Abstract

Indwelling urethral (Foley) catheter insertion is routinely performed prior to abdominal hysterectomy procedures as well as many other gynecological operations. It is imperative to properly prepare a patient prior to the insertion of a urethral catheter to avoid catheter-associated urinary tract infection. This article demonstrates a technique to thoroughly prepare and insert an indwelling urinary catheter prior to a hysterectomy.

Case Overview

Background

Indwelling urinary catheters are placed prior to gynecological operations to decrease the size of the bladder to prevent damage, to prevent postoperative urinary retention¹, and to accurately monitor urine output following surgery.² Unfortunately, Foley catheters are known to cause catheter-associated urinary tract infection (CAUTI). Approximately 80% of urinary tract infections (UTI) are attributed to urinary catheters,³ resulting in patient discomfort, increased length of hospital stay, and higher costs associated with treatment of the infection.⁴ Proper antiseptic technique when placing a urethral catheter can help prevent CAUTI.

Focused History of the Patient

A female patient undergoing an abdominal hysterectomy required urinary catheter placement prior to operation. There were no known allergies or contraindications.

Imaging

No imaging is necessary prior to urinary catheter insertion.

Natural History

CAUTI are common complications caused by Foley catheters due to the disruption of normal bodily flushing of the urethra that removes bacteria from a healthy urinary system.5 The route of transmission of bacteria is ascending, either by “hitchhiking” on the catheter from a contaminated surface to the bladder, by ascending the catheter after placement (a time-dependent process), or both.

Options and Rationale for Treatment

Before inserting an indwelling urinary catheter, one must first consider alternatives. According to the Healthcare Infection Control Practices Advisory Committee (HICPAC), operations involving the pelvic cavity are indications for urethral catheterization. Other indications include need to accurately measure urine output, to bypass bladder obstruction, urinary retention, comfort measures at the end of life, incontinent patients with sacral wounds, and others.⁵ In this case, the patient was undergoing an abdominal hysterectomy, an indication for Foley catheter placement.

Special Considerations

No special considerations were indicated for this patient.

Discussion

Placement of a Foley catheter creates a high risk for CAUTI resulting in increased patient morbidity, hospital costs, length of stay, and antimicrobial use; it can also lead to selection for multidrug resistant bacteria.⁵ Proper aseptic technique, choosing the smallest catheter that allows for proper drainage, and early removal is essential to aid in preventing infection.⁶ This procedure shows an aseptic technique that may prevent UTI related to Foley insertion prior to abdominal hysterectomy.

Instructions for female urethral catheterization from the Society of Urological Nurses and Associates include the following:

Place patient in supine position with legs spread in stirrup position
Perform thorough hand hygiene
Using sterile technique, drape urethra
Clean urethral opening with antiseptic (Betadine used here) while maintaining aseptic technique
Lubricate catheter
Advance catheter until urine appears
Inflate balloon with syringe included in kit (usually 10 ml)
Secure indwelling catheter

After securing the catheter, ensure that the drainage bag is placed below the bladder. Following these guidelines can prevent trauma, erosion, and CAUTI.⁷

Care surrounding indwelling urethral catheters can impact the occurrence of CAUTI as well. In addition to proper preparation prior to insertion, routine cleaning of the meatus, maintaining a closed urinary circuit, and prompt removal of the catheter can prevent CAUTI.⁵ The body of evidence suggests that indwelling catheters should be removed within 24 hours of insertion if at all possible.⁸

In conclusion, proper sterile preparation of the patient before insertion of an indwelling urethral catheter is one important factor in preventing CAUTI.

Equipment

Urinary catheter insertion kit, forceps, and betadine. A Foley catheter kit typically includes a latex or nonlatex catheter of appropriately chosen size and contour, a drainage bag and connecting tube, sterile lubricant, antiseptic solution, sterile cotton balls, sterile 5-10 ml syringe filled with appropriate amount of sterile water, and sterile gloves and drapes.

Disclosures

Nothing to disclose.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.