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  5. Difficult Catheterisation

Please note: This page is intended for healthcare professionals only. It is designed as a general educational guide and does not replace local guidance, senior clinical advice, or individual clinical judgement. Patients should not use this page as medical advice and should seek advice from an appropriate healthcare professional.

Difficult Catheterisation

Difficult catheterisation is a common urological challenge that requires care, an understanding about why the catheter is difficult and knowledge of how issues may be overcome.

Important

Do not make multiple blind catheterisation attempts. Repeated failed attempts at blind catheterisation can be incredibly painful for patients, result in significant urethral trauma, false passages (see below) and urosepsis. Seek assistance if you have reached the limit of your skill level.

Common causes & practical tips

Common urological reasons underlying difficult catheterisation:

1Prostatic enlargement

2Urethral strictures

3False passages

4Urethral trauma

5Meatal stenosis

6Phimosis

7Penile oedema

8Buried penis

9Poor technique +/- tense patient

When standard catheter insertion technique fails - a second gentle attempt may be performed with good technique if appropriate

Practical tips

  • ✓Revise your technique – know your steps (see HERE)
  • ✓Good positioning + relaxed patient is key!
  • ✓Use plenty lubrication
  • ✓Be patient and calm
  • ✓Use an appropriate catheter:
    • –Enlarged prostate = Tiemann/Coude
    • –Stricture = use smaller catheter (12Fr) or the size patient uses for ISC
  • ✓Recognise when to stop!
 

Troubleshooting specific anatomy

1Phimosis

Common condition that can make visualising the urethral meatus difficult.

  • What to do?
    • ►Retracting the foreskin as much as safely possible and hold the glans penis between fingers firmly when catheterizing
    • ►If pinhole – dilate the opening gently with ISC / disposable meatal dilators (patients use them for meatal stenosis managment). These are more pliable than regular catheter and allow to gently stretch up the opening. Start with smallest available (8 or 10Fr ) → sequentially dilate to 1 size up from the catheter you are inserting (14Fr ISC if inserting 12Fr urethral)
  • If any doubt → escalate and speak with Urology SpR
  • Once catheterised → will need follow-up either LTC or circumcision / dorsal slit
2Penile oedema

Penoscrotal oedema has many reasons – including anasarca, heart failure etc. Oedema may make the foreskin difficult to retract, restricting the view of the urethral meatus.

  • Reduce the oedema by applying gentle pressure to the penis (like decompressing oedema in lower limb) → catheterise
  • Don’t confuse oedema with infection or gangrene
  • If any doubt → escalate and speak with Urology SpR
3Urethral False Passages

A false passage is an abnormal tract alongside the urethral lumen that occurs after traumatic or forceful instrumentation (catheter, cystoscope, foreign body).

Consequence of false passage – difficult catheterisation, stricture formation, infection, bleeding

  • Suspect a false passage if there is resistance, pain, bleeding, or no urine drainage after catheter insertion.
  • Stop: do not keep trying blindly. Catheter commonly favours passing into the false passage over the urethra.
  • Further attempts usually need flexible cystoscopy and guidewire catheterisation to visualise the true lumen – call urology SpR
  • The true lumen is commonly anterior to the false passage - this knowledge can be used to find the true urethra in challenging cases
  • Next catheter change should usually be done by Urology +/- over a guidewire unless the patient can safely TWOC.
 

Advanced catheter insertion techniques

Usually done by Urology SpR. An SHO can perform this as well only after appropriate teaching.

In acute settings SHOs are often asked to assist with these procedures and they can be a great training opportunity.

Please avoid catheter insertion over guidewire blindly without a cystoscope. Without direct vision, there is no reliable way of knowing whether the wire is in the bladder and therefore whether the catheter will be correctly sited.
Flexible cystoscopy + catheter insertion over a guidewire
  • Direct visualisation of urethra using a camera.
  • Once in bladder - a guidewire is passed through the cystoscope into the bladder.
  • An open tip catheter inserted then inserted over the wire, balloon inflated and wire removed.
Tip: if open tip catheter not available – can cut the end of normal catheter (check the balloon is inflatable after this) or guidewire can be passed through a cannula

Kit

  • ►Basic catheter equipment
  • ►Irrigation fluid – for instillation during cystoscopy (normally 0.9% saline)
  • ►Giving set + drip stand
  • ►Flexible cystoscope
    • ►Disposable → scope + screen
    • ►Reusable → scope + light lead + light source + screen stack
  • ►Guidewire (usually a Terumo or Sensor/Soprano wire)
  • ►Catheter – ideally open tip
Suprapubic catheter (SPC) insertion

SPC insertion carries significant risks and must be carried out by a suitably qualified clinician.

Ideally needs Ultrasound guidance, possibly with the assistance of a radiologist.

Read HERE under “Bladder Procedures”.

Acute indications:
  • Retention with impossible or repeatedly failed urethral catheterisation
  • Urethral trauma where a single gentle attempt at standard catheterisation has failed
Contraindications:
  • Insufficiently filled or impalpable bladder
  • Bladder must be filled for successful and safe procedure
  • Bladder may not be palpable in patients with large body habitus
  • Suspicion or history of bladder cancer - haematuria of unknown cause, abnormal masses on ultrasound
  • Uncorrected anti-coagulation, recent use of some antiplatelets and/or bleeding disorders
  • Infection at the SPC insertion site
  • Previous femoral – femoral cross over
  • Previous extensive abdominal surgery (relative contraindication) – consider adhesions
  • Structures overlying the bladder – ascites, pregnancy, prosthetic devices, hernia meshes

Kit

  • ►Incontinence pads, cleaning solution for skin, sterile gloves and drapes
  • ►Ultrasound + gel (if trained to use it!)
  • ►Local anaesthetic (10mL 1% lidocaine)
  • ►SPC insertion kit (pre-packed kit example – Mediplus)
  • ►Catheter bag
  • ►Dressing
  • ►+/- Heavy Silk stitch
Percutaneous needle aspiration of urine

An emergency technique for patients who cannot be catheterised via the urethral or suprapubic route, but who are in retention. This is generally reserved for patients in acute, retention to alleviate severe pain.

Technique:
  • Position patient – supine or slightly head down
  • Palpate bladder
  • If able to use and interpret USS – check to see no overlying structures at puncture trajectory
  • Location → 2cm / 2 finger breaths above pubic symphysis in line with umbilicus
  • Insert needle perpendicular to the patient
  • Once urine is draining – aspirate urine

Kit

  • ►Spinal needle (or cannula if thin patient) + 50ml syring with Luer lock + basin to discard urine
 

Take home message

  • ✓Use adequate lubrication (one or two tubes)
  • ✓Select an appropriate catheter size
  • ✓Position patients adequately
  • ✓Understand why a catheter is difficult and how the issue(s) may be overcome
  • ✓Never force a catheter in – use gentle and steady pressure
  • ✓Handle the penis properly – perpendicular to body and stretched upwards
  • ✓Screen for contraindications – blood at meatus, pelvic fractures, known history of false passages/urethral stricture
  • ✓Consider using a curved tip catheter early for known BPH
  • ✓Seek senior help after two failed gentle attempts with ideal technique

References

  • Villanueva C, Hemstreet GP. Difficult male urethral catheterization: a review of different approaches. Int Braz J Urol. 2008;34(4):401-412.
  • Cancio LC, Sabanegh ES Jr, Thompson IM. Managing the Foley catheter. Am Fam Physician. 1993;48(5):829-836.
  • Nyman MA, Schwenk NM, Silverstein MD. Management of urinary retention: rapid versus gradual decompression and risk of complications. Mayo Clin Proc. 1997;72(10):951-956.