Overview
Definition:
Urinary catheterization in uncircumcised boys involves passing a hollow tube (catheter) through the urethra into the bladder to drain urine
Special attention is required due to the presence of the foreskin, which necessitates specific techniques to prevent injury and ensure proper placement.
Epidemiology:
Urinary catheterization is a common procedure in pediatrics, indicated for various reasons including monitoring urine output, obtaining sterile urine samples, relieving bladder outlet obstruction, and managing urinary incontinence
The incidence of needing catheterization in uncircumcised boys is similar to the general pediatric population, but the technique differs.
Clinical Significance:
Proper technique in uncircumcised boys is crucial to avoid complications such as meatal stenosis, urethral injury, paraphimosis, and infection
Understanding these nuances is vital for pediatric residents and those preparing for DNB and NEET SS examinations, as it directly impacts patient safety and outcomes.
Indications
Acute Urinary Retention:
Inability to void due to obstruction or functional issues.
Obtain Sterile Urine Sample:
For diagnosis of urinary tract infections (UTIs) in infants and young children.
Accurate Urine Output Monitoring:
In critically ill children, post-operatively, or in cases of dehydration.
Bladder Emptying In Neurological Conditions:
Such as spina bifida or other neurogenic bladder dysfunction.
Urinary Diversion:
Following certain surgical procedures or in trauma cases.
Instillation Of Medications:
Direct administration of agents into the bladder.
Technique Uncircumcised Boys
Preparation:
Gather all necessary sterile equipment: catheter of appropriate size (e.g., 6-10 Fr for infants, 8-14 Fr for older children), sterile gloves, antiseptic solution (e.g., povidone-iodine or chlorhexidine), sterile lubricant, sterile drapes, and a sterile urine collection bag or container.
Positioning:
Place the child in a supine position with legs abducted
For infants, a diaper-free area is beneficial
For older children, a supine or frog-leg position may be used.
Aseptic Technique:
Perform thorough hand hygiene and put on sterile gloves
Drape the perineal area with sterile drapes, exposing the meatus
Cleanse the penis and perineal area thoroughly with antiseptic solution, starting from the meatus and moving outwards.
Foreskin Management During Insertion:
Gently retract the foreskin to expose the urethral meatus
It is important to retract it only as far as it will comfortably go to avoid causing paraphimosis
Some clinicians recommend holding the foreskin back throughout the procedure, while others release it gently once the catheter is in place
If resistance is met, do not force retraction
alternative methods or assessment by a specialist may be needed.
Lubrication And Insertion:
Lubricate the tip of the catheter generously with a sterile, water-soluble lubricant
Gently insert the lubricated catheter into the urethral meatus
Advance the catheter slowly and steadily until urine begins to flow, indicating bladder entry
Advance a further 1-2 cm to ensure the balloon (if used) is well within the bladder.
Securing The Catheter:
Once urine flow is established, secure the catheter to the thigh with tape or a catheter strap to prevent traction and discomfort
If a balloon catheter is used, inflate the balloon with the appropriate volume of sterile water (as per manufacturer instructions) once urine is flowing freely.
Post Insertion Care:
Gently replace the foreskin over the glans if it was fully retracted, ensuring it is not trapped behind the catheter balloon (this can cause paraphimosis)
Connect the catheter to a sterile urine collection bag
Monitor urine output and assess for any signs of discomfort or complications.
Special Considerations And Challenges
Meatal Stenosis:
In boys with meatal stenosis, the urethral opening may be small and difficult to cannulate, potentially requiring a smaller catheter or specialized techniques.
Phimosis:
Tight phimosis may prevent foreskin retraction, making visualization and insertion difficult
In such cases, suprapubic aspiration or referral to a urologist may be necessary.
Paraphimosis:
This is a medical emergency where the retracted foreskin becomes trapped behind the glans
It can be caused by aggressive foreskin retraction during catheterization
Immediate management is crucial.
Urethral Trauma:
Forceful insertion or manipulation can lead to urethral injury, bleeding, or false passage formation.
Difficulties In Infants:
The small size and mobility of the genitalia in infants can make accurate insertion challenging.
Complications
Urinary Tract Infection Uti:
The most common complication, risk increases with duration of catheterization.
Urethral Trauma And Bleeding:
Caused by forceful insertion, friction, or incorrect technique.
Paraphimosis:
Edema and strangulation of the glans due to trapped foreskin.
Meatal Stenosis Irritation:
Chronic irritation can lead to meatal scarring.
Bladder Spasms:
Can cause discomfort and lead to accidental catheter removal.
Obstruction Of Catheter:
Due to blood clots, mucus, or kinking of the tubing.
Prevention Of Complications
Strict Aseptic Technique:
Minimize risk of UTIs.
Gentle Technique:
Avoid forceful insertion and manipulation.
Appropriate Catheter Size:
Use the smallest size that allows urine flow without trauma.
Adequate Lubrication:
Facilitates smooth insertion.
Secure Catheter Placement:
Prevent traction injuries and accidental dislodgement.
Timely Removal:
Remove catheter as soon as it is no longer indicated.
Foreskin Care:
Ensure foreskin is returned to its natural position post-catheterization to prevent paraphimosis.
Key Points
Exam Focus:
The technique for foreskin management during catheterization in uncircumcised boys is a frequently tested area, focusing on preventing paraphimosis and meatal injury
Indications, contraindications, and common complications are also high-yield.
Clinical Pearls:
Maintain a calm environment
Use ample lubrication
If resistance is met, stop and reassess rather than forcing
Always check for and reduce any signs of paraphimosis post-procedure
Consider suprapubic aspiration if urethral catheterization is impossible or contraindicated.
Common Mistakes:
Forgetting to retract the foreskin, forcing the catheter if resistance is met, not lubricating adequately, using too large a catheter, failing to secure the catheter properly, and not returning the foreskin after catheter removal.