MD PROGRAMME

YEAR 2 PHASE 1
ACADEMIC SESSION 2021/ 2022

1
 CONTENT

Urinary bladder catheterization

1 Relevantanatomy
2 Indication Reasonfordoingso
3 Equipment
4 Steps
5 Complications
anagemedical complication
Urethral I bespte.LY
f
stricture
Ascending
infection m
cystitis Ffa 25 4 Lengthofurethra
pyelonephritis 2

Needto makesure the catheter is in

the bladderbeforeinflatingthe balloon
Incorrecttechniqueof CBDleadsto urethralstricture
 List 8indicationsof foleycatheter

URINARY BLADDER CATHERIZATION

LEARNING OUTCOMES

At the end of this session, the students are expected to be able to:

1. Describe the anatomy and physiology of the genitourinary system in both male and female.
2. Describe the characteristics of normal and abnormal urine.
3. List the indications for catheterization.
4. Describe the proper technique for the insertion of a urinary catheter.
5. Describe the steps to remove an indwelling catheter.
6. Identify the most commonly ordered urinary lab tests.

A. BACKGROUND MATERIALS

RECALL THE ANATOMY AND PHYSIOLOGY OF THE GENITOURINARY SYSTEM

Figure 1.0: Anatomy of genitourinary system

The genitourinary system is made up of the following structures:

 The kidney: is a bean shaped structure that is covered by a renal capsule. A cross
section through the kidney reveals a cortical section and a medullary section. Both the
cortical and medullary sections contain tubules but with the majority in the medullary
region. The tubules perform the function of filtration.

3
  The kidneys are located posteriorly and retro-peritoneally just below the diaphragm
and measures approximately 4-5 inches long, 1 inch thick and 2-3 inches wide. The
right kidney is lower than the left due to the presence of the liver.

 The functional unit of the kidney is the NEPHRON. When viewed microscopically, it
consists of:

A glomerular apparatus, a Bowman’s capsule, a proximal convoluted tubule, a

Loop of Henle, a distal convoluted tubule and collecting ducts.

Figure 1.1: Nephron anatomy

The nephron functions to:

 Regulate of extracellular fluid volume

 Regulate osmolality of the blood
 Maintain ion balance and keeping it in a normal range
 Regulate blood pH (i.e. acid base balance)
 Excrete wastes and foreign material
 Produce hormones.eg. erythropoietin and renin

Note: The student is expected to know the sites of the nephron where these functions occur
and the mechanisms involved.

4
OTHER COMPONENTS OF THE RENAL SYSTEM.
 The Ureter extends down from the renal pelvis approximately 10 – 12 inches to
join the bladder. Urine passes through the ureters by peristaltic waves. Back flow
of urine is prevented by a ‘valve’ locate at the ureter- bladder junction.

 Urinary bladder is a hollow sac that can expand to hold a volume of about 500ml.
Two rings of muscle called sphincters are found between the urethra and the
bladder. When approximately 250 ml of urine fills the bladder, the resulting
distention of the bladder triggers a micturition reflex.

 Urethra is a small canal through which the urine exists the body.

 In the female, it measures 1.5 inches and is embedded in the anterior wall of the
vagina. It exists between the clitoris and the vaginal opening.

 In the male, the urethral is approximately 8 inches long. It passes through the
prostate gland to end at the glans penis. It also serves as a passage way for
semen

CHARACTERISTICS OF A NORMAL URINE

Normal urine consists of:

 95% water
 Contains nitrogenous waste products from protein breakdown. eg. urea, uric acid and
creatinine
 Contains toxins
 Contain hormones
 Disposes of extra minerals such as sodium, potassium, calcium, chlorides, sulfates
and phosphates
 Contain yellow pigment from bile

CHARACTERISTICS OF AN ABNORMAL URINE

An abnormal urine may contain one or more of the following:

 Albumin/ protein that may indicate possible kidney disease, infection, trauma
 Glucose/ sugar that may indicate diabetes mellitus, cancerous tumors, trauma and
head injury
 Erythrocytes/ blood indicating infection, kidney disease, cancerous tumors and
trauma
 Leucocytes/ WBC indicating urinary tract infection

5
  Ketone bodies that may indicate diabetes mellitus, starvation or any other metabolic
condition involving a fast breakdown of fat
 Abnormal pH levels which may indicate gout, calculi and infection
 Abnormal levels of specific gravity that may be due to kidney disease, electrolyte
imbalances burns and liver disorders
 Bilirubin. Its presence in the urine may indicate liver dysfunction, biliary obstruction
and hepatitis

Figure 1.2: Normal and abnormal urine

URINARY BLADDER CATHERIZATION

DEFINITION

Urinary bladder catheterization is performed by the insertion of a catheter through the

urethral route into the urinary bladder.

INDICATIONS
Listdown 4indicationsoffoleycatheter
The indications for performing such a procedure are as follows:

 Relief urinary retention to determine youshould if

whatcauses ufpht increase the drop
outflowobstruction  After surgical procedures to the urethra Ñ of
dosage medication
tumour
BPH

anesthesia etc.) condcious
patient
g
Monitoring urine output flow in unconscious patients (i.e. in coma, surgical

 In cases where the bladder needs to be kept empty (decompression) and urinary
calculus flow output assured
stricture  To perform a micturating cystourethrogram 74 9 4 7The
decompressed
m n
neurogenic  Measurement of bladder residual volume
bladderd ysfunction whenthere'sincompletevoidance
bloodclot we wantto measurepostroidalvolume
6
Howadays we
use ultrasound
  Make a definitive diagnosis of urinary tract infection if supra pubic puncture is
contra indicated
 Obtain an uncontaminated urine sample
urineitselfissterile
butasitpassesthrough
theurethra theepithelium
EQUIPMENT REQUIRED the urine
 TYPES OF THE URINARY CATHETER
8h91min teleter
Catheter tubes are measured using the (Fr) French size which range from 14 to 24 for adults.
Each unit is roughly equivalent to 0.33 mm in diameter (that is, 18 Fr. indicates a diameter of
6 mm). The smaller the number, the smaller the catheter. There are many different types of
urinary catheters for different purposes:

 Coudé catheter - a catheter with angled tip that is designed to be easier

to insert when enlargement of the prostate is suspected.

 Foley catheter - has a balloon at its tip that is inflated after insertion so it
remains in the bladder.
Typesofurinarycatheter
Normal urine
rerrodoftime
at initieter t ay

Figure 1.3: Foley Coude catheter

7
 Figure 1.4: Two-way Foley catheter

 Pezzer or Malecot catheter - catheters that have triangular or knotted-

looking tips. They are designed to be used to drain urine from the renal
pelvis, or can be used for a suprapubic catheterization.

Figure 1.5: Malecot catheter

 Simple urethral catheter - a straight catheter designed for in and out

procedures.

 Three-way indwelling catheter - has a balloon at its tip that is inflated

after its insertion. It also has another lumen that can be used for
continuous bladder irrigation.
Anotherchannelthatwe
can feuskin fluidfor
irrigation 8
 Figure 1.6: Three- way Foley catheter

 Suprapubic catheter - a catheter that is surgically inserted through the

abdominal wall above the symphysis into the bladder to divert urine from
the urethra.

 Self catheter – it is same as simple urethral catheter which is longer for

male and shorter for female. It is inserted by patients themselves after they
were taught the procedure. The tip of the catheter can be straight or coude
tip.

Figure 1.7: Self catheter

9
 OTHER NEEDED EQUPMENT

 Catheterization set/ tray (sterile) 1 makesure the valueof

 Sterile drape urinary bag is closed
to prevent leakage
 Sterile gloves
 Lubricant (KY gel / lignocaine gel) 2 FoleyCoudecatheter
 Antiseptic solution
 Sterile distilled water (10 ml) 3 Lubricant
 Syringe (10 ml)
 Drainage bag (for continuous bladder drainage) 4 Syringe
 Surgical mask 5 Gloves Sterile Disposible
 Non-allergenic tape (optional)
 Urine specimen container (if required)

h chlorhexidine
a Ypᵈ
PROCEDURE

1. Greet the patient and introduce yourself.

2. Ensure the right patient, explain the procedure and get verbal consent.
3. Ensure privacy for the patient.
4. Wash your hands with antiseptic
5. Position patient and expose necessarily for procedure
6. Ensure the availability of all the appropriate equipment and good lighting.
7. Open the catheterization tray/ set while maintaining sterile technique

the
Gp8

Figure 1.8: Catheterization set

Catheter
should be
inffffhcff.tnout
10
checkthe integrity of the
catheter inflating air
If there'sresistance catheter can withstand upto
consult your 400of air Ipumpof thesyringe 10cg
consultant others usually locc to soce of air inflation
is sufficient
 male 14 16French
size female 12 14French
catheter
8. Pour the antiseptic into the container/ gallipot
8 94 ftp.flatethe
9. Put on the sterile gloves salinewill crystallize
10. If inserting a Foley catheter, inflate the balloon first to ensure it works
properly ustually
in exam
11. Prepare the sterile distilled water for balloon inflation bothsalineand
12. Catheter insertion for male;
proatta be
Choose
With your non dominant hand grasp the of penis just below the glans
WATER
and hold upright (use a piece of gauze)

Note: If the patient is uncircumcised, retract the foreskin. Replace the

foreskin at the end of the procedure.

 With your dominant hands, use forceps to hold cotton balls soaked in an
antiseptic solution and cleanse the glans in a circular motion, starting at the
center of meatus and working outward. Each cotton ball for single circular
motion
 Drape with a sterile hole towel
 Lubricate the urethra by inserting the lignocaine gel into the urethra

Figure 1.9: Lubricating the urethra using lignocaine gel

 Place the kidney dish containing the catheter next to the patient’s thighs

11
 With your dominant hand, pick up the catheter
 Insert the catheter gently into urinary meatus while holding the penis
vertically straight up till you may feel some resistance at the prostatic
sphincter

Figure 2.0: Insertion the catheter

 Lower the penis down to a horizontal position and continue to advance

the catheter completely and urine flows (this is to ensure proper
placement of the catheter in the bladder and prevent urethral injuries and
hematuria that results when the foley catheter balloon is inflated in the
urethra)

Figure 2.1: Draining out the urine

12
13. Catheter insertion for female;

 Position patient in supine position with knees flexed and

separated, feet flat on the bed
 With your thumb, middle and index finger of your non-dominant
hand, separate the labia majora and labia minora. Pull slightly
upward to locate the meatus. Maintain this position to avoid
contamination.
 With your dominant hand, cleanse the urinary meatus, using
forcep to hold cotton balls soaked in an antiseptic solution. Each
cotton ball for a single downward stroke only.
 Place the kidney dish containing the catheter between the
patient’s thighs

Figure 2.2: Cleaning the female urinary meatus

13
  Pick up the catheter with your dominant hand using forcep

 Insert the lubricated tip of the catheter into urinary meatus.

Advance the catheter about 5.0 – 6.0 cm until the urine begins to
flow, then advance the catheter further 1-2 cm

Note: If the catheter slips into the vagina, leave it there to assist as a
landmark. With another lubricated sterile catheter, insert into the urinary
meatus until you get urine back. Remove the catheter left in the vagina
at this time.

14. After insertion of the catheter, inflate the catheter balloon with distilled
water. Gently pull back on the catheter until the balloon engages the
bladder neck.

Note: Improperly inflated balloons can cause drainage and leakage

difficulties. Do not use normal saline for inflation because this will cause
crystal formation in the balloon leading to failure of balloon deflation later
on.

Figure 2.3: Balloon inflation

15. Attach a drainage bag and drain the urine from the bladder (continuous
bladder drainage –CBD).

14
 Figure 2.3: Position of the catheter

16. After catheterization procedure

 Clean up the patient and equipment.

 Remove gloves appropriately and wash your hands.
 Ensure drainage tubing and bag are positioned properly. Tape
the catheter at the patient thigh to prevent accidentally traction by
a full drainage bag and cause discomfort to the patient.
 Note the characteristic of obtained urine. Label and send
specimen to the lab if necessary.
 Answer any questions the patient may have regarding the
catheterization procedure
 Record the procedure done in the patient file.

15
PROCEDURE FOR CATHETER REMOVAL

1. Deflate the balloon with the syringe. Ensure that the full volume of injected
water is removed.
2. Gently pull out the catheter.

LAB TESTS THAT ARE COMMONLY ORDERED

 Routine urinalysis- for glucose, acetone, albumin, blood, bilirubin and pH.

 Urine culture and sensitivity (C&S).

 Creatinine clearance to determine for Glomerular Filtration Rate (GFR).

Collect 24 hours urine sample with Serum Creatinine sample and calculate the
GFR.

16