Understanding Urinary Catheters: A Guide to Male Catheterisation

What is an indwelling urinary catheter?

A urinary catheter is a medical device that is inserted through the urethra into the bladder to allow urine to flow. The catheter is a sterile thin plastic tube that has a balloon at the end which can be inflated inside the bladder to keep it insitu. It can be performed for any aged male but is more common in elderly patients.

Indications

There are many reasons as to why a male patient may need a urinary catheter to be inserted. There are both acute and chronic conditions which can necessitate placement. 

1. Urinary Retention

One of the most common reasons for catheterisation is urinary retention, a condition where a person is unable to empty their bladder. This can result from obstructions in the urinary tract, such as those caused by benign prostatic hyperplasia (BPH), urethral strictures, or bladder stones. In addition, neurological disorders that affect the nerves controlling the bladder, including spinal cord injuries, multiple sclerosis, and Parkinson's disease can cause urinary problems.  

2. Surgical Procedures

Catheters are often used during and after certain surgical procedures to monitor urine output, which is a vital sign of kidney and overall health during surgery. Catheters are also used to manage urinary retention that may result from anaesthesia or the effects of surgery on the urinary tract, especially surgery involving the prostate, genitals, or lower abdomen.

3. Acute Medical Conditions

Certain acute conditions may necessitate the temporary use of a catheter, such as critical illnesses or conditions where the patient is immobilised or in a coma, and natural urination is not possible. During critical illness, it is important that the fluid status of a patient is monitored and controlled. 

4. Chronic Conditions

Patients with chronic conditions that affect bladder control may require long-term catheterisation.

5. Urinary Incontinence

For men who experience severe urinary incontinence and are unable to manage it through other means, it may be that the medical and nursing staff recommend a catheter placement.  For example, it could be used to prevent wound and skin contamination.

Contraindications

If there is or suspected presence of trauma to the lower urinary tract then the patient and proposed procedure should be discussed with the urology team before it is attempted. 

Insertion

As a nurse I have inserted thousands of urinary catheters during my 30 years practice.  As a male nurse one of the first clinical skills that I was taught was how to insert a male catheter by another male nurse.  In my experience, patients can become a little uncomfortable during the procedure, but it is not usually a painful procedure. 

Pre-Procedure

• Patient Communication: Thoroughly explain the procedure to the patient, ensuring they understand and consent to the process.

• Patient Positioning: Assist the patient into a supine position with legs apart to facilitate access to the urethral opening.

• Genital Prep: Remove any clothing obstructing the genital area and cover with a sterile towel, retracting the foreskin (if present) enough to clean the urethra. 

• Physical prep: Hands should be thoroughly cleaned and PPE worn/applied.

Procedure: Detailed Steps

• Aseptic Technique: Put on a disposable apron and sterile gloves and prepare the catheterisation pack on the sterile field.

• Genital Cleaning: Clean the penis with 0.9% sodium chloride, ensuring to handle the foreskin correctly.

• Lubrication: Apply anaesthetic gel within the urethra to minimise discomfort, waiting for the gel to take effect.

• Catheter Insertion: With one hand, hold the penis and with the other, introduce the catheter gently into the urethra until urine begins to flow, then advance it to the appropriate length.

• Balloon Inflation: Inflate the catheter balloon as per manufacturer's instructions to secure the catheter within the bladder.

• Connection the catheter bag and irrigation fluids: Attach the catheter bag to the correct port and start by slowly running in the irrigation fluid and carefully titrate to the required speed.

Post-Procedure

• Reposition Foreskin: This is critical; after catheter insertion, immediately reposition the foreskin (if present) to its natural state to prevent paraphimosis.

• Patient Comfort: Assist the patient to redress and ensure they are comfortable, with the catheter properly secured.

• Monitor and record urine and irrigation: record the urine output and irrigation amounts.

• Documentation: Log all pertinent details including the type, size, and length of the catheter, and the volume of water used for balloon inflation.

• Waste Disposal: Dispose of all used equipment and waste materials according to clinical waste protocols.

Complications

The insertion of a male catheter, while generally safe when performed correctly, can sometimes lead to complications or issues. These can range from minor discomforts to more serious medical conditions. Here are some of the things that can go wrong with the insertion of a male catheter:

1. Urinary Tract Infections (UTIs)

One of the most common complications is the development of urinary tract infections. The introduction of a catheter can introduce bacteria into the urinary tract, leading to infection if not managed properly. Symptoms include fever, painful urination, and cloudy or foul-smelling urine. The UTI could also progress to sepsis. 

2. Urethral Injury

The insertion process can cause trauma or injury to the urethra. This may result in bleeding, inflammation, or the formation of urethral strictures (narrowing of the urethra caused by scar tissue) over time, which can affect urinary function.

3. Bladder Spasms

Some patients experience bladder spasms during or after catheter insertion. These spasms can be uncomfortable or painful and may cause leakage of urine around the catheter.

4. Difficulty Inserting the Catheter

In some cases, particularly when there is an enlarged prostate or a urethral stricture, inserting the catheter can be challenging. This may lead to multiple attempts, which increase the risk of trauma or infection.

5. False Passage

Repeated or incorrect attempts at catheter insertion can lead to the creation of a false passage—a new channel formed by the catheter as it mistakenly punctures the urethral wall. This can lead to significant complications, including bleeding and infection.

6. Hematuria

The presence of blood in the urine (hematuria) can occur due to irritation or injury of the urinary tract tissues during catheter insertion. While often temporary and mild, it requires monitoring to ensure it resolves.

7. Catheter Blockage

Catheters can become blocked by urinary sediment or crystals, especially if not managed correctly. Blockages can lead to inadequate drainage of the bladder, causing discomfort, urinary tract infections, or even bladder distention.

8. Allergic Reactions

Some individuals may have an allergic reaction to the catheter material, typically latex. Symptoms can include itching, redness, and swelling in the urethral area.

9. Paraphimosis

Paraphimosis is a common urological emergency that occurs in uncircumcised males when the foreskin becomes trapped behind the corona of the glans penis. When the catheter is inserted, the foreskin must be returned to its original position, if not, this can lead to strangulation of the glans and painful, vascular compromise, oedema and even necrosis. 

Medico-Legal Considerations

Male catheterisation, while clinically necessary in many instances, carries with it significant medico-legal responsibilities. Healthcare providers must navigate the intricate balance between clinical needs and legal obligations to ensure patient safety, dignity, and legal compliance. The following points highlight some of the key medico-legal considerations.

Informed Consent

Of course, patients must be provided with clear, understandable information about the reasons for catheterisation, the procedure itself, potential risks, and alternative options if any. This consent should be obtained freely and documented appropriately before the procedure.

Competency and Training

Only trained and competent healthcare professionals should perform catheter insertions. This requirement underscores the importance of proper education, training, and competency assessment in preventing complications. The legal ramifications of a poorly performed catheterisation can include negligence claims if the practitioner is deemed to have lacked the necessary skills or knowledge.

Adherence to Guidelines

Following established clinical guidelines and best practices is vital for minimising the risk of complications. Healthcare practitioners are obligated to stay informed about current standards of care and to apply them in their practice. Deviation from these standards without valid reason can lead to medico-legal issues.

Documentation

Comprehensive documentation is essential in the medico-legal context. Detailed records should include information on the informed consent process, the individual performing the catheterisation, the type of catheter used, how the procedure was performed, the amount of residual urine, the equipment used, any complications or difficulties encountered, and post-insertion care instructions. This documentation can be crucial in the event of legal scrutiny.

Managing Complications

Should complications arise from catheterisation, timely and appropriate management is critical. This includes recognising symptoms of potential complications, such as infection or urethral injury, and taking prompt action. Failure to adequately address complications can lead to patient harm and legal liability.

Conclusion

Male catheterisation, when executed correctly, is a low-risk procedure that provides critical relief and medical monitoring for patients. Understanding its purpose, method, and the care required afterwards is essential for healthcare practitioners. Continuous education and adherence to medical standards safeguard the well-being of patients and the legal integrity of medical practice. It's our responsibility as healthcare providers to perform catheterisation with the utmost precision and consideration and minimising potential complications.

My nursing expert witness practice includes provides opinions in many medico-legal cases when things have gone wrong for a patient having had a catheterisation procedure carried out.  My practice has involved cases where patients have developed severe infections, product allergic reactions, men requiring surgery due to trauma during the procedure, poor post operative fluid monitoring, health care practitioners using poor technique causing injury, failure to plan the long-term care and the development of paraphimosis. 

Author

Scott Harding-Lister

Scott is a qualified nurse and solicitor. He was a senior nurse within the NHS before leaving to pursue a career as a solicitor in City practices. In 2013 he set up Apex Health Associates and the expert witness practice has gone from strength to strength. Scott is a medico-legal expert, a nursing expert, and head of practice at Apex.