ClInICal PRaCTICe PRoCeduRe Urinary Catheterization of the Adult Female Introduction nique of aseptic catheterization should insert a catheter. The professional should be familiar with Urinary catheterization is an invasive medical the facility or practice policy and standard precau- procedure (referred to as “in and out” catheterization tions for urethral catheterization. Prior to insertion, or straight catheterization) that involves the inser- an order from a health care provider should be veri- tion of a single-lumen urinary catheter through the fied. The patient and the patient’s family and/or urethra and into the bladder for urine drainage or caregiver, if present, should be informed of the rea- collection. The catheter is removed once the bladder son for catheterization and what to expect in terms of is drained. Catheterization is performed in all care discomfort. Other considerations prior to beginning settings, but more frequently, in acute care hospitals. the procedure are as follows: Catheterization is a common procedure performed • Determine any potential allergies (e.g., latex, by urology nurses in an outpatient setting or urologic betadine). Note any pertinent past medical and practice. Catheterization is often performed before, urologic history that may impair passage of the during, or after certain types of surgery; following catheter, including urethral strictures (rare), trauma; and during childbirth. Table 1 lists indica- pelvic organ prolapse and prior bladder, urethral tions for urinary catheterization. It may also be per- or pelvic surgery or radiation, or any pathologi- formed to deliver liquids used for treatment (e.g., cal condition that may impair passage of the chemo therapeutic agents) or for the diagnosis of catheter. bladder conditions (e.g., X-rays, urodynamic tests). • Assess the patient’s ability to cooperate with the This Clinical Practice Procedure provides informa- procedure (e.g., level of consciousness, ability to tion for the health care professional on the sterile keep knees separated during procedure), and insertion of a non-dwelling catheter through the ure- history of recent and/or difficult catheteriza- thra for bladder drainage in an adult female patient. tions. • Consider obtaining assistance (e.g., two-person Preparation insertion, mechanical aids, additional lighting) to facilitate appropriate visualization and to Female urethral catheterization is generally sim- ensure aseptic insertion technique in high-risk ple, straightforward, and uncomplicated, allowing populations (e.g., patients who are obese or with for ease of catheterization, whether inserting any dementia/behavioral issues). urethral catheter. The length of the female urethra is • Challenging aspect of female urethral cathe - approximately 4 cm long, 6 to 8 mm in diameter terization is localization of the urinary mea- (Figure 1, Female Urethra), slightly curved, extends tus. from the bladder neck to the vaginal vestibule, and ends between the clitoris and vagina (Figure 2, Female External Genitalia). Catheter methods and Task Force Chair characteristics are found in “Teaching Tool: Methods Diane K. Newman, DNP, ANP-BC, FAAN, BCB-PMD and Types of Urinary Catheters Used for Indwelling or Intermittent Catheterization.” The most challeng- Task Force Contributors Susanne A. Quallich, PhD, ANP-BC, NPC, CUNP, FAUNA, ing aspect of female catheterization is locating the FAANP meatal orifice, even more difficult in an obese Margaret A. Hull, DNP, WHNP-BC woman with a large girth or in women with anatom- Gina Powley, MSN, ANP-BC ical differences (e.g., intravaginal urinary meatus) or Katie Wall, MSN, FNP-C post-menopausal vaginal atrophy. If the patient has an artificial urinary sphincter, the implant must be Peer Review opened before catheterization. Urologic Nursing and the Society of Urologic Nurses and If catheterization is being performed in an insti- Associates appreciate the assistance of the individuals listed tution (e.g., acute care, nursing home) or in the below who contributed to this project by providing com- patient’s home by a visiting nurse, aseptic technique ments and direction during the peer review process. is maintained throughout the insertion (see Their reviews do not necessarily imply endorsement of these “Teaching Tool: Methods and Types of Urinary documents. Catheters Used for Indwelling or Intermittent Catheterization”) because failure to properly adhere Laura R. Flagg, DNP, ANP-BC, CUNP to strict aseptic technique when catheterizing the David Martin Julien, DNP, FNP-C, CUNP bladder has been linked to infections and sepsis. Michelle J. Lajiness, MSN, FNP-BC, FAUNA Only health care professionals trained in the tech- Donna L. Thompson, MSN, CRNP, FNP-BC, CCCN-AP UROLOGIC NURSING / March-April 2021 / Volume 41 Number 2 65 Clinical Practice Procedure Table 1. Figure 1. Indications for Urinary Catheterization Female Urethra • Post-operative urinary retention. • To obtain a sterile urine specimen. • Relieve urinary obstruction. • To assess residual urine in the bladder after voiding (if a bladder scanner is not available). • Suspected incomplete bladder emptying/urinary retention in patients with neurogenic lower urinary tract dysfunction causing incomplete bladder emptying, detrusor-sphincter dyssynergia, underactive bladder, or atonic bladder, which leads to incomplete bladder emptying or urinary retention. Neurological conditions include multiple sclerosis, Parkinson’s disease, stroke, diabetes mellitus, spinal bifida, spinal tumors, cerebral palsy, multiple system atrophy, spinal-cord injury, and motor neuron disease. Source: Courtesy of Diane K. Newman, DNP. • Instillation of chemotherapeutic drugs, antibiotics in patients with recurrent urinary tract infections. • Irrigation of blood clots (passive irrigation). Figure 2. • Chronic urinary retention, inability to empty any Female External Genitalia amount of bladder volume due to anatomical or functional bladder outlet obstruction. • Preferred treatment option for urethral stricture dilation and catheterization method of continent urinary diversions. • To empty bladder before and during surgery, and before certain diagnostic examinations. • Use of epidural anesthesia during labor and delivery. • Postnatal urinary retention. • Following procedures used to treat urinary urgency and frequency (e.g., Botulinum toxin injections to the bladder). • Acute bladder outlet obstruction (e.g., gross hematuria, pelvic organ prolapse, strictures). • Administration of drugs directly into the bladder (e.g., chemotherapeutic medication to treat bladder cancer). Source: Courtesy of Diane K. Newman, DNP. equipment • If unsure about size, always start with a standard 14 Fr and increase diameter as Assemble all equipment before beginning proce- needed. dure. • The use of an anesthetic gel is usually not nec- • Lighting as needed. Consider use of a flashlight essary because the main benefit may be from the to assist in visualization of meatus. lubrication as opposed to the anesthetic effect • Disposable clean medical gloves. (Averch et al., 2014). But its use should be con- • Waterproof pad. sidered if this is the patient’s first catheteriza- • Catheter insertion trays (kit) may differ, but most tion or if a difficult catheterization is suspected, include cleaning solution incorporated into an especially if actual discomfort with catheter applicator or swab or added to cotton balls, sterile insertion is anticipated (see “Clinical Practice fenestrated drape with opening in the center, sec- Procedure: Insertion of an Indwelling Urethral ond square-shaped drape may also be available, Catheter in the Adult Female”). sterile gloves, single-use lubricant, 14 Fr single- • Check for lidocaine sensitivity if using a lumen catheter, and measuring container for lubricant containing lidocaine. urine (Figure 3, Catheterization Insertion Tray). • Consider need to assess patient’s bladder for • If the patient has been identified as having fullness (e.g., scan bladder). an allergy to latex, use a 100% silicone catheter. 66 UROLOGIC NURSING / March-April 2021 / Volume 41 Number 2 Urinary Catheterization in the Adult Female Figure 3. Figure 4. Catheterization Insertion Tray Draping Perineum Photo: Courtesy of Diane K. Newman, DNP. Photo: Courtesy of Diane K. Newman, DNP. Procedure • Hygiene before aseptic catheterization re- moves secretions, urine, and feces that Provide as much privacy for the patient as possible. could contaminate the sterile field. • Identify patient using two identifiers (name, • Remove and discard soiled gloves. date of birth) according to facility/practice poli- Set up sterile tray for catheter insertion and cy. maintain a sterile field throughout the catheteriza- • Perform hand hygiene and put on clean medical tion procedure. If there is a break in sterile tech- gloves. nique during preparation or the actual procedure, • Raise bed and position lighting as necessary to restart process with new insertion tray, sterile provide adequate visualization of perineum. gloves. • Assist patient into a dorsal recumbent position • Place the tray so it is more easily accessible (e.g., with knees drawn up and separated in a frog on a mayo tray, bedside table, between the position or with feet flat on bed. patient’s legs), within reach so as to minimize • Sim’s (upper leg drawn up flexed at knee chance of contamination. The tray can be used and hip [supported with pillows, if neces- as a container for urine collection. sary], knee to chest) or lateral position can • Open the outer