Procedure: Male Urethral Catheterisation

Casebank Combined
1

Who you are:
You are FY2 in A&E department

Who the patient is:
Tony Samson, 41-year-old male who has presented with an abdominal discomfort.

What you must do
Take focused history, perform the emergency management, and address the patient’s concerns.

History talking

  • Start the station well (I can see from my notes that you are here as you are having some abdominal discomfort.)
  • IPS:
    – Pick up on non-verbal cues (if the patient is holding his tummy in pain)
    – Build Rapport.
  • P1 Explore the main complaint
    – Pain: SOCRATES
    – Ask about waterworks (and when was the last time he has passed urine)
  • C/I:
    – Bleeding from down below
    – Discharge (UTI)
    – Any trauma or recent instrumentation
  • P2 (start with an open question, then specify)
    – Medical Conditions (specify any history of stones, problems in the male gland, and bleeding disorders)
    – Medications (specify any blood thinners)
    – Allergies (ask about any allergy to latex)

Examination (do not forget to verbalise this)

  • Vitals
  • GPE- blood on the meatus
  • Abdominal examination

Provisional Diagnosis

From the information you have given me and according to my examinations (Always briefly mention the positive findings you have found in history and Examination), I am suspecting that you have a urinary retention.

Patient preparation:

Patient:

  • Benefit in order to relieve the patient’s pain or discomfort, you will need to insert a catheter.
  • Risk: It will be a bit uncomfortable, but I will be as quick and gentle as possible.
  • Explain: For the purpose of that I will be inserting a thin rubber tube into your penis. It will be a bit uncomfortable, but I will be as quick and gentle as possible.

Doctor:

  • Position : I would like you to lie flat on your back with your legs slightly separated
  • Exposure: I would you to undress yourself from waist down below and to take your undergarments off.

Both:

  • Privacy: I will ensure your privacy.
  • Chaperon: one of the medical stuff will be presented at the time of the examination as a chaperon.
  • Consent: Do I have your consent to proceed.

Procedure:

Collect your equipment

  • 2 kidney trays
  • Sterile gauze
  • 3 cotton pieces
  • Sterile forceps
  • Antiseptic solution / Normal saline
  • Anesthetic jelly filled syringe (1%)
  • Normal distilled water filled syringe (10mls)
  • Urine bag
  • Male Foley catheter – 12-14 French size

Prepare your equipment

  • Keep the catheter ready for insertion: Remove outer packaging and take the tip of catheter few centimeters out from the inner packaging using non-touch technique.
  • Place the kidney tray between the patient’s thighs.
  • Assume you are wearing double sterile gloves

Cleaning:

  • With the help of a sterile forceps place a piece of gauze over the shaft of the penis. Dispose the plastic forceps into clinical waste bin.
  • Hold the penis with your left (non-dominant) hand and make sure that you do not leave it until you have fully inserted the catheter. This hand is contaminated and should now not touch the aseptic trolley.
  • Using your right hand and with the help of a sterile forceps pick up a cotton piece, soak it into normal saline/antiseptic solution and clean the penis in concentric circles beginning at the glans penis, and moving progressively outwards (Use 3 cotton pieces, make each circle with one swab to clean the glans and the whole area around the glans). Dispose the plastic forceps and cotton pieces into the
    clinical waste bin.
  • Assume to take one pair of the sterile gloves off.

Insert the anesthetic gel:

  • Explain to the patient that you are going to insert some anaesthetic gel to make the procedure more comfortable (apply it with a syringe, not on the catheter)
  • Pick up the syringe labelled as anesthetic jelly. Holding the glans, pull firmly upward and place the nozzle of the syringe of anesthetic gel into the urethral meatus. Slowly expel the contents into the urethra.
  • Verbalize giving the gel 3-5 minutes to take full effect.

Inserting the catheter:

  • Place the draining end of the catheter in the kidney tray.
  • Warn the patient that you are going to insert the catheter.
  • Right hand only touch the wrapper, left hand only touch the gauze, and the penis will only touch the catheter.
  • While you are holding the base of the glans with your left hand, apply gentle upward traction to the penis and insert the exposed catheter tip into the urethral meatus with your right hand.
  • Advance the catheter by slowly removing the wrapper to expose more catheter, using a non-touch technique by touching only the packaging i.e. insert without taking the catheter completely out of the packaging.
  • To remove the wrapper without also pulling the catheter back out, ensure a good grip on the penis as you pull back on the wrapper.
  • Continue to advance the catheter until it is fully inserted up to the Y- junction.

Inflating the catheter balloon:

  • Once fully inserted, attach the distilled water syringe to the balloon port
    of the catheter. Insert about 5ml of distilled water slowly while looking at the patient’s face to check for any pain or resistance. Then inject the rest of distilled water, ensuring that it does not cause any pain.
    Dispose the syringe into the clinical waste bin. Once the balloon is fully inflated, gently pull on the catheter until resistance is felt.

Note: If the mannequin had foreskin, replace/reposition the patient’s retracted foreskin and discard the gauze you were using to hold the shaft of the penis into the clinical waste bin. Hold the Y junction with your left hand.

Attaching the urine bag:

  • Remove the cap from the tubing and plug the plastic tube end into the catheter, ensuring a tight seal.
  • Place the urine bag below the level of the patient. “Ideally I would place the urine bag below the level of my patient and I will stick the catheter on the thigh.”

Ensure area and patient is clean:

  • Tear the drape and dispose it into the clinical waste bin. However, in the exam you will be asked not to do so.
  • Dispose of equipment into the clinical waste bin.
  • Clean the patient and ensure his dignity by making sure that he is comfortable and covered: Thank the patient and ask him to dress up.

Label:

  • Record the date and time of insertion, size of catheter and volume and color of urine drained. After evacuating the urine, the Blood pressure may fall .

Take the patient’s observations again after the procedure

Management

  • Shift to the observation unit
  • Senior
  • Investigations: (Bloods :RFT ), Imaging : Ultrasound
  • Symptomatic treatment:
  • PCM if still in pain after the procedure
  • IV fluids if blood pressure after the procedure is low
  • Medication to relax the neck of bladder
  • Antibiotics if there is a UTI
  • Specialist (Urologist)

Safety net:

  • Any pain, burning sensation or fever
  • Blockage of the catheter
  • If blood is noticed in the catheter.
  • If the catheter is full.
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