Prepare the patient

The procedure should be explained to the patient. A description of any procedure is always appropriate in a conscious adult, but it is particularly important in a procedure involving the genitalia. Explain to the patient that a thin tube will be gently placed into his/her bladder. You may suggest that the procedure, although uncomfortable, can usually be completed quickly. Point out that while this is usually the case, occasionally, obstruction is encountered and bleeding may occur. In that case, other catheters may be used, and rarely, consultants may need to be called to assist in the procedure.

Allergies

Ensure the patient has no allergies. If the patient has an allergy to latex you want to ensure that you do not use latex gloves or catheter. If the patient has an allergy to iodine do not use betadine prep.

 

Pain control

It may be appropriate in some circumstances to systemic analgesics like opiates or benzodiazepines to help facilitate catheter placement.

Positioning

In both males and females, the patient should be positioned supine (lying flat). Females should be placed in the frog-leg position so you can more easily access the urethral meatus.

Prepare the equipment

Sterility

Utilize sterile, well-fitting gloves for the procedure. Your dominant hand will place the catheter. Your non-dominant hand will become unsterile because it will be holding the genitals. It is important to remember that sterility is essential in this procedure since urinary tract infections and bacteremia can be the consequence of poor technique. You should put on the sterile gloves after the opening the packaging and before touching any of the supplies. It is important to have the equipment laid out neatly and within reach.

 

Test and Prepare your equipment

Before inserting the catheter, ensure that the balloon inflates and deflates easily. Use only water - not normal saline - to inflate the balloon as normal saline can precipitate, making the balloon difficult to deflate when the patient is ready for catheter removal. Final steps in preparation include attaching the catheter to the collecting tubing, opening the sterile package of viscous lidocaine or topical lubricant, and pouring the betadine solution onto the cotton balls, which will be used in the next step.

 

 

STERILE Prep

Female

Place the sterile, fenestrated drape found in the Foley catheter kit over the region. Separate the labia with your non-dominant hand and locate the urethral meatus. (N.B. this hand is now considered unsterile, and should not be removed from the labia, or touch any sterile equipment, during the procedure.) Be sure to distinguish the meatus from the vaginal introitus. Use the wet cotton swab to prep the urethral meatus in the direction from the urethral meatus toward the anus. (This will help avoid contaminating the vagina, urethra and catheter with rectal flora.) Do this at least 3 times until the urethral meatus and surrounding area is cleansed.

Male

Place the sterile, fenestrated drape over the penis. If the patient in not circumcised, you will need to expose the glans penis by retracting the foreskin proximally. Hold the penis in your non-dominant hand (which is now considered unsterile and should not be removed from the penis or touch any sterile equipment during the procedure.) Use the betadine-soaked cotton swabs to prep the urethral meatus (using your dominant hand) and surrounding glans, beginning in the center and swabbing in enlarging circles. Do this at least 3 times until the urethral meatus and surrounding area (a couple of centimeters around) is cleansed.

Anesthetize and lubricate

Female

The tip of the Foley catheter should be coated with the sterile lubricant found in the Foley catheter kit.

 

The use of viscous lidocaine is not mandatory in females, but if desired, can be injected directly into the urethral meatus.

Male

Particularly in males, it is important to use lidocaine jelly to numb the urethra. Male urethras are much longer than females and Foley placement can be very uncomfortable without anesthetic jelly. The vial of jelly (commonly availabe as a "Urojet", as depicted in the animation) should be inserted gently into the distal urethra and slowly injected. Wait about a minute for the lidocaine to numb the urethra. It is also prudent to cover the urethral meatus or gently hold the tip of the penis, after you have placed the lidocaine so that it does not leak out.

If you suspect a difficult TUC placement you may utilize two or three vials of jelly, as this will sometimes facilitate TUC passage through the urethra. If for some reasone you choose not to use lidocaine jelly (e.g. allergy to lidocaine), the tip of the catheter should be lubricated with the sterile lubricant as depicted above.

Placement

Female

With your non-dominant hand continuing to separate the labia, the tip of the catheter is gently passed into the urethra. If you accidentally insert the catheter into the vagina, do not remove it and replace it into the urethra. If you do so, you may contaminate the urethra with vaginal flora. Instead either remove the tubing and use a new catheter or leave the tubing in temporarily in order to better locate the urethral meatus. In this case you must use a new catheter as well. Once you see urine in the tubing, pass the catheter all the way to the bifurcation and inflate the balloon as mentioned above.

Gently pull the catheter back until you feel resistance. Do not inflate the balloon unless you visualize urine in the tubing. Secure the catheter to the patient's leg with tape, allowing for movement by the patient.

 

 

Male

For a male patient, start by using your non-dominant hand to hold the penis at a perpendicular angle to the patient's abdomen and gently grasp it pulling upward. The tip of the catheter is gently passed into the urethra. Watch the tubing in order to identify urine as soon as it appears. Once you see urine in the tubing, pass the catheter all the way to the bifurcation of the Foley and inflate the balloon. Then, gently pull the catheter back until you feel resistance. Do not inflate the balloon unless you visualize urine in the tubing. Secure the catheter to the patient's leg with tape, allowing for movement by the patient. Make sure that you re-place the uncircumcised male patient's foreskin.

3-WAY IRRIGATION

Three-way TUC should be used when a patient presents with gross hematuria or urinary blood clots causing AUR. Prior to initiating normal saline or sterile water drip irrigation via a three-way TUC, it is important for you to manually irrigate the bladder of any clots with a large bore (twenty-four French, for example), standard catheter using two to four liters of normal saline or sterile water. If manual irrigation is not attempted preliminarily, continuous bladder irrigation may not be successful because of catheter occlusion. We recommend, prior to clot irrigation, using one dose of a flouroquinolone (for excellent prostate penetration) and premedication with analgesics when indicated.

 

A three-way catheter has an outlet for urine, an inlet for water for balloon inflation and an inlet for either a sterile water or normal saline drip. (Either may be used safely.) The latter inlet is attached to an IV bag and water or saline is dripped in via that inlet into the bladder, ideally "washing out" the bladder of hematuria and blood clots. This process is called "continuous irrigation." A large bore, three-way catheter is recommended for continuous irrigation (twenty-four French, for example) because the larger outlet allows bigger clots to be cleared. It is important to ensure that an automatic pump does not control the saline or water drip: If a clot lodges in the catheter outlet, the pump can force expansion of the bladder, possibly leading to rupture. Most patients requiring three-way irrigation will require urology consultation and admission to the hospital. Exceptions may include a patient who has old blood in the bladder that is easy to clear.

 

 
If you suspect a difficult TUC placement you may utilize two or three vials of jelly, as this will sometimes facilitate TUC passage through the urethra. Lubricate the tip of the catheter, especially if you are not utilizing xylocaine jelly.
 
 
 
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