🩺 Male Urinary Catheterisation

Male urinary catheterisation is the insertion of a sterile tube through the urethra into the bladder to drain urine. It is a common procedure in NHS hospitals for managing urinary retention and monitoring output. Due to the length and curvature of the male urethra, the procedure carries risks of trauma and infection, necessitating a high standard of aseptic technique and the use of local anesthetic gel. Proper positioning and advancing the catheter fully to the hub before balloon inflation are key safety steps. Long-term management requires a focus on infection control and regular review of the ongoing necessity of the catheter.

Male urinary catheterisation is indicated for the relief of acute or chronic urinary retention (e.g., due to Benign Prostatic Hyperplasia) and for the accurate measurement of urinary output in critically ill or hemodynamically unstable patients. It is used peri-operatively for certain surgeries (e.g., prolonged procedures, pelvic or urological surgery). It allows for bladder irrigation in patients with gross hematuria and clot retention. Catheterisation may also be indicated for the administration of intravesical medications or for urodynamic studies. In some cases, it is used for end-of-life care to maintain comfort and skin integrity if other methods of incontinence management are inadequate.

The absolute contraindication to male catheterisation is suspected urethral trauma, typically seen in the context of pelvic fractures (signs include blood at the urethral meatus, high-riding prostate on rectal exam, or perineal bruising). In such cases, a retrograde urethrogram is required before any attempt. Catheterisation should also be avoided or performed by a specialist in patients with known severe urethral strictures or recent urological surgery (e.g., radical prostatectomy). Active acute prostatitis is a relative contraindication as the procedure is extremely painful and Risks seeding bacteria into the bloodstream. Small-diameter catheters should be avoided in patients with gross hematuria, as they will quickly occlude with clots (3-way catheters are preferred here).

A sterile catheterisation pack (containing gallipots, swabs, drapes, and forceps) is required. A sterile Foley catheter (usually 12-14 French for general use) and a pre-filled syringe of sterile water for balloon inflation are essential. For anesthesia and lubrication, a syringe of 2% lidocaine gel (Instillagel) is used. Sterile gloves (two pairs often recommended) and an apron are needed. A sterile drainage bag (urobag) and a catheter securement device are required. Materials for cleaning the meatus (usually 0.9% sodium chloride or sterile water) and a clinical waste bag should be at the bedside. Appropriate lighting and a comfortable bed height are necessary for a safe procedure.

Introduce yourself, confirm identity, and gain consent. Wash hands and set up a sterile field. Position the patient supine with legs slightly apart. Don sterile gloves and drape the patient. Clean the glans and meatus using sterile technique. Inject lidocaine gel into the urethra and wait at least 3-5 minutes for effect. Switch to a second pair of sterile gloves. Using your non-dominant hand (now 'non-sterile') to hold the penis, insert the catheter with your dominant sterile hand. Advance the catheter until the hub is at the meatus. Wait for urine flow. If urine flows, advance slightly further, then slowly inflate the balloon with sterile water. Gently pull back until resistance is felt. Connect the drainage bag, secure the catheter, and ensure the foreskin is replaced. Document all details carefully.

Success is confirmed by the spontaneous flow of urine into the catheter tubing; if no urine appears, the catheter may be 'kinked' or wrongly positioned in the urethra or a false passage. If the patient has a very empty bladder, gentle suprapubic pressure may help express urine. The volume and characteristics of the urine (color, clarity, presence of blood/sediment) should be documented. In cases of acute retention, the 'initial drain' volume must be recorded, as draining more than 1 liter rapidly can occasionally lead to decompression hematuria or post-obstructive diuresis (which requires close monitoring of electrolytes and fluid balance). The balloon should be inflated with the specified volume of sterile water (usually 10ml) and should not cause pain during inflation.

A critical error is failing to advance the catheter all the way to the side-port/hub in a male patient before inflating the balloon; inflating the balloon in the urethra rather than the bladder causes severe trauma, pain, and potential permanent stricture. Inadequate lubrication or not allowing the lidocaine gel enough time (3-5 minutes) to work makes the procedure unnecessarily painful and increases the risk of urethral trauma. Using the wrong size catheter (too large) can cause discomfort and tissue damage. Contamination of the 'sterile field' by non-sterile hands or equipment is a common cause of healthcare-associated urinary tract infections (CAUTIs). Forgetting to reposition the foreskin (if present) after the procedure can lead to paraphimosis, a clinical emergency.

Always explain the 'sting' that may occur when the anesthetic gel is introduced. Hold the penis at a 90-degree angle (vertical) to the patient's body to 'straighten' the urethra and facilitate easier passage through the bulbar and prostatic regions. If you meet resistance at the external sphincter, ask the patient to take deep breaths or cough, which can help relax the muscle. Never force the catheter; if it will not pass, stop and seek help. Use the 'sterile sleeve' of the catheter if provided to maintain sterility during insertion. Most importantly, always remember to return the foreskin to its original position at the end of the procedure.

Students must be able to describe the 'double-gloving' or 'clean hand/dirty hand' technique to maintain sterility. UK national policy (HCAI prevention) emphasizes that catheters should only be inserted when absolutely necessary and removed as soon as possible to prevent CAUTIs. Documentation in the patient's 'Catheter Passport' or medical record must include the reason for insertion, the date, the catheter type (e.g., silicone vs. latex), size (Ch/Fr), batch number, the volume of water in the balloon, and the date the catheter is due for change or removal (TWOC - Trial Without Catheter). Awareness of the anatomy of the male urethra—including the prostatic and membranous portions and the sharp angle at the bulb—is essential for safe insertion.