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Atraumatic urethral catheterization of children.

Urethal catheterization is often perceived by the child and parents as an invasive and painful procedure. However, with adequate preparation of the child and skill on the part of the nurse, the discomfort and anxiety associated with catheter insertion can be dramatically reduced or avoided. Preparation of the child must be tailored to the child's developmental level as well as the parent's needs. Discomfort is minimized if the nurse chooses an appropriate size and type of catheter, and prepares the uretha with local anesthetic. Special strategies are necessary for children who have been sexually abused children with myelodysplasia, those who have undergone urological surgery, and boys with epispadias or classic exstrophy.

Urethral catheterization is a common urological procedure. Catheterization may be performed for a variety of reasons: to obtain a urine specimen, to relieve urinary retention, to allow the bladder to rest or heal after surgery, to dilate a urethral stricture, or for diagnostic testing such as voiding cystourethrography or urodynamics. With inappropriate equipment or poor technique, catheterization becomes a traumatic event for the child and the parents. However, with a careful explanation of the procedure, proper choice of equipment and supplies, and skillful technique, insertion of a catheter can be completed without trauma.

Patient Preparation

A careful explanation of the procedure and its rationale is completed prior to any catheterization. The explanation must be tailored to both the developmental level of the child and the needs of the parents. For infants, it is important to reassure the parents that the procedure will not cause pain, that neither the bladder nor urethra will be damaged, and that subsequent incontinence or infertility will not occur. In some cultures, parents may fear that catheterization will disrupt the hymen and harm the child's virginity. A careful review of the procedure, and an explanation of the anatomic relationship between urethral meatus and hymen, will allay these fears (Wong, 1995).

In addition to explaining the steps of the procedure and its purpose, the nurse should reassure the older infant or child that catheterization will not feel like having a needle or sharp object inserted into the urethra. Nonetheless, children should be told that catheterization will create a very intense desire to urinate and feelings of pressure in the urethra. Toddlers and older children typically appreciate seeing and manipulating a nonsterile catheter in order to feel its softness and pliability for themselves.

The child should be taught to relax the pelvic muscles prior to insertion of the catheter. The younger child is taught to remain in a supine position, and emphasis is placed on leaving the hips flat on the procedure table, bed, or stretcher. Toddlers and younger children may be encouraged to blow a pinwheel. The preschool or schoolaged patient is taught to blow out and gently press the hips against the table. This maneuver is repeated as the catheter is inserted, in order to avoid breath holding and raising the hips from the procedure table, which tightens the periurethral muscles and increases discomfort. Adolescents are taught to isolate, contract, and relax the pelvic muscles prior to catheterization, and to breathe slowly and deeply as the tube is inserted. Adolescent girls may prefer to be catheterized by a female health care professional, and adolescent boys may wish to be catheterized by a male caregiver. These requests should be honored whenever feasible, and every child or adolescent must be catheterized in the presence of a chaperone.

Since catheterization typically provokes some discomfort and anxiety, assistance and gentle restraint may be indicated. Most children prefer their parents remain in the room during the catheterization, and many parents wish to help gently restrain their child. Ideally, the parent remains at the head of the bed or procedure table; and she or he is encouraged to hold the child's hands as the catheter is inserted. Parents also may wish to distract the child during catheterization by reading from a favorite book, or by playing with the child, using small hand-held toys. Older children and adolescents may wish to listen to music using a radio, audiotape, or compact disc (CD) player with headphones. The adolescent patient and family should be allowed to determine who remains with the adolescent to chaperone during the procedure; this decision is made before exposure of the perineum and preparation of the sterile field.

Children often wish to control the timing of catheterization; and many will ask the caregiver to delay the insertion of the catheter repeatedly, in an attempt to prepare themselves better for the procedure or to ask additional questions. While the catheterization is delayed until a full explanation is provided for the child and the parents, excessive delays are avoided since they heighten rather than alleviate anxiety. When anxiety interferes with voiding, the results of certain studies may be affected.

Catheter Selection

Catheter selection is particularly important when catheterizing a child. Considerations differ depending on the purpose and expected duration of catheterization (see Tables 1 and 2). Choice will also be affected by the child's age and any special circumstances, such as those described later.
Table 1. Selecting a Catheter for Specimen Collection

Age                 Equipment               Rationale

Infants (0-1        4-5 French,             * Small French
year of age)        15-inch feeding         size promotes
                    tube                    comfort
                                            * generally
                                            less expensive
                                            than pediatric
                                            catheters

                    6 French in and         * Small French
                    out catheter            catheter may
                                            be necessary
                                            for technically
                                            challenging
                                            catheterizations
                                            * A coude tipped
                                            catheter is used
                                            for urethal
                                            angulation

Toddlers,           4-5 French,             * Small French
Preschoolers        15-inch feeding         size promotes
(13 months to       tube                    comfort
to 5 years of                               * Generally less
age), School                                expensive than
Aged Children                               pediatric
(up to 12                                   catheters
years of age)
                    6-10 French             * Straight tipped
                    in and out              catheters may be
                    catheter                used for older
                                            boys with more
                                            angulated
                                            urethas, or for
                                            technically
                                            difficult
                                            catheterizations

Adolescents         8 French feeding        * Smaller French
(12-18 Years        tube for                promotes comfort
of age              adolescent girls        and is adequate
                                            for specimen
                                            collection

                    8-12 French in          * Shorten length
                    and out catheter        of in and out
                    for adolescent          catheter may
                    girls                   provide easier
                                            insertion

                    8-12 French straight    * Straight tipped
                    or tipped catheter      catheters provide
                    for adolescent boys     greater control for
                                            catheterization of
                                            more angulated uretha
                                            noted with prostatic
                                            maturity

                                            * Generally less
                                            expensive than
                                            coude tipped
                                            catheters

                    8-12 French tipped      * Coude tipped
                    catheter for older      catheters for
                    adolescents             technically
                                            challenging
                                            boys, or when
                                            straight tipped
                                            catheter can not
                                            be inserted due to
                                            urethal angulation

Table 2. Selecting an Indwelling Catheter

Age                 Equipment               Rationale

Infants (0-1        5 French feeding        * Feeding tube
year of age)        tube                    carefully secured
                                            to perineum
                                            adequate for
                                            temporary drainage
                                            * Less expensive
                                            than smaller
                                            Foley catheters

                    6-8 French Foley        * Small French
                    catheter, inert         size Foley
                    material (silicone),    catheters preferred
                    or hydrophilic          for long-term
                    material with           drainage, or
                    lubricious coating      when debris present
                                            in urine
                                            * Inert or
                                            lubricious-coated
                                            catheter material
                                            reduces urethal
                                            irritation and
                                            associated discomfort
                                            when catheter left
                                            in for 72 hours or
                                            longer

Toddlers,           6-8 French Foley        * Indwelling
Preschoolers        catheter with 3         catheter, secured
(13 months to       cc retention            to perineum
5 years of age),    balloon, inert           preferred over
School Aged         material or             feeding tube for
Children (up        hydrophilic             prolonged drainage
to 12 years         material with           * Inert or
of age)             lubricious coating      hydrophilic
                                            material with
                                            lubricious
                                            coating necessary
                                            for catheter left
                                            in place more than
                                            72 hours
                                            * A standard balloon
                                            size is
                                            preferred over
                                            larger sizes
                                            (10-30 ml), since
                                            they increase bladder
                                            neck irritation and
                                            the risk of bladder
                                            spasm

Adolescents         8-14 French Foley       * Smaller French
(12-18 Years        catheter with           size promotes
of age)             5 cc retention          comfort and
                    inert material          provide adequate
                    or hydrophilic,         drainage
                    lubricious coated       * Inert or
                    material preferred      hydrophilic
                                            material with
                                            lubricious
                                            coating necessary
                                            for catheter left
                                            in place more than
                                            72 hours

                    Coude tipped 8-16       * Coude tipped
                    French Foley            catheter occasionally
                    catheter with 5 cc      required for more
                    retention balloon       angulated uretha
                    may be required         or for technically
                    for boys                difficult
                                            catheterization




When catheterizing only for the purpose of obtaining a specimen, a feeding tube can be used in infant boys and girls. The nurse selects a feeding tube that is relatively short and pliable. Toddlers, preschoolers, and school-aged children also may be catheterized with a feeding tube, although a small French sized catheter is also appropriate. With maturation of the prostate, adolescent boys are typically catheterized with a straight or coude-tipped catheter (see Figure 1). Because their urethral course remains relatively straight, adolescent girls should be catheterized with a feeding tube for in and out catheterization, or a smaller Foley catheter when the tube is left in for longer periods. Smaller catheters are preferred for all children and adolescents because they produce less discomfort than tubes with larger diameters.

[Figure 1 ILLUSTRATION OMITTED]

When a catheter will remain indwelling, the material of construction should influence selection. In the neonate and young infant, a feeding tube carefully secured to the penis or perineum may be used for continuous drainage. In the toddler or older child, a Foley catheter (containing a retention balloon) is preferred. A silastic Teflon[R]-coated catheter is selected only for short-term use. Otherwise an inert material (such as silicone) or a catheter with a hydrophilic coating is preferred. The catheter also should be constructed of a material with a low friction coefficient (Gray, 1994; Gray, 1992); an example is the Bard Lubricious Coated Catheter[R] (Bard Urological, Covington, GA). These materials are preferred because they produce less urethral irritation than do silastic, Teflon[R]-coated catheters.

In choosing a catheter, the nurse should also consider the internal and external diameter of the catheter. The French size of the catheter is a measure of its external diameter, and smaller diameter catheters are preferred for their ability to reduce discomfort with insertion. However, since the indwelling catheter must drain urine over an extended period of time, its internal as well as external diameter are considered. In all catheters, the internal diameter is smaller than the external diameter. Thus, a 10 French catheter may have an internal diameter of 6 French or less. If blood, blood clots, or other debris are present in the urine, a larger French size catheter, with a maximum internal vs. external diameter, is chosen. The internal vs. external diameter of a particular catheter may be assessed by cutting a catheter at its mid-point, and visually comparing these variables.

Procedure

Since catheterization carries a 1%-2% risk of urinary tract infection, the procedure is completed using aseptic technique (Wyker, 1991). The sterile field should contain the following materials: a specimen container, povidone-iodine or other cleanser, cotton balls or swabs, two pairs of sterile gloves, and an appropriate catheter. If an indwelling catheter is to be inserted, the balloon is checked for patency and integrity prior to urethral preparation.

One pair of sterile gloves are worn by the nurse, who explains that they are intended to protect the patient from infection. The child is told that the cleanser will feel like cool water but will not cause pain. In girls, the labia are gently separated, and the meatus is thoroughly cleansed using cotton balls soaked with a Betadine/povidone iodine or similar cleanser. In boys, the foreskin (when present) is gently pulled back and the entire surface of the glans penis is cleansed. In both boys and girls, following cleansing, the area is patted dry with cotton balls or with a sterile drape to avoid irritation of the surrounding mucosa and skin.

The urethra is prepared before the catheter is inserted in both boys and girls. When attaining a specimen or inserting an indwelling catheter in boys, a sterile lubricant containing 2% Xylocaine is gently inserted into the urethra and retained for 1-3 minutes by gently occluding the meatus. This provides temporary, effective local anesthesia to the distal urethra and typically to the membranous urethra and bladder neck. In girls, 2-3 ml of sterile lubricant containing 2% Xylocaine are inserted into the urethra, and 2-3 ml are applied to the mucosa immediately adjacent to the urethra. This provides temporary, effective anesthesia for the urethra and the surrounding mucosa.

To insert Xylocaine into the urethra, a specially designed delivery system may be used (such as Urojet[R], a product of International Medication Systems, El Monte, CA). Alternatively, a 2% Xylocaine water soluble lubricant can be obtained in a tube format (such as Astra Medical Products) and drawn up into a syringe. For girls and younger boys, 5 ml of the lubricant provides adequate urethral anesthesia; a dosage of 10 ml is indicated for older, adolescent boys. Other Xylocaine preparations are used only with caution, because they may cause significant stinging when applied to the urethral mucosa.

Following cleansing and preparation of the perineum, the second pair of sterile gloves are applied. While a single pair of sterile gloves may be sufficient in the cooperative adult patient, two pairs are preferred in the child. This diminishes the risk of inadvertent introduction of cutaneous or other pathogens into the bladder.

The catheter is coated with additional lubricant and gently inserted into the urethra as the child blows on a pinwheel or exhales slowly. Some children may move suddenly or briskly lift their hips from the table when catheterization is attempted. When these events occur, the procedure is temporarily halted, the child is repositioned and the procedure is repeated. The catheter should be inserted slowly until urethral sphincter resistance is encountered. At this point, the child is again asked to exhale, and the catheter is slowly inserted into the bladder vesicle until urine return through the catheter is observed. With experience, the nurse learns to recognize the feel of the urethral sphincter tone and inserts the catheter when this resistance is temporarily reduced during expiration.

A smaller catheter may become temporarily occluded with lubricant following urethral preparation. If urine does not return promptly, the catheter can be gently advanced to ensure that it is in the bladder. It is then left in place for several seconds until urine return is noted. A small amount of sterile saline (2-3 ml) may be inserted if urine return does not occur promptly. If no urine is seen after gentle irrigation, or if the saline leaks around the catheter, it is assumed that the tube has not entered the bladder vesicle. The catheter is slowly removed and the procedure is repeated using a new tube.

If an indwelling catheter is inserted, it is advanced as far as possible and urine return is observed. The child is then advised that she or he should not feel discomfort as the balloon is gently inflated. When undue resistance is encountered, or when balloon inflation causes the child to perceive intense pressure or discomfort, inflation is immediately stopped. Initially, the nurse attempts to advance the catheter further into the bladder using gentle, steady pressure. If these efforts are not successful, the catheter is removed.

Special Populations

In certain instances, special considerations change the typical procedures used for atraumatic catheterization. The trauma and risks associated with catheterization are reduced when the nurse recognizes these special circumstances and adjusts her instruction and technique accordingly.

Sexual abuse victims. The child who has a history of sexual abuse may be particularly resistant to the catheterization procedure. In this case, the visualization of the perineum, cleansing of the perineum and insertion of the catheter often provoke extraordinary fear and resistance. If the child is undergoing evaluation after a recent sexual assault, catheterization occurs following collection of forensic evidence. Whenever prior sexual assault is known or suspected, the child is catheterized in the presence of a known and trusted chaperone. The investment of time, compassion, and patience as well as acknowledgment of the child's fears and embarrassment provide both immediate and long-term benefits. The purpose of the test is explained, and the child is reassured that the caregiver is "touching down here" only to perform this necessary medical procedure. Whenever possible, a caregiver of the same gender is selected to perform the catheterization. Occasionally, mild sedation may be necessary prior to urethral catheterization. In these unusual circumstances, the chaperone remains present throughout the procedure.

Myelodysplasia. Children with myelodysplasia are often perceived as particularly simple to catheterize, typically because diminished urethral sensations and immobility render the procedure technically simple. However, these children have special needs that must be considered if catheterization is to remain an atraumatic procedure. Pelvic and urethral sensations are determined by asking the child or parents about prior catheterizations before the procedure begins. In the neurologically intact child, a Xylocaine lubricant preparation is used whenever feasible. In the myelodysplastic child, an anesthetic impregnated lubricant may or may not be required. Nonetheless, the urethra should be prepared with a water soluble lubricating jelly to minimize the risk of urethral trauma. If a boy does not perceive urethral sensations, 5-10 ml of a sterile lubricant may be aspirated into a syringe and injected into the urethra (Carter, 1992; Wyker, 1991). Girls may be catheterized after adequately coating the catheter with a water soluble lubricant.

Myelodysplastic children are at risk for hypersensitive reactions, including life threatening anaphylaxis, when exposed to latex products (Meeropol, Leger, &Frost, 1993). Because of this significant risk, a nonlatex catheter (such as an all silicone catheter), and a nonlatex sterile field are routinely used for these patients, and careful documentation of latex allergy is documented prominently in the child's chart.

Technically difficult catheterizations, Urological surgery may render urethral catheterization particularly difficult. Girls and boys with intrinsic sphincter deficiency and severe stress urinary incontinence may undergo implantation of an artificial urinary sphincter. In this case, local erosion and subsequent infection must be avoided if the implant is to function properly. Meticulous aseptic technique is used when catheterizing a child who has an artificial urinary sphincter. The urethral cuff is deflated immediately prior to catheter insertion. If the nurse is not very familiar with the artificial sphincter, the child or parent is asked to deflate the pump for catheterization. The catheter is inserted immediately after the pump is deflated. If resistance is met, the cuff may need to be deflated again before insertion continues.

Boys who are born with epispadias or classic exstrophy have a congenital absence of the urethral sphincter mechanism. A Young-Dees-Leadbetter procedure is frequently performed to improve continence (Gonzalez, 1992). In this procedure, the urethra is angulated with respect to the bladder base to improve continence, and this acute angle makes catheterization a challenge. Boys who have been subjected to multiple catheterizations may form false urethral passages that render urethral catheterization difficult. Likewise, boys with congenital or acquired urethral strictures may be difficult to catheterize.

When a technically difficult catheterization is suspected, special preparation is needed. A coudetipped catheter is routinely chosen, and a smaller catheter size is selected whenever possible. The urethra is prepared by the insertion of 5-10 ml of lubricant containing Xylocaine, using gentle pressure. The urethra is filled until the child perceives pressure, and the lubricant is held in place by occluding the meatus. This strategy provides anesthesia of the urethra and encourages slight urethral opening prior to catheter insertion. The catheter is inserted without allowing lubricant to leak from the urethra. It is important to note that scarring in the urethra may prevent complete anesthesia (as compared to the child with normal mucosa), and increased discomfort may be produced by catheterization. In rare instances, systemic sedation may be necessary prior to urethral catheterization.

A smaller catheter is preferred when performing the technically difficult catheterizations, since it may slip past stenotic areas, whereas a larger catheter may require greater pressure and painful dilation of narrow urethral passages. When urethral resistance persists, despite the installation of lubricant into the urethra, several milliliters of sterile saline or water may be inserted into the catheter as gentle but persistent pressure is applied to the catheter. Often, this additional pressure will temporarily open the urethra sufficiently to allow advancement of the catheter into the bladder vesicle.

When reasonable efforts to catheterize fail, the procedure is discontinued. An elective catheterization should be attempted no more than twice in a single setting. Because of urethral edema, subsequent attempts are likely to prove increasingly painful and unsuccessful. In these instances, a pediatric urologist is consulted, and catheterization is completed using endoscopic guidance, urethral dilation, and adequate local anesthesia or systemic sedation.

Urethral catheterization has been traditionally perceived as a painful, invasive procedure. However, with careful preparation, skillful technique and recognition of situations that are likely to complicate instrumentation, the procedure can be performed in an atraumatic manner benefiting both the child and parents.

References

Carter, H.B. (1992). Instrumentation and endoscopy. In P.C. Walsh, A.B. Retik, T.A. Stamey, & E.D. Vaughan (Eds.), Campbell's urology (6th edition) (pp. 331-338). Philadelphia: W.B. Saunders Company.

Gonzalez, R. (1992). Urinary incontinence. In P.P. Kelalis, L.R. King, A.B. Belman (Eds.), Clinical pediatric urology (pp. 393-394). Philadelphia: W.B. Saunders Company.

Gray, M.L. (1992). Genitourinary disorders. St. Louis, MO: Mosby-Yearbook.

Gray, M.L. (1994). Functional alterations: Bladder. In J. Gross, & B.L. Johnson (Eds.), Handbook of oncology nursing (pp. 528-556). Boston: Jones and Bartlett Publishers.

Meeropol, E., Leger, R., & Frost, J. (1993). Latex allergy in patients with myelodysplasia and in health care providers: A double jeopardy. Urologic Nursing, 13(2), 45-47.

Wong D.L. (Ed.). (1995). Whaley & Wong's nursing care of infants and children. St. Louis: Mosby-Yearbook.

Wyker, A.W. (1991). Standard diagnostic considerations. In J.Y. Gillenwater, J.T. Grayhack, S.S. Howards, & J.W. Duckett, Adult and pediatric urology (pp. 63-77). St. Louis, MO: Mosby-Yearbook.

Mikey Gray, PhD, CUNP, CCCN, FAAN, is a Nurse Practitionerr in the Department of Urology and Associate Professor of Nursing at the University of Virginia in Charlotteville, VA. He is also an adjunct professor in nursing at Bellarmine College, Lansing School of Nursing, in Louisville, KY.
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Date:Jul 1, 1996
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