James Kearns, MD
BASICS
DESCRIPTION
• The terms “urethral catheter” and “Foley catheter” are often used interchangeably. Urethral catheter is a general description of a tube that traverses the urethra whereas a Foley catheter refers to a urethral catheter with a retention balloon.
• Common types of urethral catheter include:
– Foley: rounded tip with balloon
– Council: hole at distal tip to allow for passage over wire or on the end of a stylette
– Coude’: angulated distal tip to allow for navigating past large prostates or elevated bladder necks
• 2-way catheters have a single drainage port and a balloon port
• 3-way catheters have a drainage port, an infusion port, and a balloon port
– NOTE: Drainage channel is larger in a 2-way catheter than 3-way catheter of the same size
• Size measured in Charrier or French (Fr) scale
– Fr = D × 3, where D = diameter in mm
– Common sizes include 5–10 Fr in the pediatric population and 16–24 Fr in the adult population
• Common materials include latex and silicone
– Latex appropriate for short-term (<1 mo)
– Silicone better for longer-term or latex allergy
• Hydrophilic coatings may facilitate easier passage of catheter
• Problems can occur with insertion, drainage, or removal
EPIDEMIOLOGY
Incidence
Unknown but very common in hospitalized patients
Prevalence
N/A
RISK FACTORS
Hospitalized patient requiring strict documentation of urine output, BPH, urethral stricture disease, bladder neck contracture, previous urethral or prostate surgery, trauma, immobility, obesity
Genetics
N/A
PATHOPHYSIOLOGY
Indications for urethral catheterization include need for bladder decompression, need for accurate monitoring of urine output, immobility during postoperative setting, diversion of urine from wounds, instillation of therapeutic agents, and facilitation of certain diagnostic studies (eg, urodynamics, VCUG, cystogram)
ASSOCIATED CONDITIONS
• BPH
• Balanitis xerotica obliterans (BXO)
• UTI
• Urinary retention
• Neurogenic bladder
• Liver failure, heart failure—edema
GENERAL PREVENTION
• Minimization of unnecessary urethral catheterization
• Removal of urethral catheter as soon as clinically indicated
• Proper insertion technique prevents false passages and potential bladder neck or urethral strictures
– Catheter should always be placed without undue force, using copious lubrication
Excess force may lead to false passage creation
ALERT
Do not inflate foley balloon unless the catheter is confirmed in the bladder.
• Look for urine return and insert catheter until “hub” reaches urethral meatus.
• If no urine return with “hubbed” catheter, irrigate normal saline into the bladder with a catheter-tipped syringe; 120 mL is often necessary before fluid can be aspirated.
• Inflation in urethra or prostate may lead to significant hematuria or future urethral stricture as well as inability to place another catheter:
– Always inflate balloon with water as saline may crystallize and is usually not necessary to test balloon prior to insertion
DIAGNOSIS
HISTORY
• Previous difficulty with catheterization
• Urethral instrumentation in the past
• Episodes of urethral catheterization
• Prior pelvic radiation or brachytherapy
• History of urinary symptoms
– Quality of urinary stream, urinary frequency, sensation of emptying, history of urinary retention
• Circumcision may lead to meatal stenosis
PHYSICAL EXAM
• Abdominal examination for palpable bladder, dullness to percussion over lower abdomen
• DRE feels for evidence of prostate cancer (nodularity or hardness), prostatic abscess (tender prostate), urethral disruption (high-riding or nonpalpable prostate)
• Bimanual examination to evaluate for bladder or pelvic masses
• Palpate penis for strictures
– Both location and length of stricture important
• Blood at meatus suggests trauma/urethral disruption
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Electrolytes and creatinine to evaluate for renal function
– Decreased renal function in an obstructed patient is risk factor for postobstructive diuresis
Imaging
• Generally unnecessary
• Retrograde urethrogram can demonstrate urethral disruption, injury, or stricture
• Cystourethroscopy, if needed
Diagnostic Procedures/Surgery
• Catheterization is both diagnostic and therapeutic
– See treatment section
Pathologic Findings
If performed in OR, may consider biopsy of strictures
DIFFERENTIAL DIAGNOSIS
• Difficulty placing catheter
– Urethral sphincter spasm
– BPH
– Urethral stricture
– Bladder neck contracture
– Urethral disruption
– Urethral false passage
– Phimosis
– Meatal stenosis
– Penile/foreskin edema
– Obesity/buried penis
– Retracted meatus in women
– Urethral stone or foreign body
• Problems with drainage
– Clot retention
– Bladder debris (tumor or stone)
• Difficulty removing catheter
– Improper coupling of syringe to balloon port
– Obstructed balloon port
– Encrustation of balloon or catheter
– Catheter sutured in place
TREATMENT
GENERAL MEASURES
• Assess need for urethral catheterization
• For difficult placement, start with an 16–18-Fr Foley and note location of difficulty
– If stricture suspected, attempt 1 pass with 12–16-Fr Foley
– If BPH suspected, attempt 1 pass with 18–22-Fr coude
• Choose proper catheter size for pediatric population
– Newborns/neonates based on body weight (no retention balloon)
<1000 gm: 3.5 Fr
1000–1800 gm: 5 Fr
1800–4000 gm: 6.5 Fr
>4000 gm: 8 Fr
– Children
Age <5 yr, 5–8 Fr
Age 5–10 yr, 8–10 Fr
Age 10–14 yr, 10 Fr
Age >14 yr, 10–14 Fr
MEDICATION
First Line
Intraurethral lidocaine jelly may be useful in difficult catheter placement
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Urethral sphincter spasm
– Provide reassurance and ask patient to relax and take slow, deep breaths
– Intraurethral lidocaine jelly may not decrease pain (1)
– Instruct patient to attempt to void when encountering the sphincter
• BPH
– Use a coude catheter to help navigate the prostate
Bend of catheter always facing up toward ceiling (often matches a raised area on balloon port)
– Larger (ie, 20–22 Fr) preferable because less likely to bend on itself
• Urethral stricture/bladder neck contracture
– If unable to pass 14 Fr or larger catheter, dilation likely necessary
– General principle is to place catheter over a wire into the bladder using Seldinger technique
– Flexible cystoscopy is ideal
Advance scope to level of stricture
Pass 0.038” wire through stricture into bladder
– If cystoscope unavailable, consider filiforms with followers, or blindly pass 0.038” soft-tip wire into bladder and confirm location of wire in bladder
Portable pelvic x-ray
Insert 5-Fr open-ended catheter over wire and aspirate; presence of urine indicates bladder location of wire
ALERT
Never dilate urethra unless wire in bladder.
• Wire rigid enough to potentially undermine bladder neck or enter rectum:
– Dilate over wire using serial Amplatz-type renal dilators to 1 size larger than desired catheter (ie, 22 Fr for 20-Fr catheter)
• If dilators unavailable, serial silicone catheters may be rigid enough for dilation:
– Insert Council catheter over wire until return of urine and inflate balloon
• If Council unavailable, use 14-gauge Angiocath to thread wire into Foley.
• Urethral disruption
– Retrograde urethrogram generally necessary for diagnosis, but consider blind passage of catheter in trauma patient without pelvic fracture or signs of urethral injury (ie, blood at meatus, perineal hematoma, high-riding prostate) (2)
– Consider cystoscopically inserting catheter
– Low threshold for suprapubic catheter
• Urethral false passage
– False passage generally down, so use coude with tip pointed up
– If unable to pass coude, use cystoscope to place wire in bladder and place catheter over wire
• Phimosis
– Attempt to retract foreskin
– If able to visualize meatus, attempt to place Foley through meatus normally
– If unable to visualize meatus, perform dorsal slit in foreskin under local anesthesia
• Meatal stenosis
– Inject lidocaine gel
– Serial dilation with Van Buren sounds
• Penile/foreskin edema
– Manually compress edematous skin to minimize edema
– Place catheter once meatus visible
• Retracted female meatus
– Inserting a finger into the vagina may bring meatus forward
– Manually direct catheter into meatus
• Urethral stone or foreign body
– Cystoscopically remove stone/foreign body
• Clot retention with no catheter output
– Ensure at least 20-Fr 2-way catheter in place
– Manually irrigate catheter
– If urine does not remain clear after irrigation, consider placing 3-way catheter (22 or 24 Fr) for continuous irrigation
ALERT
If outflow from catheter stops while on continuous bladder irrigation (CBI), immediately stop inflow.
• Decreased catheter output from bladder debris:
– Manually irrigate
– Consider insertion of larger catheter
• Inability to remove catheter:
– Place syringe on balloon port for 30 min
– Cut balloon port and wait for fluid output
– Insert stiff end of wire through balloon port to attempt to unclog the port
– If still unable to remove catheter:
Under US guidance, spinal needle may be inserted into balloon percutaneously
In women, transvaginal US and needle placement may be preferable
If balloon palpable in bulbar or pendulous urethral, transcutaneous placement of a 22-gauge needle may decompress balloon
– If catheter sutured in place and suture resorbable, consider waiting before removing catheter
– Open cystotomy with retrograde removal is a final resort
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
If unable to place urethral catheter, suprapubic catheterization may be necessary
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
N/A
COMPLICATIONS
• False passage
• Hematuria
• Catheter-associated UTI
– Many catheters have antimicrobial coatings, which may not be beneficial (3)
FOLLOW-UP
Patient Monitoring
• Before removing difficult Foley, ensure no foreseeable indication for recatheterization
• Consider removing catheters at midnight so a failed voiding trial can be managed early during the day
Patient Resources
N/A
REFERENCES
1. Gordetsky J, Bendana E, O’Brien J, et al. (Almost) painless surgery: A historical review of the evolution of intraurethral anesthesia in urology. J Urology. 2010;77:12–16.
2. Lückhoff C, Mitra B, Cameron PA, et al. The diagnosis of acute renal trauma. Injury. 2010;42:913–916.
3. Siddiq D, Darouiche RO. New strategies to prevent catheter-associated urinary tract infections. Nat Rev Urol. 2012;9:305–314.
ADDITIONAL READING
Hollingsworth M, Quiroz F, Guralnick ML. The management of retained Foley catheters. Can J Urol. 2004;11(1):2163–2166.
See Also (Topic, Algorithm, Media)
• Benign Prostatic Hyperplasia
• Foley Catheter Problems (Insertion and Removal) Images 
• Foley Catheter Problems (Insertion and Removal) Algorithm 
• Postobstructive Diuresis
• Urethral Stricture Disease
CODES
ICD9
• 996.64 Infection and inflammatory reaction due to indwelling urinary catheter
• 996.76 Other complications due to genitourinary device, implant, and graft
• V53.6 Fitting and adjustment of urinary devices
ICD10
• T83.51XA Infect/inflm reaction due to indwell urinary catheter, init
• T83.89XA Other specified complication of genitourinary prosthetic devices, implants and grafts, initial encounter
• Z46.82 Encounter for fitting and adjustment of non-vascular catheter
CLINICAL/SURGICAL PEARLS
• Proper initial catheter placement will prevent many subsequent problems.
• A calm patient and proper equipment are critical for success.
• If dilation is necessary, always confirm wire in bladder before dilating.
• Perform voiding trials at times that allow for reinsertion of difficult catheter at a convenient time.
• Suprapubic catheterization is a reliable method of bladder drainage, if needed.
• Remove catheter as soon as possible to reduce risk of catheter-associated UTI.