Foley catheters

Contraindications to urethral catheter placement

  • Absolute: Known or suspected urethral injury (e.g. pelvic fracture, blood at meatus, perineal ecchymosis, high-riding prostate on DRE) - perform retrograde urethrogram (RUG) first
    • If Foley has already been placed: no imaging needed if suspicion for urethral injury is low and no blood at meatus
      • If continued blood at meatus - pericatheter RUG (place angiocath next to Foley)
    • If emergent setting and must have Foley - a single attempt at catheter placement BY UROLOGY with 18 Fr Coude is acceptable.
      • Otherwise, cysto over a wire, or place SPT. If in OR, can do antegrade and retrograde cystoscopy. Do a pericatheter RUG afterwards
  • Relative: Artificial urinary sphincter (AUS) - need to deactive prior to catheterization

Catheter types

  • Foley: indwelling, has balloon port
  • Coude: Foley with curved tip to pass prostatic urethra more easily (e.g. in BPH)
  • Council tip: has hole at end of catheter (instead of just at sides) so it can be passed over a guide wire
  • Robinson/Red Robnel: for short-term catheterization (e.g. CIC - clean intermittent catheterization)
    • **hide**Rob Nel = Robinson Nelaton
  • 6 eye: no balloon, more holes for irrigation to remove clots
  • 3-way: triple lumen - balloon port + irrigation port for continuous bladder irrigation (CBI)

Catheter duration

  • Retention - roughly 1 day for every 100 cc over 300 cc?
  • Traumatic Foley - 72 hours

Pediatric Foley

  • Pediatric urojet - use 5cc Luer Lock with an angiocath to instill lido jelly
  • Male infants - typically have high bladder necks
    • Use Rusch silicone catheter with stylet to fashion more of a Coude
    • Use pinky finger in rectum to help navigate catheter through bulbar/prostatic urethra
    • Can try 5 Fr Kendall catheter - but this has no balloon so you have to tape it down (if asleep can suture to foreskin)
  • Phimosis - if necessary, use hemostat to gently open ring and visualize meatus (make sure to do foreskin care with bacitracin/vaseline afterwards)
  • Female infants - make sure to pull labia -outwards- to expose the urethra rather than retracting to the side
  • When in doubt, ask attending

French sizing: Fr = diameter x 3 mm. Larger Fr = larger diameter.

Clinical situation Catheter type/size
Average male 16-18Fr
Average female 14-16Fr
Neonate 3-6Fr (insert 5-6 cm)
Infant 5-8Fr (insert 5-6 cm)
Toddler/Preschool 8Fr (insert 5-6 cm for girls, 6-8 cm for boys)
School age 8-14Fr (insert 6-8 cm for girls, 10-15 cm for boys)
Adolescent 10-14Fr
Gross hematuria

22-24Fr 6 eye - irrigate until no clot return, then use similar sized 3-way for CBI
May inflate larger balloon (30cc) for traction/tamponade on prostate

Valley has - Rusch hematuria catheters - 3 way catheter with large open beak/mouth ("Couvelaire tip") which allows for clot irrigation. Otherwise cannot irrigate effectively through normal 3 way. But is very stiff/silicone/uncomfortable

Stanford has (in OR) - Hematuria Coude catheter - latex/more comfortable, but with all of the benefits above
BPH, hx of prostatic surgery Coude, larger Fr
Stricture

Smaller Fr (eg 12 Fr silicone/stiff catheter)
± guide wire to help pass the catheter (will need a hole at the end, e.g. Council tip or use a 14 ga angiocath to make a hole for the guidewire)

Dilation 

  • Always dilate over an Amplatz super stiff wire, nothing softer
  • If patient has history of pelvic radiation, etc dilate especially carefully
  • Options - Heyman dilators (individual red dilators, softer/gentler), Cook S dilators, Amplatz dilators (straight dilators)
Difficult Foley 1. Approach as BPH (coude)
2. Approach as stricture (see below). 
3. Bedside cysto to visualize passage
Buried penis

Positioning - place pillow under bottom, multiple nurses to hold away pannus, press down on suprapubic pad for maximal retraction

Use finger to feel for glans/meatus, then try blind placement, or guide a wire/5 Fr catheter over finger
Cannot place urethral catheter Suprapubic tube (see below for how to place)
SPT exchange must be quick/immediate (< 1-2 hrs) - cystotomy closes very quickly, even if mature, and prevents re-insertion 
Post-op urinary retention Straight cath
If large volume on bladder scan, consider home with Foley x 24 hrs
Acute urinary retention Foley x ~3 days, return to clinic for void trial

Difficult Foley Cart Locations

  • Stanford - take elevator in 300P - stairwell next to pre-op- down to Central Supply on ground floor. The cart is in the far back corner and you can sign it out
    • Call number on cart to have it taken care of
  • Valley - located in clinic stock room
  • VA - call central supply; see logistics page

 

How to place a Foley catheter - Thumbroll tutorials

  • Ensure urine return prior to inflating balloon to avoid inflation in the urethra. Hub the catheter in males.
    • Sterile water or saline may be used for balloon (saline theoretically can crystallize and obstruct balloon port during deflation, but lack of evidence to support this)
  • Kit prep
  • Male
  • Female
  • Secure Foley catheter (with some slack) with leg bag/Statlock
  • Removal - make sure balloon is completely deflated prior to removal
    • If balloon does not deflate with syringe, 
      • Advance catheter to make sure balloon is inside the bladder.
      • Cut balloon port proximal to valve, and pass guide wire into balloon port to gently puncture balloon
      • May over-inflate balloon to pop it - make sure balloon is in bladder, not urethra!
      • Sometimes the balloon deflates irregularly; gently re-inflate with 1-2 cc air/water to smooth out the wrinkles and try again
    • Pinch tubing to minimize leaking during removal

Suprapubic tube (SPT) placement 


  • Place patient in Trendelenburg (head down)
  • Feel 2 finger breadths above pubic bone
  • Inject local
  • Make skin incision for trocar (~ 1.5 cm)
  • Confirm trajectory by aspirating urine with needle (use a long spinal needle)
  • If in OR, visualize during cystoscopy
  • Abrupt firm insertion of trocar into bladder (slow insertion may push the bladder away)
  • Remove obturator; Immediately insert 16 Fr Foley before bladder decompresses, inflate balloon
  • Silicone 16 Fr is a bit larger and doesn't go into the trocar as easily
  • Plastic trocar peels off
  • Tie to skin with 0-silk.
    • Gently seat balloon against abdominal wall first before tying
  • If open approach - small transverse incision at 2 finger breadths above pubic bone; incise rectus sheath transversely, identify bladder in space of Retzius. Place two stay stitches in bladder, then make cystostomy and introduce catheter.
  • Urology to remove/exchange in 4-6 weeks, do not remove prior to that to avoid losing tract
    • If SPT clogs and cannot be irrigated, place urethral Foley for drainage instead of exchanging fresh SPT
    • After first exchange, routine exchanges can be done by any provider 
 
  • Supplies
    • SPT trocar/introducer
    • 16 Fr Foley kit (non-silicone) with bag
    • Local/lidocaine
    • Scalpel, spinal needle, Luer lock syringe
    • 0-silk
    • Betadine, sterile towels/drape

 

 

Catheter-associated UTI (CA-UTI)

  • Daily rate of BACTERIURIA with indwelling catheter: 5%
    • Basically 100% of patients with Foley will have bacteriuria at 1 month
    • But only 10-25% of these have actual symptomatic ifnections
  • Intermittent (eg straight cath) catheterization has lower infection rate than indwelling catheter
    • No difference between sterile/nonsterile (outpatient) intermittent catheterization
  • Insufficient data to say if intermittent cath is better for infection than suprapubic tube
  • "A commonly cited prospective study comparing the different methods of bladder management in patients with acute SCI reported an incidence of CA-UTI per 100 person-days of 2.72 in the IC group, 0.41 in the CIC group, 0.36 in the condom catheter group, 0.34 in the SPC group and 0.06 in the normal voiding group"
author: admin | last edited: Sept. 14, 2021, 9:05 p.m. | pk: 56

  1. http://www.auanet.org/education/auauniversity/medical-student-education/medical-student-curriculum/bladder-drainage
  2. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America.