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• To refresh your knowledge of the anatomy and physiology of the male urinary system
• To familiarise yourself with the procedure for undertaking male urethral catheterisation
• To understand how various issues that may occur during catheterisation can be addressed
Rationale and key points
This article provides a step-by-step guide explaining how to prepare for and perform male urinary catheterisation in a safe, effective and supportive manner. Nurses undertaking this procedure must ensure they have the knowledge and skills to do so and work within the limits of their competence.
• Urethral catheterisation is an invasive procedure and carries a risk of infection. It should only be undertaken after thorough clinical assessment and when other alternatives have been considered.
• The procedure can be anxiety-provoking for the patient, so the nurse should explain what is involved and proceed carefully, while keeping the patient informed throughout.
• Due to the risk of catheter-associated urinary tract infection, it is important to regularly review the patient’s need to be catheterised and the catheter should be removed as soon as practically possible.
Reflective activity
‘How to’ articles can help to update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of:
• How this article might improve your practice when planning and undertaking male urinary catheterisation.
• How you could use this information to educate nursing students or your colleagues on the procedure for male urinary catheterisation.
Nursing Standard. doi: 10.7748/ns.2024.e12150
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Dekkers R (2024) How to undertake male urinary catheterisation. Nursing Standard. doi: 10.7748/ns.2024.e12150
DisclaimerPlease note that information provided by Nursing Standard is not sufficient to make the reader competent to perform the task. All clinical skills should be formally assessed according to policy and procedures. It is the nurse’s responsibility to ensure their practice remains up to date and reflects the latest evidence
Published online: 29 July 2024
The role of the urinary tract is to produce, store and excrete urine from the body. If this function is compromised or requires monitoring – for example due to age-related prostate enlargement in men – it may become necessary to insert a urethral catheter. The earliest recorded records of catheterisation date from around 1500 BC in ancient Egypt where transurethral bronze tubes, reeds, straws and rolled-up palm leaves were used. However, the introduction of the Foley catheter in the 1930s meant that short-term and long-term catheterisation became available to men and women; before this, catheterisation was almost exclusively performed on men with urinary retention (Feneley et al 2015). This piece of medical equipment is still used today with little change to its original form.
Box 1 outlines the main indications for urethral catheterisation.
• Managing acute retention of urine, which can have various causes such as prostate enlargement, constipation or anaesthesia
• Managing chronic retention of urine if renal function is compromised, such as in obstructive uropathy caused by an enlarged prostate or bladder stones, for example
• Monitoring of the patient’s renal function and/or hourly urinary output during critical illness
• Monitoring, recording or draining residual bladder volumes if a bladder scanner is not available
• Recording urine output accurately during and after surgery
• Performing bladder irrigation
• Instilling medicines such as chemotherapy drugs into the bladder
• Bypassing an obstruction and/or voiding difficulties, for example due to prostate enlargement
• Performing bladder function tests such as urodynamic studies
• Managing intractable incontinence that is damaging the patient’s skin integrity, or supporting open sacral or perineal wound healing
• Obtaining a sterile sample of urine
(Royal College of Nursing 2021, European Association of Urology Nurses 2024)
It is essential for nurses to understand the anatomy and physiology of the male lower urinary tract before undertaking male urethral catheterisation. The urinary system comprises the kidneys, ureters, bladder and urethra. The function of the kidneys is to produce urine, which will excrete waste products. Urine passes through the ureters into the bladder, which acts as a storage vessel before the urine is expelled via the urethra. At the exit of the bladder is the bladder neck (internal urethral sphincter), which retains the urine in the bladder until it is convenient for it to be emptied. The bladder neck is also responsible for preventing any backflow of urine and semen (in men) into the bladder. The urethra is a tubular structure that is around 19cm-20cm long in men compared with around 3cm-4cm long in women. For this reason, catheterisation can be more challenging to perform in men than in women (Waugh and Grant 2018).
In men, both urine and semen are expelled through the urethra. Urine is forced from the contracting bladder and passes through the bladder neck as it relaxes then continues through the first section of the urethra, which is known as the prostatic urethra and is around 3cm-4cm long. The prostatic urethra is surrounded by the prostate gland and contains the opening of the ejaculatory duct. As the prostate enlarges with age, it can begin to apply pressure to the urethra causing a deterioration in urine flow and potentially complete retention of urine. Prostate enlargement can also make it challenging to insert a catheter.
Continuing from the prostatic urethra is the membranous urethra, which is around 1cm-1.5cm in length and is the narrowest section of the urethra. The membranous urethra is surrounded by another ring of muscle known as the external urethral sphincter, which has a vital role in the voluntary control of urine flow and therefore continence.
The final section of the male urethra is the penile or spongy urethra, which runs along the length of the penis and, at around 15cm, is the longest section of the urethra. It is surrounded by the erectile tissue of the penis and opens externally via the urethral meatus – a vertical slit at the tip of the penis (Knight et al 2024).
Figure 1 shows a cross-section of the male urinary system.
In line with The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council (NMC) 2018) and the RCN (2021) catheter care guidance, any nurse undertaking male urethral catheterisation must be deemed competent in the procedure. Skills for Health (2010) provides a useful list of competencies in relation to urinary catheterisation; for example, it states that the healthcare professional will need to understand ‘how to assess the function of a urethral catheter’ and ‘how to minimise any unnecessary discomfort during and after the procedure’. Nurses must work within their level of competence and know where to seek advice as necessary (Skills for Health 2010).
Nurses must also have up-to-date knowledge and understanding of current legislation regarding catheterisation and adhere to national and local procedures, policies and guidelines, as well as clinical governance. It is the nurse’s responsibility to ensure they obtain appropriate consent from the patient before any treatment or procedure. In addition, the nurse must also be familiar with the Mental Capacity Act 2005 and its application, while also recognising that people have the right to refuse treatment (NMC 2018).
• It is essential that you are familiar with the range of catheters available, and which is most suitable for the patient. Consider the design and size of the catheter, as well as the length of time it can remain in situ and the balloon capacity. Take the patient’s clinical history and check if they have any allergies, in particular to local anaesthetic gel and latex.
• Ensure that you are using the catheter in accordance with the manufacturer’s recommendations, to avoid harming the patient.
• Select a male catheter – these are typically 40cm-44cm in length. Female catheters must not be used because they are shorter (23cm-26cm in length), so there is a risk of the catheter not reaching the bladder and the balloon being inflated in the urethra, resulting in trauma.
• Figure 2 shows some of the equipment required for male urethral catheterisation. The necessary equipment for this procedure includes:
• Equipment trolley.
• Disposable single-use apron.
• Sterile catheterisation pack. Figure 2 shows the contents of this – a sterile receiver tray (labelled ‘receiver with saline’), sterile gauze swabs, two pairs of sterile gloves and a sterile sheet.
• Protective sheet.
• Sterile paper towel.
• 0.9% sodium chloride solution (normal saline).
• Male catheter.
• Sterile drainage bag with either straps (for a leg bag), a stand or a holder (for a 2L drainage bag). Alternatively, a catheter valve may be used, which enables the bladder to retain its urine storage function and to be filled and emptied.
• Catheter fixation device.
• Sterile local anaesthetic gel in a pre-filled syringe (11mL).
• Sterile urine receptable. A larger sterile container may be required for large residual volumes.
• Sterile urine sample container, if required.
• Disposable bag.
1. Introduce yourself to the patient and explain the catheterisation procedure. Ensure they fully understand the procedure before obtaining their consent to proceed with it.
2. Ensure the area where you will undertake the procedure is suitable to maintain the patient’s privacy. Offer for a chaperone to be present due to the intimate nature of the procedure.
3. Confirm the patient’s allergy status.
4. Prepare the patient by asking them to remove their lower clothing and lie on the bed or clinical couch with a protective sheet underneath their hips.
5. Place a suitable covering such as a sheet over the patient’s genitalia to preserve their dignity while you prepare the equipment trolley.
6. Decontaminate your hands according to local infection prevention and control policy.
7. Clean the trolley in line with local infection prevention and control guidelines, then place the necessary equipment on the bottom shelf. Check any expiry dates and do not use the equipment if it is not in date. Take the trolley to the bedside or clinical couch.
8. Don a disposable single-use apron and decontaminate your hands again.
9. Open the outer layer of the catheterisation pack on top of the trolley, taking care not to touch the inside of the pack.
10. Place a disposable bag onto the side of the trolley for waste disposal.
11. Open the catheterisation pack using an aseptic non-touch technique. Open and pour the 0.9% sodium chloride solution into the sterile receiver tray.
12. Open the local anaesthetic, drainage bag or catheter valve and catheter packaging onto the trolley. If there is no pre-filled syringe with sterile water for balloon inflation included in the catheter packaging, ensure a separate syringe with sterile water is available and check the manufacturer’s instructions for the quantity of water to be used.
13. Remove the covering that was placed over the patient’s genitalia earlier.
14. Decontaminate your hands as per local policy and put on a pair of sterile gloves.
15. Place a sterile paper towel across the patient’s thighs, ensuring their scrotal area is covered but not the penis. Place the sterile receiver tray between the patient’s legs.
16. Open out and fold a sterile gauze swab lengthways and wrap this around the penis creating a ‘hammock’ with your non-dominant hand. This will enable you to keep the penis in position using an aseptic non-touch technique then retract the foreskin (prepuce) if present.
17. Clean the urethral meatus using sterile gauze swabs soaked with 0.9% sodium chloride solution. Start at the urethral meatus and away from the glans, ensuring your fingers do not touch the glans.
18. Position the penis at a 90° angle to the patient’s thigh extending upwards.
19. Prime the local anaesthetic gel in the pre-filled syringe before applying it to the urethral meatus, advising the patient that they may experience a stinging sensation as the gel passes down the urethra. Slowly syringe the gel into the urethra, then remove and discard the syringe in the disposable waste bag.
20. Gently squeeze the end of the penis to prevent any loss of the local anaesthetic gel and leave the gel in situ for the time detailed by the manufacturer’s recommendations – usually 3-5 minutes.
21. Dispose of the gloves, decontaminate your hands appropriately and don a new pair of sterile gloves.
22. Keeping the penis upright at 90°, begin to advance the catheter into the urethra while continuing to communicate with the patient. This insertion of the catheter can be performed with an aseptic non-touch technique by using the packaging wrapper surrounding the catheter, which can be eased back slowly as you advance the catheter into the urethra. Patients usually experience some resistance and discomfort when the catheter reaches the external sphincter and prostate – to ease this, you can ask them to strain gently as if passing urine.
23. Continue to advance the catheter until urine appears. Collect this in a sterile receptacle then advance the catheter further by a few centimetres. If the patient has a very enlarged prostate, you may have to insert the catheter all the way to the bifurcation (where the catheter divides in two, with one channel for urine drainage and the other channel for balloon inflation) before you see any urine. This is because a very enlarged prostate can infiltrate the bladder and elevate the bladder neck.
24. Slowly inflate the balloon with the sterile water, checking that the patient is not experiencing any discomfort; this helps to ensure that the balloon is not being inflated inside the prostatic urethra.
25. Gently draw back the catheter until you feel some resistance. This indicates that the balloon is appropriately located inside the bladder at the bladder neck.
26. Once the urine has stopped draining, attach the drainage bag or valve to the end of the catheter, then attach the catheter fixation device to the patient’s preferred leg.
27. Gently pull back the foreskin (if present) into its normal position to avoid paraphimosis (when the foreskin becomes trapped in the retracted position).
28. Ensure the patient is clean, dry and comfortable.
29. Measure the residual urine volume obtained and note the colour; for example, ‘reddish’ or pink urine can indicate blood, while ‘cloudy’ urine might indicate infection. If necessary, collect a sample and perform a urinalysis.
30. If possible, ask the patient to stand to ensure that the catheter length is adequate to enable movement and that there is no ‘kinking’ of the tubing.
31. Once the procedure has been completed, dispose of waste as per local infection prevention and control policy (the collected urine will usually be disposed of in the sluice), clean the clinical area and decontaminate your hands. You may wish to retain any labels from the catheter packaging to insert or record in the patient’s medical notes. This will help to inform other healthcare professionals of the equipment used.
32. Take some time to explain the catheter care required to the patient; for example, regularly washing the penis with warm soapy water. Provide written information if necessary.
33. Arrange and complete the patient’s catheter passport or local equivalent. This provides information about the catheter that is kept by the patient and can be updated as necessary if there are changes to their catheter care. It is usually provided in booklet form and aids personal care when the patient is transferred between healthcare professionals and teams (Codd 2014).
34. Ensure that appropriate referrals have been made to any healthcare professionals taking over the patient’s onward care, such as a community nursing team or GP, and check that the patient understands where to obtain supplies of catheter products such as new drainage bags if necessary.
35. Ensure that you fully complete the necessary documentation. The Code (NMC 2018) and the RCN (2021) catheter care guidance state the importance of nurses keeping clear and accurate records relevant to their practice. Details of the catheterisation need to be recorded as soon as practicably possible after the insertion and should include:
• The patient’s verbal consent.
• Reason for the catheter insertion.
• Date and time of insertion.
• Catheter size, length and type.
• Expiry date of the catheter.
• Volume of water used to inflate the balloon.
• Batch number and expiry date of the local anaesthetic gel.
• Any issues encountered during the procedure or with the equipment.
• Date for review and change of catheter.
Urethral catheterisation is an invasive procedure, and the benefits and risks should be fully considered before it is undertaken. Having a urethral catheter in situ can be a traumatic and painful experience for patients, and alterations in their body image, sexuality and mobility are important considerations (European Association of Urology Nurses 2024).
Catheters are a source of infection, with bacteriuria (the presence of bacteria in the urine) found in ‘nearly all people’ one month after catheterisation (National Institute for Health and Care Excellence (NICE) 2018). Catheter-associated urinary tract infection (CAUTI) is defined as a symptomatic infection in the bladder or kidneys in someone with a catheter (NICE 2018). The risk of CAUTI is directly proportional to the length of time the catheter is left in situ (Adams et al 2012); therefore, it is important to regularly review the patient’s need to be catheterised and the catheter should be removed as soon as practically possible.
The HOUDINI protocol (Box 2) can be used as an assessment tool to support timely catheter removal because it details the acceptable criteria for the continued use of a catheter; if none of these are present, this indicates that the catheter can be removed (Adams et al 2012). This nurse-led protocol was developed as a patient safety tool, and a pilot study concluded that it led to fewer urethral catheterisations, fewer CAUTIs and a reduction in the number of days that patients had a catheter in situ. The HOUDINI protocol was also found to be simple for nurses to use and provided them with the confidence to remove catheters when necessary (Adams et al 2012).
• H –haematuria
• O –obstruction (urinary)
• U –urologic surgery
• D –decubitus ulcer (open sacral or perineal pressure ulcer in a person with incontinence)
• I –input-output fluid monitoring
• N –not for resuscitation or receiving palliative or end of life care
• I –immobility due to physical constraints
NICE (2017) guidelines also recommend that indwelling urethral catheters should only be used after alternative methods have been considered, and they should be regarded as a ‘last resort’ (European Association of Urology Nurses 2024). Other options include: clean intermittent catheterisation (undertaken either by the patient themselves or carer – while this is not a sterile technique, it is performed under clean conditions in the home to avoid infection); external male catheters; suprapubic catheterisation (where the catheter is inserted through the abdominal wall directly into the bladder); or containment products such as continence pads. The clinical need for catheterisation should be reviewed regularly and the catheter should be removed as soon as possible (NICE 2017).
Male urethral catheterisation can be a challenging procedure for nurses and repeated attempts to insert the catheter can cause unnecessary stress, pain and potential trauma for patients. For the nurse, a calm and confident approach can be helpful as the patient may be anxious about having a catheter inserted. Talking them through the procedure and explaining everything in simple terms can help them to relax, which in turn will ease the insertion of the catheter. In addition, if the patient is tense and anxious, asking them to take slow deep breaths as the catheter is advanced along the urethra can help to relax the external sphincter. The external sphincter may also tighten as the catheter is advanced because it is under the control of the pelvic floor muscle and the patient might inadvertently tighten this muscle in response to discomfort. Therefore, it may be useful for the nurse to ask the patient to ‘bear down’ as the catheter is advanced, as if gently squeezing out the last drops of urine after urinating, because this can also relax the external sphincter (European Association of Urology Nurses 2024).
If there is still resistance to the advancement of the catheter following these measures, it might be that prostate enlargement is causing a blockage in the urethra. If, after a couple of gentle attempts, the nurse cannot pass the catheter through the prostate gland, it may be worth considering an alternative type of catheter. For example, coudé or Tiemann tip catheters are manufactured with a bent tip, which enables easier passage through the prostate gland. However, these types of catheters must be inserted by an experienced healthcare professional. In addition, bleeding is quite common in patients with prostate enlargement during catheterisation and afterwards because the prostate is highly vascularised, so blood might be seen inside the catheter or the drainage bag. While any bleeding should gradually cease after insertion, the patient should be encouraged to drink plenty of water to reduce the potential for blockages in the catheter’s drainage holes caused by blood clots (European Association of Urology Nurses 2024).
Another potential issue for the nurse when seeking to advance the catheter is the presence of a urethral stricture – a narrowing in the urethra caused by scarring. Strictures can occur in any part of the urethra, although most develop in the bulbar urethra (located towards the bladder end of the urethra). There are various potential causes of urethral strictures but they can occur due to the previous insertion of a catheter, so the nurse should enquire about this when taking the patient’s clinical history before catheterisation. The management of a stricture will usually involve a urologist because it may require urethral dilatation or surgery (Reynard et al 2019).
Another issue with catheterisation can be caused by hypospadias, a congenital defect where the opening of the urethra is not located at the tip of the penis. The opening can be anywhere from just below the tip of the penis (on the ventral or underside) to the scrotum (Reynard et al 2019).
Hypospadias can also be iatrogenic and caused by the trauma of having a long-term catheter in situ. Alternatively, phimosis (when the foreskin is very tight and cannot be retracted) can occur as a result of infection, trauma or inflammation and may require circumcision or a dorsal slit (a single incision along the upper length of the foreskin) to release the tightness (Nair and Peate 2013).
If the nurse identifies any of these issues or abnormalities they should seek the advice of a urologist; similarly, they should seek advice and expert opinion after two failed attempts to insert a male urethral catheter (European Association of Urology Nurses 2024).
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