ED indications
- Acute urinary retention — painful inability to void with a palpable/distended bladder.
- Accurate output monitoring — critically unwell or haemodynamically unstable patients.
- Suspected obstruction — e.g. relief of obstructive uropathy pending definitive management.
- Sample collection where a clean specimen cannot otherwise be obtained, per local policy.
Male technique
Aseptic technique
Sterile gloves, drapes, and cleaning of the glans/meatus with antiseptic solution, retracting the foreskin fully if present.
Instil anaesthetic gel
Instil lidocaine/chlorhexidine gel (typically around 11 mL) into the urethra and allow several minutes (around 3–5) for effect before insertion, per product guidance.
Insert to the hilt
Choose a standard 14–16F catheter for routine adult use. Insert gently, advancing the catheter fully to the bifurcation/hilt.
Confirm urine flow BEFORE inflating the balloon
Do not inflate the retention balloon until urine is seen draining. Inflating within the urethra risks serious urethral injury.
Inflate, withdraw gently, secure
Inflate the balloon with the manufacturer's specified volume of sterile water, withdraw gently until resistance is felt (balloon seated at the bladder neck), then reduce the foreskin fully back over the glans.
Never inflate the balloon without confirmed free urine drainage. If in doubt, advance further and re-check before inflating.
Female technique
- Position supine with hips flexed and abducted; good lighting and, if needed, an assistant to part the labia.
- Aseptic technique — clean labia and meatus from anterior to posterior, identify the urethral meatus (may be difficult to visualise — palpation can help).
- Instil anaesthetic gel, insert catheter gently until urine flows, then inflate the balloon and withdraw gently to seat it.
Difficult catheterisation
Suspected prostatic enlargement
- Resistance at the prostatic urethra: try a larger or stiffer catheter (e.g. 18F) or a Coudé-tip catheter, inserted with the curved tip pointing anteriorly (towards the abdomen).
- Never force the catheter. Excess resistance risks false passage and urethral injury.
Escalation
- Persistent failure — escalate to urology; sequential dilators/filiform catheters are specialist techniques.
- Suprapubic catheterisation only by a trained operator, with imaging guidance where appropriate.
Paraphimosis caution: always reduce the foreskin back over the glans after catheterisation — a retracted foreskin left in place can cause paraphimosis, a urological emergency.
Retention aftercare
- Record the initial residual volume drained — this informs the trial without catheter (TWOC) plan and urology follow-up.
- Consider an alpha-blocker to improve TWOC success in men with retention, per NICE/local pathway.
- Arrange TWOC timing and urology/community follow-up per local retention pathway; safety-net for recurrent retention.
CAUTI prevention
- Catheterise only when clinically indicated, and document the indication and planned review/removal date.
- Maintain a closed sterile drainage system; keep the bag below bladder level.
- Remove or review the catheter as soon as the clinical indication has resolved — the strongest CAUTI-prevention measure.
Documentation
- Indication, consent, catheter type/size, anaesthesia used, insertion difficulty, residual volume, complications, and follow-up/TWOC plan.
Supervision pointers
Generic ED skills entrustment levels — not a named curriculum DOPS:
| 1 | Observed only — describes indications, aseptic principles and the balloon-inflation safety rule. |
| 2a | Performs straightforward catheterisation with supervisor scrubbed alongside; confirms urine flow before inflating. |
| 2b | Performs with supervisor in department; recognises and manages simple resistance appropriately. |
| 3 | Indirect supervision; manages difficult catheterisation and knows when to escalate to urology. |
| 4 | Independent; teaches and troubleshoots, including retention aftercare planning. |
References
- Instillagel Summary of Product Characteristics — lidocaine/chlorhexidine gel dosing and onset time.
- A Simple Method to Overcome Difficult Male Urethral Catheterisation. PMC.
- Difficult Foley Catheterization. StatPearls, NCBI Bookshelf.
- NICE — Lower urinary tract symptoms in men: management (alpha-blocker use around catheter removal/TWOC).