prostate or urethra.[1] The final step is always to make sure the foreskin has been replaced to avoid any risk of paraphimosis.

If Standard Placement Fails:

• A 16 or 18 French coude catheter should then be gently inserted into the urethra with the curve facing the ceiling anteriorly.[21] (Smaller catheters are generally too soft and floppy while larger catheters become increasingly difficult to pass. 16 French is a good compromise.) Patients after transurethral resection will often have a hollowed-out prostatic urethra with an elevated bladder neck. Regular Foley catheters will often get stuck, creating a hole in the posterior prostatic fossa, but a coude catheter with its elevated tip facing anteriorly can often penetrate the correct lumen without additional trauma. Coude catheters are also able to bypass some obstructions that are impassable with standard Foley catheters.
• If still unable to pass the catheter, an attempt using a smaller caliber (12 Fr) silicone Foley catheter may be successful due to its smaller size and greater catheter rigidity, which may resist recoil.[2] This rigidity can be increased by inserting an 0.035" guide wire into the catheter up to but not beyond the tip (the "Liss: maneuver).[2][22] Silicone catheters also have the advantage of a relatively large lumen which allows reasonable bladder drainage considering the small overall diameter. This step may optionally be tried prior to using a coude catheter, depending on the clinical situation and urological history.

Many clinical environments have guidelines for catheter placements and for when urologic consultation is recommended. After the unsuccessful placement of a catheter with the above techniques, a urologic consultation is typically recommended. Successful catheter placement may be achieved after passing a guide wire, either using the direct visual guidance of a flexible cystoscope or with a simple blind passage. Sequential dilation of strictures in the urethra or at the bladder neck may be required.[2][23]

An initial attempt at passing a soft 0.035" guidewire directly into the urethra is quite safe and highly beneficial when successful as it gives clear, protected access to the bladder.[2][24][25][26] A guide wire can be successfully passed in 80% of patients who fail passage of both a coude and a 12 French silicone catheter.

At the bedside, a hydrophilic guidewire with a soft tip may be placed into the urethra. The soft tip can be passed beyond obstructions and into the bladder. Any obstruction will either be bypassed by the guide wire, or the wire will reverse direction and pass back out through the urethral meatus. If the guide wire is able to pass into the bladder, a council catheter or sequential urethral dilators can be passed over the wire.[23][27] If a urinary catheter does not easily pass over a guidewire into the bladder, additional blind attempts may cause additional trauma, and dilation will be required. Cystoscopic visualization or retrograde urethrography performed with the catheter in place can be helpful in identifying and bypassing the problem but may cause significant delays and are not absolutely required in most cases.[2][12]

Retrograde Urethrography Assisted Catheterizations

In difficult situations, a retrograde urethrogram can be of help. In a recent study, Almost 70% of otherwise intractable cases were successfully catheterized with the assistance of retrograde urethrography. This is not a perfect solution as there are logistical problems and delays associated with obtaining imaging, especially in the middle of the night, but it can be helpful in selected cases.[28] The technique involves using an 18 French 3-way catheter that has a hole in the tip to place a guide wire. The irrigation port is connected to diluted contrast material 1:2. The guide wire is advanced under fluoroscopic guidance.[28] If the catheter cannot be directly advanced, the guide wire is left in place, and cystoscopy, balloon dilators, or appropriate sounds are used for dilation as previously described.

Flexible cystoscopy is recommended when standard passage techniques have failed, possibly including the blind passage of a guide wire that was not successful. The use of a flexible cystoscope permits the identification of any obstructions or false passages, which can often be bypassed under direct vision with a guide wire which can then be advanced directly into the bladder.[29] If a urethral stricture is encountered, a guide wire may be directed through the narrowed lumen into the bladder, allowing for sequential dilation using Heyman or Goodwin sounds or alternatively using a high-pressure balloon dilator. Dilation should be continued until at least two French sizes larger than the minimum acceptable desired final Foley catheter size. Patients with a known stricture or false passage should be catheterized cautiously, preferably with the use of a guide wire to avoid creating or exacerbating any existing false passages and further traumatizing the urethra.[30] A coude catheter is usually preferred in these patients.

When using a flexible cystoscope, the patient is prepped sterilely, and the lower extremities are covered with a sterile drape. The cystoscope is assembled and lubricated. With direct vision, the cystoscope is maintained in the center of the urethral lumen to avoid trauma to the urethra. If a false passage is encountered, angling the cystoscope anteriorly towards the ceiling will frequently bypass the damaged urothelium. A guide wire should be placed through the narrowed lumen if a stricture is encountered rather than attempting to force the cystoscope through the narrowed lumen. Once the wire is in place, the cystoscope is removed, and a Heyman or Goodwin sound is placed over the wire and advanced gently into the bladder. Sequential dilation then continues as above. A high-pressure balloon dilator may also be used.

Direct vision video-assisted Foley catheters have been developed to facilitate placement in difficult patient situations. These catheters are designed to be used with an integrated fiberoptic video system and monitor. They are used with lighting and allow irrigation through a side port. The irrigation port can also be used to advance a guide wire. The image is very similar to a flexible cystoscope, although the tip cannot be adjusted and does not have any maneuverability or angulation potential that a cystoscope does.[1] The catheter is only designed for viewing the urethra to facilitate Foley catheterization and does not replace a cystoscope. One significant advantage is that nurses and specialized catheterization teams can use it without requiring the presence of a physician.[31] It has been shown to be helpful, particularly initially in difficult Foley catheterization situations, but it is not inexpensive. It is most suitable for larger, tertiary care institutions where it can serve multiple areas such as Emergency Department, Operating Room, and inpatient floors. 

"Soft" dilation refers to the technique of leaving a small French-size catheter, as in a very strictured urethra, for 24 to 48 hours and then replacing it with the next larger-sized Foley. Just leaving a catheter in the urethra for 24 to 48 hours will gently dilate the strictures and allow easy replacement with a slightly larger catheter. This is then replaced again in another 24 to 48 hours, and the process is repeated until the optimal French-size Foley is successfully placed. While it takes time and may be inconvenient, this technique is a very safe, painless, and effective way of dilating a strictured urethra.

Follow-up and self-dilation after successful catheterization will depend somewhat on the nature, severity, and location of the stricture or obstruction. For most patients with significant strictures, the final Foley catheter size is usually 16 French to 20 French. If the catheter is not at the optimal size, the "soft" dilation technique described above can be used. The initial catheter is generally left in place for 10 to 14 days and then removed. (This can be extended to four or even six weeks if necessary.) The patient is taught self-intermittent catheterization. A catheter size (usually 14 French to 20 French) and material (latex (soft) or vinyl (stiff)) are selected. The patient is started on self-catheterization daily for at least a week to ensure he has learned the technique. The catheter should remain in place for about 20 to 30 seconds. The daily catheterizations are then converted to twice a week for six weeks, then weekly for six weeks, then twice a month for six weeks, and then monthly.[17] Maintaining monthly catheterizations ensures that the stricture has not recurred. If at any point the patient has difficulty in passing the catheter, the schedule is adjusted to the earlier, more frequent guideline, and the process is repeated.  

Suprapubic tube placement is the treatment of last resort when all other methods of gaining access to the bladder through the urethra have failed. If a wire cannot be passed through the lumen of a urethral stricture or bladder neck contracture, the patient will most likely require suprapubic catheter placement to decompress the bladder. In the United States, about 15% of all men with acute urinary retention due to urethral strictures will be treated with suprapubic tubes.[32] Nationwide, the trend to go directly to a suprapubic tube appears to be increasing, with younger patients and those with public insurance enjoying a higher incidence.[32]

Finally, if significant instrumentation was required to achieve urinary catheterization, the use of antibiotics should be considered. If a male patient is uncircumcised, returning the foreskin to the anatomic position following catheterization is mandatory to avoid paraphimosis. For male patients, the catheter should be completely inserted "to the hub" before the Foley balloon's inflation. The balloon should be inflated slowly to ensure it is not malpositioned in the prostatic urethra. A bladder ultrasound should be used to verify the final catheter position if there is any doubt about its location.

Recommended Algorithm and Summary for Difficult Male Foley Catheterizations: 

• First, make sure that a Foley catheter is indicated and absolutely necessary. It is very discouraging to utilize significant, painful urological instrumentation to place a catheter for a minor or temporary condition, but it leaves the patient with long-term problems due to permanent urethral scarring and stricture formation. 
• Premedicate the patient for pain if safe to do so prior to painful manipulations.
• Determine from the patient's history and the experience of others who have attempted catheter placement the likely location and nature of the difficulty.
• If the problem is a buried penis, consider using a laryngoscope or flexible cystoscope. 
• If there is a very distal stricture, the problem can generally be handled relatively easily with blind Van Buren sounds or Hegar dilators; usually without the need for guide wires or cystoscopy.
• Consider injecting 20 mL of sterile lubricant, 2% lidocaine jelly, or a mixture of the two directly into the urethra with a Toomey syringe. (Recommended)
• If the problem is in the penile urethra or more proximal, consider trying to gently use a straight or coude catheter with proper technique and optimal lubrication.
• A 16 or 18 French coude catheter is typically tried next.
• If not successful, a smaller catheter (12 French silicone) generally follows.
• A direct vision video-assisted Foley catheter can be used if available.
• Passing a guide wire and using a council tip Foley catheter is usually the next step. 
• If a catheter is passed successfully, insert it into the hub before inflating the balloon.
• If a guide wire is passed, but the catheter cannot be advanced, or if all previous steps fail and a catheter is still deemed necessary, a urology consult is indicated for further treatment.
• Urology will usually review the indications and will often first attempt a standard or coude Foley insertion. Even if this fails, it provides the urologist with important information on the location and nature of the problem.
• Placing a guide wire either blindly or with cystoscopic guidance will likely be attempted next. 
• Alternatively, a retrograde urethrography-assisted technique may be attempted.
• Blind dilations without guide wires are not generally recommended anymore except for extremely distal strictures at the meatus or fossa navicularis.
• Once a guide wire is in place, Heyman or Goodwin sounds can be used to sequentially dilate the stricture, usually to 2 French sizes larger than the intended Foley catheter.
• Urethral balloon dilators may also be used for gentle dilation of urethral strictures.
• The "Blitz" technique or council tip Foley catheters are then advanced into the bladder over the wire.
• The "soft" dilation technique, where the Foley is changed every 24 to 48 hours to the next larger size, can be used if only a very small catheter can be placed initially.
• If no opening or lumen can be seen cystoscopically and the guide wire cannot be passed, consideration should be given to placing a suprapubic tube. 
• Don't forget to replace the foreskin when all the procedures are concluded.

Complications

Difficult catheterizations and repeat attempts at Foley placement cause patients substantial pain, anxiety, and possible long-term complications. Instrumentation and trauma to the urethra can increase the risk of post-instrumentation infection. If continued pressure is placed when resistance is encountered during urinary catheterization, the urinary catheter can cause a false urethral passage, undermine the bladder neck, or perforate the urethra or bladder. Trauma to the urethra, prostate, or bladder neck can lead to hematuria, infection, and scarring. In the setting of prior surgeries or radiation, rectal perforation has also been seen. In poorly mobile or immunocompromised patients, trauma from unsuccessful catheterizations can contribute to urinary tract infections, Fournier gangrene, or peri-urethral abscess formation.

In the longer term, urethral trauma from instrumentation may lead to permanent or long-lasting urethral stricture disease.

Patients who are confused, have dementia, or have a brain injury may seek to traumatically remove their Foley catheters by pulling on them. If the balloons are removed intact, this will obviously cause possibly significant traumatic injury to the urethra with bleeding, pain, possible infection, and the potential development of further scarring and strictures. If the balloon is not intact, if pieces are missing, or if the catheter cannot be found at all, a cystoscopy is recommended to make sure that no balloon fragments are left behind in the bladder, where they can calcify and form bladder stones.

Clinical Significance

The urinary bladder is designed to hold urine at low pressure and allow for volitional voiding at socially appropriate intervals. When a patient cannot void effectively or if prompt drainage of urine is required, a urinary catheter is needed. While most urinary catheterizations occur without difficulty, complications surrounding urinary catheterizations cause significant distress and create both short-term and long-term complications for the patient. It is critical to patient care for physicians to comfortably assess the cause of the difficult catheterization and choose interventions most likely to result in successful catheter placement.

Enhancing Healthcare Team Outcomes

Clear communication with the patient and treatment team relieves distress and improves outcomes when a difficult catheterization is encountered.

A two-person indwelling urinary catheterization team was found to decrease the incidence of catheter-associated urinary tract infections (CAUTIs) in a 2017 study.[33] A team of emergency room leaders, infection prevention members, nursing, and research specialists was created to evaluate a process of indwelling catheterization that would start with a safety time-out, much like a pre-procedural/surgical time-out, to assess pertinent history, physical exam findings, appropriateness of the catheterization, and would include a review of the insertion techniques to educate and familiarize the entire team. After a time-out, one physician executed the insertion while the other monitored for compromise of sterility. This approach significantly favorably impacted the rate of CAUTI at this particular institution. This time-out approach can be applied to all patients requiring catheterization, whether it is a formal time-out or a personal checklist that is reviewed before catheterization. This time-out could potentially address the 40% or more cases when urology consults would have been unnecessary and help intercept inappropriate techniques, tools, and staff performing the catheterization.[33]

The "flipped classroom" approach to nursing education, where students view online lectures and read current review articles before class, has proven successful in improving nursing knowledge and skills regarding Foley catheterization.[34]

Improving Healthcare Team Education and the Use of Skilled Nursing Catheterization Teams:

Prospective analyses looking at Foley placement problems reported that urologic consultations for difficult Foley catheterizations were unnecessary in 41% to 70% of cases as no specialized urological instrumentation was required for successful placement.[27][35] (These numbers did not include those times when a urology nurse was called and successfully placed the catheter using only standard equipment and supplies.) Complications from prior attempts at catheterizations occurred in 37%, including significant urethral trauma in 32%. Most consultations for difficult Foley placement occurred between 5 PM and 6:30 AM. The mean time between the initial attempt at Foley catheterization and placement of a urology consultation was 262 minutes, and the average patient had about three separate attempts before urology was involved. Non-urologist physicians frequently did not attempt catheterization due to lack of training, inexperience, or "not feeling comfortable."[27]

Even physicians do not always receive adequate training or supervision for Foley catheterization. In a study done at a tertiary care academic teaching center, 76% of the interns indicated that their practical training in Foley placement was either inadequate or non-existent, and over half were not supervised during their first attempt at catheter placement in an actual patient.[36] 

Successful programs to improve successful urinary catheterizations with fewer injuries and reduced catheter-related urinary tract infections (CAUTIs) included general nursing, medical student, and resident education in urethral anatomy and proper Foley placement techniques.[37][38][39] Besides improved undergraduate education, mandatory training on a yearly or biannual basis for all clinical staff is recommended to improve skills and patient outcomes.[40] Improved education of physicians (particularly rehab, emergency room, and hospitalists) and nurses should focus on various placement techniques, different types of Foley, and the optimal management of difficult catheterization. Utilizing a difficult Foley placement algorithm and implementing a skilled nursing catheterization team has been able to greatly decrease the incidence of preventable urinary trauma.[41] The need for urological consultations for catheter placement dropped from 53% (before implementation) to about 12% afterward, and patient outcomes, including CAUTIs, improved.[41] Even just providing a few nurses with more extensive training and improved skills in Foley placement has also been shown to be helpful.[37]

Nursing, Allied Health, and Interprofessional Team Interventions

An interprofessional team approach to care will help a patient feel more comfortable and understand the need for catheterization. A Foley catheter can be a new and intimidating device for a patient. If the patient is required to maintain the catheter for longer than their hospital stay, it can be distressing and embarrassing for the patient. With the help of nursing education, patients can fully understand their limitations while the Foley catheter is in place and can safely care for their catheter on their own while still living a normal life. Education for catheter care is important for patients who may be overwhelmed by this new piece of equipment, especially if they have to manage the Foley and bag at home. The important points should be emphasized by all members of the care team and include the need to maintain a tension-free suspension with the use of a leg strap and keeping the bag below the bladder level, washing hands before handling or exchanging the catheter, and exchanging the catheter every month if it is to be in place chronically. Consideration should be given to replacing the urethral Foley catheter with a suprapubic tube in situations where long-term catheterization is likely to be needed.

To achieve the best care for the patient, every team member must be aware of and invested in the care plan. Communication throughout the catheterization process and in the post-catheterization period will help the patient recover with confidence. The ordering provider should relay both for Foley catheter placement and clearly define the anticipated duration of urinary catheterization. Once the decision has been made, there should be no delay in removing a urinary catheter.

Many members of the care team possess the basic skills required to place a Foley catheter. When a problematic Foley catheterization is encountered, the team should debrief and take the opportunity to teach team members assessment and better catheterization techniques. If members of the care team desire to practice this skill, it should be offered and overseen by more experienced healthcare professionals to improve skills that will ultimately improve patient outcomes.

Healthcare professionals may feel negatively toward themselves after a failed urinary catheterization, as urinary catheterization is generally seen as a simple procedure. The truth is that many situations can significantly complicate catheterization. It is everyone's responsibility on the healthcare team to understand their limitations when it comes to Foley catheterization. If a failed attempt occurs, it is best to step back and figure out why or ask for help before attempting another passage.

Prevention of Inappropriate Foley Catheter Self-Extractions by Patients

Some patients with dementia, brain injury, or confusion may seek to pull out their Foley catheters. They are remarkably successful in doing this despite not deflating the balloon first. Besides being painful, this risks permanent scarring and damage to the lower urinary tract. Often, the catheter has to be replaced. Use of patient restraints, a sitter, or sedation have been the traditional means of managing this, but they are costly, use valuable resources, pose some risk to the patient, and are generally not very effective.

A safe and effective nursing-based protocol has been developed and used with excellent outcomes. By making the protocol a nursing procedure, it avoids the delays in seeking a physician's order to implement safe and practical precautions in patients at risk of inadvertent self-harm. The protocol was developed in consultation with several nursing staff and was found to be very helpful and effective. While initially designed primarily for Intensive Care Units (ICU), rehab units, and recovery rooms, they can be applied to any inpatient location where patients with Foley catheters are assigned.[42] For more details on these valuable and useful nursing protocols, see our companion reference StatPearls article on "Prevention of Inappropriate Self-Extraction of Foley Catheters."[42]

• On arrival to the floor or nursing unit, nurses identify every patient with a Foley catheter that is not being removed immediately.
• The initial nursing assessment should include a relative risk of potential inappropriate patient self-extraction of the Foley catheter.
• Any increased risk should be passed on to the next nursing shift when giving a report.
• Patients awakening from anesthesia, those with pre-existing dementia or confusion, and individuals with brain injuries or strokes are most at risk, especially if they have pulled out their Foley catheters previously.
• Patients who are alert and awake are at minimal risk but may still need to be reminded to take their catheters with them if they get out of bed!
• If it is determined that a patient is at risk of inappropriate catheter self-extraction or even might just potentially be at risk, the following interventions may be immediately implemented by nursing:
  • Place the catheter and catheter bag tubing under the patient's thigh, making it harder for a confused patient to find and grab. 
  • Tape the catheter and catheter bag tubing directly to the patient's skin after leaving some slack for mobility. (This makes it harder for a confused patient to fully grasp the catheter or tubing.)
  • Use diapers, shorts, mesh pants, wide ace wraps, pajamas, pads, and/or thigh-high hose around the leg used to secure the catheter. (This adds more layers between the catheter and the confused patient's grasping hands.)
  • Tape a small straight catheter in front, right on top of the pads, shorts, and pads. This will give a confused patient a tube to pull on that will not cause any real harm. Essentially, a harmless decoy!