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A step-by-step guide to the procedure for inserting an indwelling catheter into a female patient

This article is the second part of a six-part series on urinary catheters. It provides a step-by-step guide to the procedure for inserting an indwelling catheter into a female patient.

Citation: Yates A (2017) Urinary Catheter Part 2: Inserting the Urinary Catheter into the Female Patient. Nursing time [online]; 113: 2: 50-52.

Author: Ann Yates is the Director of Incontinence Services for Cardiff and Vale University Health Committee.

Urethral catheterization involves inserting the tube into the bladder using aseptic technique (Dougherty and Lister, 2015). There are many reasons for this procedure, including:

Catheterization is associated with many complications, including:

The risk of complications means that the catheter can only be used after consideration of other incontinence management options and should be removed as soon as clinically appropriate (Loveday et al., 2014).

Before inserting the catheter, a thorough risk assessment should be performed. As with all procedures, after discussing the benefits and risks of catheterization and its impact on lifestyle and sexual relations, where possible, patient’s informed consent should be obtained and recorded (Prinjha and Chapple, 2013; RCN, 2012).

Female urinary catheter insertion is a highly skilled operation (RCN, 2012). Before performing it, you should know the following:

Health professionals should also reach the level of competence required by employers before performing female catheterization, and should abide by relevant local policies and procedures, such as incontinence management, catheterization, and infection prevention.

Indwelling catheters should be performed using Foley catheters; these have a self-fixating balloon that stays in the bladder when filled with water or a solution provided by the manufacturer.

The correct catheter for an individual patient depends on many factors, such as possible use time, catheter material type, diameter, length, and balloon size.

For short-term use (less than 28 days), uncoated latex, PVC, polytetrafluoroethylene (PTFE) or silver alloy catheters should be used; if latex-based catheters are being considered, the patient should be checked for latex allergies. For long-term use, full silicone, silicone elastomer or hydrogel coated catheters should be used.

For female patients with limited mobility, female-length catheters should be routinely used. These catheters are more concealed than standard-length catheters, and with less movement in and out of the urethra, they are less likely to cause trauma or infection to female patients (Dougherty and Lister, 2015).

For patients who are obese, bedridden or in a wheelchair, the inflation valve on the female catheter may get stuck between the thighs, which can cause pain (Dougherty and Lister, 2015). In these cases, longer standard length catheters can be used to avoid skin damage and improve patient comfort.

For routine drainage, a 10 ml balloon should be used; this is usually inflated with 10 ml sterile water. Some catheters are equipped with pre-filled glycerin solution syringes or pre-filled 10 ml sterile water balloons.

The health professional performing the catheterization is responsible for selecting the appropriate catheter and using it in accordance with the manufacturer's instructions (RCN, 2012).

1. Discuss the procedure with the patient and explain any related risks or benefits to obtain effective informed consent. Record this in the patient's notes. Check for allergies to lubrication or anesthetic gel (Yates, 2015) (Box 1). Screen the bed to ensure privacy and maintain dignity.

2. According to local policy, wash your hands and clean the trolley for the operation.

3. Follow the sterile non-contact technique (ANTT) instructions to obtain the equipment needed to perform the female catheterization procedure (Figure 1a). The equipment should include:

Assemble the device on a trolley and bring it to the bedside of the patient.

4. If necessary, help the patient to remove related clothing (ie underwear and/or pajamas). Before you are ready to start the operation, cover her thighs and genital area with a towel to make sure she is not exposed unnecessarily. Use the sheet protection cover to keep the sheets dry.

5. Help the patient to lie on their back, with legs bent and knees apart (Figure 1b).

6. Wash your hands and dry them. Wear a plastic apron and use ANTT to open the catheterization kit.

7. Use ANTT to open additional equipment. Leave the urinary catheter in its sterile plastic protective packaging until it is inserted to protect it from potential physical and environmental contamination. Remove the towel covering the patient's genital area.

8. Wash your hands and put on sterile gloves. Place sterile towels under the patient's hips and on the thighs; this creates a barren field (Dougherty and Lister, 2015).

9. Using a lint-free cotton swab, separate the labia with your non-dominant hand so that you can see the urethral opening.

10. Open the labia and use your dominant hand to move it down toward the anus with 0.9% sterile sodium chloride (Loveday et al, 2014) to clean the urethral opening in a single pass (Figure 1c). This reduces the risk of CAUTI.

11. Remove the lubrication/anaesthesia gel cap and insert the nozzle into the urethra (Figure 1d). Squeeze the gel into the urethra, remove the nozzle and discard. If you are using an anesthesia gel, leave it for about five minutes or follow the manufacturer's instructions for it to take effect. Box 1 outlines further relevant information. If you use an ordinary water-based lubricating gel that does not contain anesthetics, you can continue the procedure immediately.

12. After the anesthesia gel takes effect, wipe off the excess, discard the gloves, wash and dry your hands, and then put on new sterile gloves.

13. Place the receiver with the catheter on a sterile towel between the patient’s legs, open the catheter but leave it in the sterile packaging to reduce the risk of contamination. Keep the labia open.

14. Hold the catheter with your dominant hand, insert the tip slightly upwards and backwards into the urethral opening, and remove it from the sterile packaging (this adds a layer of physical protection during insertion). Insert the catheter about 5-6 cm (Figure 1e). The direction and length of the inserted catheter are related to the anatomy of the female genitourinary tract (Figure 2) (Dougherty and Lister, 2015). If the patient feels any pain or discomfort, stop the operation and seek medical advice.

15. Once urine begins to drain, insert the catheter into the bifurcation point to ensure that the balloon is in the bladder. The inflation of the balloon in the urethra is painful.

16. According to the manufacturer's instructions (Figure 1f), gently inflate the balloon with 10 ml of sterile water or solution. For pre-filled balloons, remove the clamp and gently squeeze the reservoir of sterile water. Observe the patient for any signs of discomfort, as inflation should be painless.

17. After the balloon is inflated, withdraw the catheter slightly to ensure that the catheter is in the bladder and secure (Dougherty and Lister, 2015).

18. If the catheter is not already connected to the drainage bag, connect it to the drainage system or catheter valve as needed (see Part 3 and Part 4 of this catheter series).

19. Make the patient feel comfortable. If necessary, help her get dressed and make sure the bed is clean and dry.

20. Discard the equipment in a medical waste bag according to local policy. handwashing.

21. Complete recording procedures, including:

If the patient is intubated for the first time, urine output should be measured and recorded at the time of insertion to help monitor renal function and fluid balance. The volume also provides important information about bladder capacity in patients with urinary retention (Dougherty and Lister, 2015).

23. Check that the patient is comfortable and provide her with information about the maintenance and care of the catheter and drainage system.

Box 1. Anesthetics and lubricating gel for female patients 

The use of anesthetic gel for catheterization is widely recognized in male patients, but its use in female patients is controversial. The EPIC (Loveday et al., 2014) and Royal College of Nursing (2012) guidelines do not distinguish between male and female patients. Loveday et al. (2014) recommend the use of "appropriate lubricant from a sterile disposable container" for catheterization. Many practitioners use a lubricating gel with a local anesthetic (lidocaine 2%), but they should follow local policies.

Cosmetic gel and female patients 

There is evidence that:

Lidocaine is a topical drug and should follow the local drug management policy. As with any medicine, it is essential to check for allergies before use (Dougherty and Lister, 2015).

This procedure can only be implemented after approved training, supervisory practices, and competency assessments, and in accordance with local policies/agreements.

Tagged as: Newly Qualified Nurse: Utility

Thank you. This article is very helpful for friends who need to catheterize themselves.

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