The anxiety, fear and discomfort experienced during catheterization can be significantly alleviated by adequate preparation of the child and parents, by selection of the correct catheter, and by appropriate technique of insertion. Specifically, generous lubrication of the urethra prior to catheterization and use of a lubricant containing 2% xylocaine may significantly reduce or eliminate the burning and discomfort frequently associated with this invasive procedure.
Preparation of the child and parents is accomplished according to the developmental level of the child and in close consultation with the parents. A careful and thorough explanation of the procedure, including its purpose, is given prior to preparation of the perineum. When catheterizing an infant, the parents are reassured that catheterization will not harm their child or damage the urethra or hymen. For the toddler or older child, catheterization is explained and an additional step-by-step description is offered as the procedure is completed. The child is reassured that insertion of the catheter will not feel like having a sharp object inserted, but will produce a feeling of pressure and desire to urinate.
Preparation for catheterization includes instruction on pelvic muscle relaxation whenever possible. The toddler, preschooler or younger child is taught to blow a pinwheel and to press the hips against the bed or procedure table during catheterization in order to relax the pelvic and periurethral muscles. The location and function of the pelvic muscles are described briefly to the older child or adolescent. The patient is then taught to contract and relax the pelvic muscles, and the relaxation procedure is repeated during catheter insertion. If the patient vigorously contracts the pelvic muscles when the catheter reaches the striated sphincter (proximal urethra in boys and mid-urethra in girls) catheter insertion is temporarily stopped. The catheter is neither removed nor advanced; instead, the child is assisted to press the hips against the bed or examining table and relax the pelvic muscles. The catheter is then gently advanced into the bladder.
Atraumatic catheterization also relies on careful selection of the catheter. When obtaining a urine sample, a soft 5-8 French feeding tube may be safely and easily inserted into the urethra of girls and pre-pubescent boys. A 6-8 French red rubber or poly-vinyl-chloride catheter provides an alternative to the use of a feeding tube. Adolescent boys and children with a history of urethral surgery may be catheterized with a coude-tipped catheter. The child with myelodysplasia or one who has been identified as sensitive or allergic to latex is catheterized with a catheter or feeding tube manufactured of an alternative material. When an indwelling catheter is indicated for urinary drainage, a Lubricious Coated or silicone catheter is selected because these materials produce less irritation of the urethral mucosa as compared to a silastic, latex catheter when left in place for more than 72 hours.
After an appropriate catheter is selected and the procedure is explained, the perineal area is cleansed in preparation for catheter insertion with a povidone-iodine soap (or alternative cleansing agent in the child sensitive to cutaneous iodine containing substances) and wiped dry with a sterile towel or cotton balls. A 2% xylocaine lubricant with applicator is assembled according to the manufacturer's instructions* and several drops of the lubricant are placed at the meatus. The child is advised that the lubricant is used to reduce any discomfort associated with inserting the catheter and that introduction of the lubricant into the urethra will produce a sensation of pressure and a desire to urinate.
In males, the tip of the applicator is gently introduced into the urethra 1-2 cm so that the lubricant flows only into the urethra. Five to ten ml of lubricant are slowly inserted into the urethra and held in place for 2-3 minutes by gently squeezing the distal penis. This maneuver allows the mucosa to absorb the active ingredient. Additional lubricant is placed on the catheter tip which is inserted into the urethra without allowing the intraurethral lubricant to exit the urethral meatus. Using this technique of retaining the lubricant as the catheter is inserted provides lubrication of the urethra and promotes opening of the sphincter mechanism.
For females, 1-2 ml of a 2% xylocaine lubricant are placed on the periurethral mucosa and 1-2 ml are inserted into the urethral meatus. Catheterization is delayed for 2-3 minutes in order to maximize absorption of the anesthetic into the periurethral and intraurethral mucosa. Additional lubricant is added to the catheter which is gently inserted into the urethra until urine returns. This additional lubrication, combined with the mild anesthetic effects of the 2% xylocaine lubricant, greatly reduces the discomfort frequently associated with insertion of a catheter.
Because the use of lidocaine jelly can increase the volume of intraurethral lubricant, urine return may not be as rapid as when minimal lubricant is used. However, with patience, a urine return will occur and the discomfort and anxiety commonly associated with catheterization will be avoided.
*Lidocaine hydrochloride jelly, 2%, 200mg (20mg/ml) plastic syringe and sterile applicator, is available from International Medication Systems, Limited (IMS), South El Monte, CA 91733.
Xylocaine 2% jelly (lidocaine HCL, 20mg/ml) in a 5 ml tube is also available from Astra USA, Inc., Westborough, MA 01581-4500. The cap is removed and replaced by a plastic cone for administration. The plastic cone that attaches to the tube must be sterilized for 5 minutes in boiling water, cooled and attached to the tube. The cone may be gas sterilized as preferred.
Gray ML: Atraumatic urethral catheterization of children, Pediatric Nursing 22(4):306-10, 1996.
See Chapters 27 and 28 in Nursing Care of Infants and Children, 5th and 6th editions.
See Chapters 22 and 27 in Essentials of Pediatric Nursing, 5th edition
March 15, 2002