Foley Catheter Placement: Indications, Maintenance, Complications, and Demonstration on a Preoperative Male Patient

Foley catheterization is a frequently-employed medical procedure to treat urinary retention, aid in bladder drainage/decompression, and facilitate measurement of urine output. This article provides an overview of the indications for Foley catheterization, the steps involved in its insertion, proper care guidelines, and potential complications associated with its use. It is of utmost importance for healthcare practitioners to be comfortable with catheterization procedures to guarantee the comfort, safety, and general welfare of their patients.

Urinary bladder catheterization serves both therapeutic and diagnostic objectives.¹ Depending on the duration of usage, urinary catheters can be categorized as intermittent (short-term) or indwelling (long-term). There are three distinct types of urinary catheters classified by their method of insertion:

1. External catheters adhere to the external genitalia in males or the pubic area in females, collecting urine after it has exited the urethra. These are valuable for addressing urinary incontinence concerns.
2. Urethral catheters are threaded through the urethra, with the tip progressing into the bladder's base.
3. Suprapubic catheters are surgically implanted into the bladder through a suprapubic approach.

Foley catheterization is indicated in the following scenarios:^1, 4

• Acute urinary retention
• Chronic urinary retention
• Preoperative and postoperative bladder drainage
• Monitoring urinary output
• Neurogenic bladder dysfunction
• Bladder irrigation for hematuria or blood clot evacuation
  

1. Assess the patient and determine the appropriate urinary catheter size based on the patient's size, age, or any urologic history. If unsure, contact the appropriate resource for guidance (typically the urology department). Be sure to read all instructions for use and take special note of the balloon threshold to determine the appropriate amount of water to fill the balloon.¹
2. Confirm allergies to ensure the patient is not allergic to any component of the urinary catheter kit, including latex (if applicable) or iodine.
3. Provide as much privacy as possible to the patient.
4. Explain the procedure to the patient before beginning if the patient is not sedated and answer any questions or concerns. For surgical patients, be sure to explain the procedure in the preoperative area so they can understand the expected outcomes or the use of the device in surgery.
5. Perform hand hygiene and don eye protection and non-sterile gloves.
6. Move any blankets or gowns to visualize the genital area, creating enough space without obstacles to ensure an adequate field.
7. For females, frog-leg the patient if possible. If unable to do so due to mobility issues, enlist an additional team member to help keep the legs open to visualize the genital area. For males, observe whether the patient is circumcised; if not, retract the foreskin to view the urethral opening.
8. Clean the region near the urethral opening with Castile soap wipes or other indicated skin cleaning products specified for the genitals (chlorhexidine gluconate is not an appropriate choice for mucosal membranes). For females, ensure to ONLY clean in a front-to-back motion and discard the towelette, obtaining a new one after each swipe of the region.
9. Doff non-sterile gloves.
10. Place the catheter kit between the patient's legs. Begin opening the urinary catheter kit by opening the flap furthest away from you first, then the two sides, and finally, the flap closest to you to create a sterile field.
11. If using the sterile gloves provided in the kit, be sure to only touch the outer packaging of the gloves by pinching the glove's packaging when extracting them from the kit to avoid contaminating the rest of the kit.
12. On a separate surface from where your kit is located, sterilely open the gloves and don them. Remember, the outer inch of the perimeter of the glove's packaging is considered unsterile and is used to open the packaging.
13. Begin setting up the kit by first draping the fenestrated drape over the genital region with the patient's genitalia visible through the hole. Next, unsheathe the catheter, taking special care not to contaminate the catheter by keeping control of the tip. Then, attach the water syringe to the balloon port (many new kits instruct not to pretest the balloon; follow the manufacturer's instructions based on the brand). Apply lube to the area of the kit free from other supplies and place the tip of the catheter into the lube.
14. Lastly, open the Betadine prep sticks and make sure they are easily accessible on the sterile field.
15. Patient prep, catheter insertion, and balloon inflation differ for males and females.
    1. Males:
       1. Hold the patient's penis with the non-dominant hand, ensuring the foreskin is still retracted if applicable.
       2. Gently lift and stretch the penis to a 60–90-degree angle and keep it in this position to ensure ease of insertion and maintain sterility.²
       3. Begin prepping with a Betadine-soaked prep stick by starting at the urethral opening and moving outward in a concentric circular motion. Then, throw the used prep stick off the field directly into a trash can and repeat this step for the remaining prep sticks, making sure to fully prep the meatus.²
       4. Once a full prep is achieved, grab the catheter near its tip with your dominant hand. Begin inserting the catheter into the urethral opening, making sure not to contact the penis with your fingertips at any point.
       5. Keep threading the catheter into the urethra without contaminating the dominant hand until the catheter hub meets the ureteral opening. If there is any resistance at any point, immediately stop insertion and follow the institution's policies and procedures for the next steps.
       6. At this point, keep the dominant hand on the catheter to ensure it does not begin to slide out of the urethra, and let go of the penis with the non-dominant hand.
       7. If urine begins to drain into the catheter, you may inflate the balloon at this time. If not, apply pubic pressure and wait for urine flash. If no urine is produced, do not inflate the balloon. There may be a false opening or other urological issues.¹ Follow the institution's policies and procedures for the next steps if urine is not draining into the catheter before inflating the balloon.
       8. Once the balloon is inflated, begin pulling out the catheter gently until resistance is met (indicating the inflated balloon is against the urethral orifice).
       9. For male patients who are not under general anesthesia or sedation, anesthetizing the urethra is a desirable step to follow to ensure the patient's comfort during the procedure. Lidocaine gel or Lidocaine-prilocaine cream can be utilized to achieve local anesthesia of the urethral mucosa.
    2. Females:
       1. Using the non-dominant hand, separate the labia as widely as possible with the thumb, index, and middle fingers and ensure that the urethral opening is visible.
       2. Keep visualization by maintaining hand placement and keeping the labia separated to allow full visualization and maintain sterility once the meatus is cleaned. If the labia closes back at any point after cleaning, the meatus must be re-prepped.
       3. Once visualization is achieved and your non-dominant hand is in a position to maintain visualization, begin prepping by taking a Betadine-soaked prep stick and first prepping the labia minora furthest from you from top to bottom. Immediately discard the prep stick (remember, one swipe per stick; do not go over the prepped area with a used prep stick).
       4. Repeat this step for the labia minora closest to you and throw the stick away.
       5. Using a clean Betadine-soaked prep stick, do one swipe from top to bottom in the area between the labia minora, making sure to cover the entire meatus and urethral opening. Once prepping is complete, the separation of the labia must be maintained until the balloon is inflated.
       6. Taking the tip of the catheter in the dominant hand, begin inserting the catheter into the urethral opening, taking care not to touch the dominant hand to any part of the patient's meatus. If resistance is met, immediately stop insertion and follow the institution's policies and procedures for the next steps.
       7. Once urine is visualized in the tubing, continue to insert the catheter for 1–2 more inches and inflate the balloon.
       8. Once the balloon is inflated, begin pulling out the catheter gently until resistance is met (meaning the inflated balloon is at the base of the bladder opening).
16. Use the stat-lock provided in the kit to lock the catheter to the patient's leg to prevent kinking or accidentally pulling out the catheter while the balloon is inflated, making sure there is enough length provided for tubing so the patient can move freely.
17. Clean up any trash leftover from the kit and cover the patient's back with a gown and blankets.
18. Discard gloves and perform hand hygiene.

Proper care of the Foley catheter is essential to prevent infection and other complications:^1, 2

• Maintain a closed urinary drainage system.
• Regularly empty the drainage bag to prevent overfilling.
• Ensure the catheter is free of kinks or obstructions.
• Maintain sterile technique during catheter care to prevent urinary tract infections.
• Encourage proper hygiene to prevent contamination during handling.

Several complications can arise from Foley catheterization:

• Urinary tract infections (UTIs)
• Catheter-associated bacteriuria^1, 2
• Bladder spasms
• Catheter blockage or occlusion
• Catheter-associated trauma or urethral injury
• Balloon inflation issues
• Blood in urine (hematuria)
• The encrustation of the catheter²
• Sepsis (rarely)

Male/Female Foley catheterization is a valuable procedure in various clinical settings for managing urinary issues. Healthcare professionals should be well-versed in the indications, insertion technique, proper care, and potential complications associated with Foley catheter use. By adhering to best practices and maintaining vigilant care, healthcare providers can minimize complications and ensure the well-being of patients requiring urinary catheterization.^1, 3

• Foley Catheter Kit

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