Indwelling urinary catheter insertion 1: children and young people

Introduction

Urinary catheters are flexible tubes that are inserted into the bladder to aid with emptying or obtaining a urine sample (Figs 1 and 2). Although urinary catheter insertion in children and young people is less common in the UK than in some other countries, it is not altogether uncommon (Crigger et al, 2021). Urinary catheter insertion should only be considered if it is not possible to obtain urine by any other means (Crigger et al, 2021; Kopač, 2013). There are, however, a number of reasons why a urinary catheter may be required in a child or young person (Table 1).

This article explores the considerations required before undertaking this procedure, including ethics and consent. There is a step-by-step guide to insertion, as well as the equipment required and possible contraindications. The implications for the patient and aftercare are also briefly discussed. The focus of this article is indwelling urethral catheterisation; however, it includes some discussion about intermittent catheterisation.

Considerations

Before the procedure is carried out, it is important to consider the patient’s:

• Age;
• Gender identity;
• Cultural and/or religious beliefs;
• Dignity and privacy;
• Physical and psychological wellbeing.

It is also essential to consider the rationale for insertion and whether a urine sample can be obtained without the need for urethral catheterisation (Leaver, 2019; Macqueen et al, 2012). ERIC’s (nd) Children’s Continence Pathway aims to inform parents and professionals about the intervention required by a child with a bowel or bladder problem to help them to achieve the best level of continence. The pathway provides an evidence base for the insertion of urinary catheters.

Inserting a urinary catheter in a child will need ethical consideration. The need for the catheter to be inserted must be discussed with the child, as well as their parent or guardian. The following should be considered:

• The clinical need for the catheter;
• Whether the patient has the capacity to consent to the procedure;
• Whether the patient will be adequately prepared psychologically and physically;
• Whether the health professional is competent, or under the supervision of someone competent, to carry out the procedure;

If a catheter is to be inserted in a child without their consent, this must be discussed with the nursing and medical team and the child’s parent or guardian. The decision and rationale must be recorded in the patient’s notes.

Contraindications

Catheter insertion is one of the main causes of urinary tract infections (UTIs) in children. Therefore, in all children it should only be undertaken when it is necessary and there are no other viable options, and for the shortest possible amount of time.

Catheterisation should still be used but with caution if the patient has any of the following:

• Previous trauma;
• Congenital abnormalities, such as epispadias (an undeveloped urethra) or hypospadias (an abnormal urethral opening in boys);
• A history of urethral stricture – unless catheterisation is being used to dilate historical strictures;
• Haematuria with an unknown cause.

It is also important to note that any foreign body may cause irritation and, in extreme circumstances, rejection by the body (Kart et al, 2021).

Catheter selection

There are different methods of catheterisation, simply differentiated as intermittent and indwelling catheterisation. Which method to use, the duration of catheterisation and the size and type of catheter should be considered alongside the initial rationale for catheterising the child.

Catheters are available in many different materials. For intermittent catheterisation, plastic (Nelaton) catheters are generally used; they should only be used for single events, then removed and disposed of. For indwelling catheterisation, many coatings are available, including hydrogel, hydromel, silicone and silicone elastomer, all of which can remain in situ for up to 12 weeks (University Hospitals of Leicester NHS Trust, 2019). For all catheters, the manufacturer’s recommendations should be followed regarding the length of time they can remain in situ. Catheters should always be latex-free, to minimise the risk of an allergic reaction to latex. Indwelling catheters are usually Foley catheters (Fig 3), which contain a 5ml or 10ml balloon to help them remain in place in the bladder when filled with water.

Catheters are usually sized using the Charrière scale; there are several methods of selecting the required size. Crigger et al (2021) observed that many are based on a child’s weight and/or age, highlighting that those that rely on estimating weight based on age may be unreliable, due to variations in the weight of children of the same age. To address this issue, Kopač (2013) developed a formula based solely on weight. Although it was developed 10 years ago, there is limited literature about it. Some hospital trusts follow Cobussen et al’s (2016) size guidance (Table 2).

The consensus is that, because each urethra can tolerate different sizes of catheter, the choice of size should be individualised to each patient to promote the most effective emptying while minimising the risk of infection (Cobussen et al, 2016). Clinical expertise, local policies and assessment of the child will determine this.

In children and young people the length of the catheter should also be considered. Depending on their age, boys require a catheter of 20-40cm; girls have a shorter urethra, so they require a length of 7-20cm (Cobussen et al, 2016).

Infection control

The National Institute for Health and Care Excellence explains that UTIs caused by catheter usage account for a large proportion of healthcare-associated infections. The longer the catheter remains in situ, the greater the risk of infection. It identified that 43% of male and 56% of female patients’ UTIs were associated with urinary catheters (NICE, 2017). Although these figures include patients of all ages, they highlight the need for continued education for nurses and healthcare practitioners who insert urinary catheters surrounding their use, insertion and management.

To reduce the risk of UTIs, all catheters are pre-packaged and sterile. Throughout the procedure, local infection prevention and control policies should be adhered to, and aseptic technique should be used to prevent harm and minimise the risk of infection (Leaver, 2019). Sterile gloves and appropriate personal protective equipment should be donned, in line with local and national guidance (World Health Organization, nd). A catheter pack can be used to aid with asepsis. After setting up the sterile field, the health professional can add the catheter, sterile water and local anaesthetic onto this, taking care to avoid contamination of the sterile area.

During the procedure, the health professional should use their non-dominant hand for the dirty procedures, such as holding the labia open or retracting the prepuce, and their dominant hand for the clean procedures, such as inserting the catheter. This is to minimise the introduction of bacteria into the urethra and bladder, which minimises the risk of UTIs.

“Inserting a urinary catheter in a child has practical, ethical and procedural considerations”

Preparation

Patients need to be positioned correctly for the procedure. Female patients should be in a supine ‘frog’ position, with heels on the bed, knees bent, and hips abducted and partially flexed outwards (Fig 4). Males should be in a semi-supine, comfortable position. In some cases, the child may need to be sedated or therapeutically held to aid the process. Therapeutic holding involves a parent or guardian gently holding the child in position, and should be discussed with them and their parent or guardian before the procedure. Distraction techniques and working with a play specialist or play therapist can also minimise patients’ anxiety (Great Ormond Street Hospital for Children, 2020). Before inserting the catheter, the health professional must ensure the patient is aware the procedure is going to take place. They should explain the process and reconfirm assent.

The following sterile equipment is required for catheter insertion:

• Latex-free catheter of the appropriate size;
• Catheterisation pack;
• 0.9% sodium chloride for cleaning;
• Drainage system;
• Latex-free gloves and apron;
• Lubricating local anaesthetic gel (for males) or water-based gel (for females)
• 10ml water to inflate the balloon of a Foley catheter (if used);
• Collection pot for sample (if required);
• Protective, absorbent pad for the bed;
• Receptacle to collect urine;
• Tape for securing drainage bag.

The procedure

The steps below indicate the ideal procedure; however, the child’s age and level of cooperation and understanding may affect this.

1. Explain the procedure (with rationale), gain assent, and prepare the patient.
2. Prepare the required equipment and area. Ensure that there is an absorbent pad underneath the child to prevent soiling and contamination, and maintain privacy and dignity.
3. Position the child correctly to allow a visible field to perform the procedure. A parent or guardian should be present to provide comfort.
4. Apply personal protective equipment according to policy.
5. In a female child, clean the vulva and labia using gauze and 0.9% sodium chloride, wiping from front to back. In a male child, clean the prepuce in a single motion and, if possible, retract the prepuce enough to visualise the urethral opening; however, do not retract the prepuce if the child is <5 years, because there is a risk of trauma.
6. Avoiding contamination of the sterile field, place the receptacle close to the patient to collect urine when the catheter has been inserted.
7. For a female child, insert water-based gel into the urethra. For a male child, insert lubricating local anaesthetic gel into the urethral meatus, with the penis at a 90-degree angle. Allow time for the anaesthetic to take effect.
8. For a female child, insert the catheter smoothly and horizontally into the urethral meatus. For a male child, coat the tip of the catheter with lubricating local anaesthetic gel, then gently insert it into the urethral prepuce.
9. There may be resistance at the bladder neck; encourage the patient to breathe deeply or cough to relax the muscles and allow the catheter to pass.
10. Insert the catheter gently until urine begins to flow. Take a urine specimen if needed.
11. Insert indwelling catheters to the hilt, to ensure the balloon is not inflated in the urethra.
12. Inflate the balloon (if used) with the correct amount of sterile water or 0.9% sodium chloride; follow the manufacturer’s guidelines.
13. Gently withdraw the catheter until resistance is felt; this will ensure the balloon is sitting at the bladder neck.
14. Attach a drainage bag to the end of the catheter and tape it to the child’s abdomen or groin. Do not stick it to the child’s leg, as this may cause disconnection, accidental removal or trauma to the urethral meatus and bladder neck (Macqueen et al, 2012).
15. Ensure the drainage bag is below the level of the bladder to aid drainage.
16. Dispose of equipment according to trust policy.

After the catheter has been inserted, it should be documented according to local policy in the child’s health record, including the:

• Date and time of insertion;
• Reason for insertion;
• Size, type and make of the catheter;
• Length of the catheter;
• Volume of water inserted into the balloon (if used);
• Date and time of the required change or removal of the catheter.

The following complications can occur when inserting urethral catheters:

• Perforation of the urethra;
• Haematuria;
• Infection;
• Paraphimosis in males;
• False passages;
• Bladder spasms;
• Strictures (narrowing of the urethra) – although catheters can also be used to dilate the urethra.

These should be considered throughout the procedure, and the patient should be assessed post-insertion. Any complications must be documented in their notes. The catheter should be removed as soon as it is no longer required, or immediately in the event of these complications.

Conclusion

Inserting a urinary catheter in a child has practical, ethical and procedural considerations. Before initiating the process, health professionals must consider the reasons for the procedure, along with correct catheter selection and preparation techniques to ensure the patient is appropriately supported throughout. Practitioners must make use of clinical frameworks and local policies to support them with this clinical skill and facilitate patient- and family-centred care. They must also consider risks to the patient to minimise harm. The second article in this two-part series will explain urinary catheter insertion in adults.