What are the recommended steps for urinary catheterisation?

Urinary Catheterization Steps

Perform urinary catheterization using aseptic technique with proper hand hygiene, appropriate catheter selection, and gentle insertion to minimize infection risk and urethral trauma.

Pre-Procedure Preparation

Hand Hygiene and Aseptic Technique

• Clean hands thoroughly with antibacterial soap or alcohol-based cleaners before catheter insertion 1
• Use clean technique for routine intermittent catheterization, as evidence shows no significant difference in UTI rates compared to sterile technique 1
• Reserve sterile technique only for patients with recurrent symptomatic infections despite proper clean technique 1
• Perform daily perineal hygiene with soap and water, cleaning the perineal region and proximal catheter for patients with indwelling catheters 1

Catheter Selection

• Choose appropriately sized catheters to minimize urethral trauma 1
• Consider hydrophilic or gel reservoir catheters, which are associated with fewer UTIs and less hematuria compared to non-coated catheters in neurogenic bladder patients 1, 2
• Use single-use catheters only; catheter reuse significantly increases UTI frequency 1, 2

Patient Assessment

• Obtain physician's order before catheter placement (institutions should require this in at least 95% of cases) 1
• Verify appropriate indication for catheterization, as restricting catheterization to those who clinically require it reduces exposure to hazards 3
• Assess for urethral stricture in patients presenting with decreased urinary stream, incomplete emptying, or dysuria using history, physical examination, and urinalysis 1

Catheterization Technique

Urethral Catheter Insertion

• If urethral stricture is encountered during catheter placement, dilate over a guidewire to prevent false passage formation or rectal injury 1
• Alternatively, perform internal urethrotomy if the stricture is too dense to be adequately dilated 1
• For failed urethral catheterization, place suprapubic cystostomy to provide urinary drainage 1

Timing and Volume Considerations

• For post-void residual (PVR) measurement via straight catheterization, perform within 30 minutes of the patient voiding to ensure accuracy 2
• Never allow bladder volume to exceed 500 mL, as excessive distention can cause permanent detrusor muscle damage 2, 4
• Catheterize immediately when bladder volume reaches ≥300 mL with symptoms (suprapubic discomfort, inability to void, bladder distention) 2, 4

Post-Procedure Management

Catheter Care and Monitoring

• Clean hands with antibacterial soap or alcohol-based cleaners after catheter insertion or manipulation 1
• For indwelling catheters, perform daily catheter hygiene including cleaning of the perineal region and proximal catheter with soap and water 1
• Remove indwelling catheters within 24 hours when clinically appropriate (e.g., stroke patients, post-surgical patients with low retention risk) 2

Intermittent Catheterization Schedule

• Perform intermittent catheterization every 4-6 hours to keep urine volumes below 500 mL per collection 1, 2, 4
• Maintain a minimum of 4 catheterizations per day even if volumes are consistently low (<200 mL) 2
• More frequent catheterization increases cross-infection risk, while less frequent results in dangerous bladder overdistension 1, 2
• Continue catheterization until the patient can void spontaneously with PVR consistently <100 mL 2, 4

Infection Prevention

• Ensure adequate hydration (2-3 L per day) to decrease UTI risk, unless contraindicated 1, 2, 4
• Monitor for signs of UTI (fever, change in mental status, cloudy urine) but do not provide prophylactic antibiotics routinely 1, 2
• Antimicrobial prophylaxis should not be routinely prescribed to prevent symptomatic UTI 1

Special Populations and Situations

Trauma and Surgical Patients

• In hemodynamically unstable patients with bladder injury, urethral or suprapubic catheter may be inserted as a temporary measure with repair postponed 1
• For blunt posterior urethral injuries, initial conservative treatment with urinary drainage (urethral or suprapubic catheter) is recommended, with planned delayed surgical treatment 1
• In pediatric patients after surgical repair of bladder rupture, suprapubic drainage is recommended 1

Neurogenic Bladder

• Intermittent catheterization is the gold standard for neurogenic bladder management, associated with lower UTI rates than indwelling catheters 2
• For spinal cord injury patients, the 4-6 hour interval is critical to prevent volumes exceeding 500 mL per collection 2
• In pediatric spina bifida patients, initially catheterize every 6 hours, then adjust to every 4 hours if residual volumes remain elevated 2

Critical Pitfalls to Avoid

• Do not catheterize less frequently than every 6 hours in patients with neurogenic bladder, as this risks bladder overdistention 2
• Avoid using indwelling catheters when intermittent catheterization is feasible, as catheter-associated UTIs account for nearly 40% of nosocomial infections 2
• Do not delay catheterization when bladder volumes approach 500 mL, even if the patient is asymptomatic 2
• Never use catheters for multiple insertions; single-use only to reduce infection risk 1, 2
• Do not perform routine antimicrobial prophylaxis, as the risk of adverse events exceeds benefit 1