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Urinary catheterization is a common clinical intervention to ensure adequate urinary drainage when patients cannot void effectively. When a urinary catheter cannot easily be placed, a thorough understanding of anatomic considerations that may impact catheter placement and fundamental working knowledge of various Foley catheterization techniques can aid physicians and other healthcare professionals in successfully enabling urinary bladder decompression. This activity reviews anatomic and clinical considerations when encountering difficult catheterizations and highlights the role of the interprofessional team in evaluating and managing difficult urinary catheterizations to improve the care for men and women undergoing Foley placement. Objectives: Identify the contraindications to urinary instrumentation in difficult foley catheterization. Describe the equipment, personnel, preparation, and technique regarding difficult foley catheterization. Review the techniques to assess and treat patients who are difficult to catheterize. Summarize interprofessional team strategies for improving care coordination and communication to improve care for difficult foley catheterization and improve outcomes. Access free multiple choice questions on this topic.

The placement of a Foley catheter is a common clinical intervention performed to allow for external urinary drainage. It is estimated that over 100 million urinary catheters are sold globally every year, with about 30 million used just in the United States.[1] Urinary catheterization may be performed to relieve bladder outlet obstruction, such as benign prostatic hyperplasia, strictures of the bladder neck or urethra, to treat acute urinary retention, or to adequately drain a hypotonic neurogenic bladder. Routine urinary drainage in perioperative periods or intensive care settings allows for improved bladder drainage, urine chemistry evaluations, and fluid monitoring. Urinary catheterization may be performed to obtain an uncontaminated specimen for culture, irrigate clots or blood from the bladder, instill therapeutic agents intravesically, and evaluate the bladder fluoroscopically or during urodynamic studies. While most patients tolerate urinary catheterization with minimal discomfort or complications, some patients will endure difficult, painful, or traumatic insertions. Such discomfort is often unnecessary, and multiple attempts at catheter insertion risk significant injury to the urethra, prostate, or bladder. Improper and sub-optimal techniques for addressing difficult urinary catheterizations can lead to bladder distension, reflux, patient discomfort, detrusor damage, unnecessary therapeutic delays, serious urological complications, avoidable urinary infections, permanent scarring, and prolonged hospital stays.[2] Both normal and abnormal anatomic variations can contribute to failed attempts at urinary catheterization. A patient's urologic history will identify prior surgical or radiological interventions that may impact anatomic relationships important to urinary catheterization. Prior instrumentation, trauma, and sexually transmitted infections can also lead to anatomic changes that could pose a challenge for Foley placement.

Both normal and abnormal anatomic variations can contribute to failed attempts at urinary catheterization. A patient's urologic history will identify prior surgical or radiological interventions that may impact anatomic relationships important to urinary catheterization. Prior instrumentation, trauma, and sexually transmitted infections can also lead to anatomic changes that could pose a challenge for Foley placement. A difficult catheterization can be anticipated and properly addressed with a better understanding of patient-reported symptoms, a detailed genitourinary review of systems, obtaining a good urological history, and a thorough physical examination. A risk prediction model to estimate the likelihood of difficult Foley urethral catheterization that will likely require extensive urologic instrumentation has been developed, although it lacks validation.[3] It is also unclear how useful it would be in actual clinical practice.[3] Education on available techniques, tools, and instruments to assist in performing urinary catheterization can improve successful Foley placements even in difficult patients, minimize preventable urethral trauma, reduce the rate of catheter-related urinary tract infections (CAUTIs), and avoid unnecessary urological consultations. This review article aims to educate and empower readers on the anatomical and physiological basis for difficult urethral catheterizations and outline a practical, reasonable approach to Foley placement when difficulty is anticipated, or several attempts have already been unsuccessful.[2]

Difficult catheterizations and repeat attempts at Foley placement cause patients substantial pain, anxiety, and possible long-term complications. Instrumentation and trauma to the urethra can increase the risk of post-instrumentation infection. If continued pressure is placed when resistance is encountered during urinary catheterization, the urinary catheter can cause a false urethral passage, undermine the bladder neck, or perforate the urethra or bladder. Trauma to the urethra, prostate, or bladder neck can lead to hematuria, infection, and scarring. In the setting of prior surgeries or radiation, rectal perforation has also been seen. In poorly mobile or immunocompromised patients, trauma from unsuccessful catheterizations can contribute to urinary tract infections, Fournier gangrene, or peri-urethral abscess formation. In the longer term, urethral trauma from instrumentation may lead to permanent or long-lasting urethral stricture disease. Patients who are confused, have dementia, or have a brain injury may seek to traumatically remove their Foley catheters by pulling on them. If the balloons are removed intact, this will obviously cause possibly significant traumatic injury to the urethra with bleeding, pain, possible infection, and the potential development of further scarring and strictures. If the balloon is not intact, if pieces are missing, or if the catheter cannot be found at all, a cystoscopy is recommended to make sure that no balloon fragments are left behind in the bladder, where they can calcify and form bladder stones.

Clear communication with the patient and treatment team relieves distress and improves outcomes when a difficult catheterization is encountered. A two-person indwelling urinary catheterization team was found to decrease the incidence of catheter-associated urinary tract infections (CAUTIs) in a 2017 study.[33] A team of emergency room leaders, infection prevention members, nursing, and research specialists was created to evaluate a process of indwelling catheterization that would start with a safety time-out, much like a pre-procedural/surgical time-out, to assess pertinent history, physical exam findings, appropriateness of the catheterization, and would include a review of the insertion techniques to educate and familiarize the entire team. After a time-out, one physician executed the insertion while the other monitored for compromise of sterility. This approach significantly favorably impacted the rate of CAUTI at this particular institution. This time-out approach can be applied to all patients requiring catheterization, whether it is a formal time-out or a personal checklist that is reviewed before catheterization. This time-out could potentially address the 40% or more cases when urology consults would have been unnecessary and help intercept inappropriate techniques, tools, and staff performing the catheterization.[33] The "flipped classroom" approach to nursing education, where students view online lectures and read current review articles before class, has proven successful in improving nursing knowledge and skills regarding Foley catheterization.[34] Improving Healthcare Team Education and the Use of Skilled Nursing Catheterization Teams:

The "flipped classroom" approach to nursing education, where students view online lectures and read current review articles before class, has proven successful in improving nursing knowledge and skills regarding Foley catheterization.[34] Improving Healthcare Team Education and the Use of Skilled Nursing Catheterization Teams: Prospective analyses looking at Foley placement problems reported that urologic consultations for difficult Foley catheterizations were unnecessary in 41% to 70% of cases as no specialized urological instrumentation was required for successful placement.[27][35] (These numbers did not include those times when a urology nurse was called and successfully placed the catheter using only standard equipment and supplies.) Complications from prior attempts at catheterizations occurred in 37%, including significant urethral trauma in 32%. Most consultations for difficult Foley placement occurred between 5 PM and 6:30 AM. The mean time between the initial attempt at Foley catheterization and placement of a urology consultation was 262 minutes, and the average patient had about three separate attempts before urology was involved. Non-urologist physicians frequently did not attempt catheterization due to lack of training, inexperience, or "not feeling comfortable."[27] Even physicians do not always receive adequate training or supervision for Foley catheterization. In a study done at a tertiary care academic teaching center, 76% of the interns indicated that their practical training in Foley placement was either inadequate or non-existent, and over half were not supervised during their first attempt at catheter placement in an actual patient.[36]

Even physicians do not always receive adequate training or supervision for Foley catheterization. In a study done at a tertiary care academic teaching center, 76% of the interns indicated that their practical training in Foley placement was either inadequate or non-existent, and over half were not supervised during their first attempt at catheter placement in an actual patient.[36] Successful programs to improve successful urinary catheterizations with fewer injuries and reduced catheter-related urinary tract infections (CAUTIs) included general nursing, medical student, and resident education in urethral anatomy and proper Foley placement techniques.[37][38][39] Besides improved undergraduate education, mandatory training on a yearly or biannual basis for all clinical staff is recommended to improve skills and patient outcomes.[40] Improved education of physicians (particularly rehab, emergency room, and hospitalists) and nurses should focus on various placement techniques, different types of Foley, and the optimal management of difficult catheterization. Utilizing a difficult Foley placement algorithm and implementing a skilled nursing catheterization team has been able to greatly decrease the incidence of preventable urinary trauma.[41] The need for urological consultations for catheter placement dropped from 53% (before implementation) to about 12% afterward, and patient outcomes, including CAUTIs, improved.[41] Even just providing a few nurses with more extensive training and improved skills in Foley placement has also been shown to be helpful.[37]

An interprofessional team approach to care will help a patient feel more comfortable and understand the need for catheterization. A Foley catheter can be a new and intimidating device for a patient. If the patient is required to maintain the catheter for longer than their hospital stay, it can be distressing and embarrassing for the patient. With the help of nursing education, patients can fully understand their limitations while the Foley catheter is in place and can safely care for their catheter on their own while still living a normal life. Education for catheter care is important for patients who may be overwhelmed by this new piece of equipment, especially if they have to manage the Foley and bag at home. The important points should be emphasized by all members of the care team and include the need to maintain a tension-free suspension with the use of a leg strap and keeping the bag below the bladder level, washing hands before handling or exchanging the catheter, and exchanging the catheter every month if it is to be in place chronically. Consideration should be given to replacing the urethral Foley catheter with a suprapubic tube in situations where long-term catheterization is likely to be needed. To achieve the best care for the patient, every team member must be aware of and invested in the care plan. Communication throughout the catheterization process and in the post-catheterization period will help the patient recover with confidence. The ordering provider should relay both for Foley catheter placement and clearly define the anticipated duration of urinary catheterization. Once the decision has been made, there should be no delay in removing a urinary catheter. Many members of the care team possess the basic skills required to place a Foley catheter. When a problematic Foley catheterization is encountered, the team should debrief and take the opportunity to teach team members assessment and better catheterization techniques. If members of the care team desire to practice this skill, it should be offered and overseen by more experienced healthcare professionals to improve skills that will ultimately improve patient outcomes.

Many members of the care team possess the basic skills required to place a Foley catheter. When a problematic Foley catheterization is encountered, the team should debrief and take the opportunity to teach team members assessment and better catheterization techniques. If members of the care team desire to practice this skill, it should be offered and overseen by more experienced healthcare professionals to improve skills that will ultimately improve patient outcomes. Healthcare professionals may feel negatively toward themselves after a failed urinary catheterization, as urinary catheterization is generally seen as a simple procedure. The truth is that many situations can significantly complicate catheterization. It is everyone's responsibility on the healthcare team to understand their limitations when it comes to Foley catheterization. If a failed attempt occurs, it is best to step back and figure out why or ask for help before attempting another passage. Prevention of Inappropriate Foley Catheter Self-Extractions by Patients Some patients with dementia, brain injury, or confusion may seek to pull out their Foley catheters. They are remarkably successful in doing this despite not deflating the balloon first. Besides being painful, this risks permanent scarring and damage to the lower urinary tract. Often, the catheter has to be replaced. Use of patient restraints, a sitter, or sedation have been the traditional means of managing this, but they are costly, use valuable resources, pose some risk to the patient, and are generally not very effective. A safe and effective nursing-based protocol has been developed and used with excellent outcomes. By making the protocol a nursing procedure, it avoids the delays in seeking a physician's order to implement safe and practical precautions in patients at risk of inadvertent self-harm. The protocol was developed in consultation with several nursing staff and was found to be very helpful and effective. While initially designed primarily for Intensive Care Units (ICU), rehab units, and recovery rooms, they can be applied to any inpatient location where patients with Foley catheters are assigned.[42] For more details on these valuable and useful nursing protocols, see our companion reference StatPearls article on "Prevention of Inappropriate Self-Extraction of Foley Catheters."[42]

A safe and effective nursing-based protocol has been developed and used with excellent outcomes. By making the protocol a nursing procedure, it avoids the delays in seeking a physician's order to implement safe and practical precautions in patients at risk of inadvertent self-harm. The protocol was developed in consultation with several nursing staff and was found to be very helpful and effective. While initially designed primarily for Intensive Care Units (ICU), rehab units, and recovery rooms, they can be applied to any inpatient location where patients with Foley catheters are assigned.[42] For more details on these valuable and useful nursing protocols, see our companion reference StatPearls article on "Prevention of Inappropriate Self-Extraction of Foley Catheters."[42] On arrival to the floor or nursing unit, nurses identify every patient with a Foley catheter that is not being removed immediately. The initial nursing assessment should include a relative risk of potential inappropriate patient self-extraction of the Foley catheter. Any increased risk should be passed on to the next nursing shift when giving a report. Patients awakening from anesthesia, those with pre-existing dementia or confusion, and individuals with brain injuries or strokes are most at risk, especially if they have pulled out their Foley catheters previously. Patients who are alert and awake are at minimal risk but may still need to be reminded to take their catheters with them if they get out of bed! If it is determined that a patient is at risk of inappropriate catheter self-extraction or even might just potentially be at risk, the following interventions may be immediately implemented by nursing: Place the catheter and catheter bag tubing under the patient's thigh, making it harder for a confused patient to find and grab. Tape the catheter and catheter bag tubing directly to the patient's skin after leaving some slack for mobility. (This makes it harder for a confused patient to fully grasp the catheter or tubing.) Use diapers, shorts, mesh pants, wide ace wraps, pajamas, pads, and/or thigh-high hose around the leg used to secure the catheter. (This adds more layers between the catheter and the confused patient's grasping hands.)

Tape the catheter and catheter bag tubing directly to the patient's skin after leaving some slack for mobility. (This makes it harder for a confused patient to fully grasp the catheter or tubing.) Use diapers, shorts, mesh pants, wide ace wraps, pajamas, pads, and/or thigh-high hose around the leg used to secure the catheter. (This adds more layers between the catheter and the confused patient's grasping hands.) Tape a small straight catheter in front, right on top of the pads, shorts, and pads. This will give a confused patient a tube to pull on that will not cause any real harm. Essentially, a harmless decoy!