Bladder Catheterization
Jane Germano
1. To obtain urine for culture, particularly when suprapubic collection is contraindicated and when clean-catch specimen is unsatisfactory.
Although suprapubic bladder aspiration is considered the most reliable method of obtaining urine for culture in infants and young children (see Chapter 21), bladder catheterization is an acceptable alternative method. Bladder catheterization has been shown to be less painful than suprapubic bladder aspiration in girls and uncircumcised boys and has a higher success rate, especially if the practitioner is inexperienced in bladder aspiration (5). However, urine samples collected by catheterization have a higher false-positive rate than suprapubic aspiration (6, 7, 8), and catheterization can introduce bacteria colonizing the distal urethra into the bladder, causing a urinary tract infection (see F). The diagnosis of urinary tract infection cannot be made reliably by culturing urine collected in a bag (9, 10, 11).
2. To monitor precisely the urinary output of a critically ill patient
3. To quantify bladder residual
4. To relieve urinary retention (e.g., in neurogenic bladder) (12)
5. To instill contrast agent to perform cystourethrography (13)
Contraindications include pelvic fracture, urethral trauma, and blood at the meatus. In the presence of uncorrected bleeding diathesis, potential risks and benefits must be considered.
C. Equipment
All equipment must be sterile. Commercial prepackaged urinary drainage kits, with or without collection burettes for closed drainage, are available.
1. Gloves
2. Gauze sponges and cup with iodophor antiseptic solution (not containing alcohol), or
3. Prepared antiseptic-impregnated swabs
4. Towels for draping
5. Surgical lubricant
6. Cotton-tipped applicators
7. Urinary catheter
Silicone urinary drainage catheters are available in 3.5, 5, 6.5, and 8 French (Fr) sizes. A 3.5- or 5-Fr umbilical catheter may be substituted for a urinary catheter
8. Sterile container for specimen collection or collection burette for continuous closed drainage
D. Precautions
1. Use strict aseptic technique.
2. Use adequate lighting.
3. Try to time the procedure for when the infant has not recently voided (1 to 2 hours after the last wet diaper). Portable ultrasound can be helpful in determining when there is sufficient urine present in the bladder, reducing the chance of an unsuccessful attempt (14, 15).
4. Avoid vigorous irrigation of the perineum in preparation for catheterization. This may increase the risk of introducing bacteria into the urinary tract.
5. Avoid separating the labia minora too widely, to prevent tearing of the fourchette.
6. Use the smallest-diameter catheter to avoid traumatic complications. A 3.5-Fr catheter is recommended for
infants weighing <1,000 g and a 5-Fr catheter is recommended for larger infants.
infants weighing <1,000 g and a 5-Fr catheter is recommended for larger infants.
7. If the catheter does not pass easily, do not use force. Suspect obstruction and abandon the procedure.
8. To avoid coiling and knotting, insert the catheter only as far as necessary to obtain urine.
9. If urine is not obtained in a female infant, recheck the location of the catheter by visual inspection or by radiographic examination. It may have passed through the introitus into the vagina.
10. Remove the catheter as soon as possible, to avoid infectious complications.
11. If the catheter cannot be removed easily, do not use force. Consult urology, as catheter knots can occur.
E. Technique
1. Set up equipment and squeeze a small amount of lubricant onto a sterile field.
2. Restrain the infant supine in the frog-leg position.
3. Wash hands thoroughly and put on sterile gloves.
4. Stabilize the shaft of the penis with the nondominant hand. This hand is now considered contaminated.
5. If the infant is uncircumcised, gently retract the foreskin just enough to expose the meatus. Do not attempt to lyse adhesions. The young male infant has physiologic phimosis, and the foreskin cannot be fully retracted (16). If the foreskin is tightly adherent, attempt to line up the preputial ring and the meatus.
6. Apply gentle pressure at the base of the penis to avoid reflex urination.
7. Using the free hand for the rest of the procedure, clean the glans three times with antiseptic solution. Begin at the meatus and work outward and down the shaft of the penis.
 FIGURE 22.1 Anatomic drawing demonstrating bladder catheterization in the male. |
8. Drape sterile towels across the lower abdomen and across the infant’s legs.
9. Place the wide end of the catheter into the specimen container.
10. Lubricate the tip of the catheter well.
11. Move the specimen container and catheter onto the sterile drape between the infant’s legs.
12. Gently insert the catheter through the meatus just until urine is seen in the tube (Fig. 22.1).
a. During insertion, apply gentle upward traction on the penile shaft to prevent kinking of the urethra (see Fig. 22.1).
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