Male & Female Catheterisation, MSU, Urinalysis & Pregnancy Testing
Aims
To demonstrate female and male catheterisation and give Medical Students knowledge
about the procedure.
To demonstrate how to collect a mid-stream specimen of urine (MSU).
To demonstrate how to perform urinalysis.
To demonstrate how to perform pregnancy testing.
Learning outcomes
By the end of session students will be able to:
•
Explain the principles of the procedures.
•
Identify the equipment required for MSU, urinalysis, pregnancy testing and
catheterisation.
•
Demonstrate understanding of male and female anatomy during simulated practice.
•
Demonstrate catheterisation on manikins using an aseptic technique.
•
List the possible complications associated with catheterisation.
•
Describe how to gain informed consent from patients undergoing the procedures.
•
Explain how to complete the relevant documentation for each procedure.
•
Apply standard infection prevention measures during simulated practice.
Male and Female Catheterisation
Introduction
Catheterisation is the insertion of a tube into the bladder using an aseptic technique.
The tube is inserted to either drain or instil fluid.
Supra-pubic is chosen if it is to be permanent or cannot be inserted via the urethra.
Anatomy
The female urethra is 4-6cm long.
Male urethra is 18-20cm long.
Urethral catheterisation can cause bruising and trauma to the urethral mucosa which then
acts as entry points for micro-organisms into the blood and lymphatic system.
Scar tissue is easily formed as a result of trauma.
The bladder lies just behind the symphisis pubis.
When empty the bladder collapses into a pyramid shape.
As urine accumulates it expands and becomes pear shaped.
A reasonably full bladder holds 500ml.
It can hold 1 litre if necessary.
During micturition the detrusor muscles in the bladder wall contract and compress the
bladder pushing urine into the urethra. The neck of the bladder is closed by two rings of
muscle – the internal sphincter (involuntary control) and external sphincter (voluntary
control).
Stimulation from the CNS keeps the external sphincter fibres contracted except during
micturition.
When 250ml of urine has collected, stretch receptors in the bladder walls are stimulated
and excite sensory parasympathetic fibres, which relay information to the spine and then to
the thalamus and cerebral cortex.
Parasympathetic motor neurons are excited and contract the detrusor muscles in the
bladder. Bladder pressure increases and the internal sphincter opens.
When urine enters the urethra, somatic motor neurons supplying the external sphincter are
inhibited allowing the sphincter to open and urine to flow out, assisted by gravity.
The brain can override the micturition reflex.
Male Anatomy
Female Anatomy
Reasons for Inserting a Urinary Catheter
To empty the bladder prior to surgery.
To monitor renal function post-op
To drain urine when the patient is in urine retention.
To closely monitor urine output in critically ill patients.
To instil fluid, irrigation or cytotoxic drugs.
For bladder function tests to be performed.
As a last resort for urinary incontinence when all other methods have failed.
Possible Contraindications
Recent urological surgery
Trauma to the pelvis or abdomen
Cancer in the lower urinary tract
Haematuria of unknown cause
Catheter Selection
PTFE (Teflon) max 4 weeks
Hydrogel- max 12 weeks
Silicone - max 12 weeks
Intermittent catheters
Catheter Size
Catheters are measured by Charriere gauge (CH).
The charriere is the external diameter of the catheter 1/3 of a millimetre, for example:
CH No. = external diameter in mm
3
Therefore a 12ch catheter has an external diameter of 4mm.
Use the smallest possible size, large catheters can be associated with bypassing, pain and
blockage.
Sizes 12 – 14 are used for routine drainage
Sizes 16 is used if there is debris in the urine
Size 18 should only be used when blood clots are present
Potential Problems

Infection and sepsis
UTI is the most common infection acquired in acute hospitals and long-term care facilities.
Aseptic technique and universal precautions must be used and urine samples sent for
testing if infection is suspected.

Encrustation and blockage;
The cause of the blockage must be identified and the appropriate catheter maintenance
solution used.
Sodium chloride to wash out debris e.g. blood, mucus, or pus.
Citric acid for dissolving crystals.
Mandelic acid to reduce micro-organisms

Urine not draining
The catheter may be in the wrong place, deflate the balloon and gently reposition.
The drainage bag may be positioned above the level of the bladder preventing good flow.
Drainage tubing may be kinked, check position and tubing.
Catheter may be blocked by debris, gently flush with sterile saline.

Haematuria
May result from trauma post-catheterisation, infection, prostate enlargement, calculi,
carcinoma.
Observe and document severity, encourage fluids, seek medical advice if necessary.

Urine bypassing the catheter
May be due to infection - obtain CSU.
Bladder spasm- consider use of medication.
Constipation- increase fluid intake and dietary fibre.
Incorrect position of drainage system - position below bladder.

Bladder irritation/pain
The eyelets of the catheter may be occluded by urothelium due to hydrostatic suction –
raise the bag above the level of the bladder for 15 seconds.

Catheter retaining balloon will not deflate
Valve port may be compressed or their may be a faulty mechanism.
Check there are no external problems, aspirate valve port slowly, and try injecting a small
volume of sterile water and then aspirating again.
If this fails seek medical advice do not cut the catheter as it may retract into the bladder.
Advice to Patients with Urinary Catheters
Hand washing.
Strict hygiene when looking after catheter.
Explain how to empty the catheter and change bags.
Encourage fluid intake of at least 1.5 – 2 litres fluid per day.
Give contact numbers in case of problems and refer to district nurse.
Equipment Required for Urinary Catheterisation
Silver trolley
Apron
Alcohol gel
2 pairs of sterile gloves
Catheterisation pack
2 catheters – correct size and type
10ml water for injections and 10ml syringe
Sterile cleansing solution
Sterile gauze
Drainage bag and stand
Sterile instillagel (11ml for men / 6ml for women)
(NB Ensure you check expiry dates on all equipment used)
Before you begin the procedure
Introduce yourself
Obtain informed consent
Place a waterproof sheet under the patient.
Assist the male patient to lie in a semi-recumbent position
Assist the female patient to lie down with their knees flexed and legs apart
Cover the patient and maintain privacy and dignity
Reassure the patient
Wash your hands and prepare your equipment
The Procedure
Once the patient is prepared and comfortable wash your hands and put on the apron
Clean your trolley
Place equipment on the bottom shelf, checking all expiry dates and seals as you do so.
Take the trolley to the patient’s bedside, ensure your patient is prepared and comfortable
Clean your hands using alcohol gel
Using aseptic technique open catheter pack onto the top of the trolley and place other
equipment onto the pack
Expose the genital area, wash hands and put on sterile gloves
For males retract the foreskin, cleanse shaft, glans and the urethral meatus using normasol
For females separate the labia minora to expose the urethral meatus using normasol
Clean away from the urethral orifice using single downward strokes
For males arrange the sterile drape so the penis passes through the hole and use gauze to
hold behind the glans
For females place the sterile drape under the patient
Insert the anaesthetic jelly into the urethra and leave to take effect for 3-5 minutes (11ml for
men / 6ml for women)
Wipe away any excess gel, dispose of gloves, wash and dry hands and reapply new sterile
gloves (Pratt, 2007)
Place the catheter in the receiver
For men use the gauze to hold the penis at an angle between 60 – 90 degrees
For women use the gauze to separate the labia
Introduce the tip of the catheter into the urethra and insert fully up to its bifurcation point to
make sure the catheter has cleared the prostatic bed and is in the bladder
Ask the patient to take deep breaths to ease discomfort
Once urine flows inflate the balloon and connect to drainage system
For men ensure the foreskin is replaced over the glans to prevent constriction and oedema
Dispose of waste, wash your hands, ensure the patient is comfortable and dry
Documentation
The following should be recorded in the patient’s notes:
Time and date
Clinical reason for procedure
Informed verbal consent
Aseptic technique used
Instillagel used
Catheter size, type and expiry date
Any problems encountered
Amount of urine drained
Record urine output on the fluid balance chart
Complete Care Pathway
Catheter Care Pathway
Catheter Care
Removal of Urinary Catheters
Explain the procedure and obtain informed consent
Wash hands and apply gloves, Use saline to clean the meatus and catheter and then
change gloves, Remove water from the balloon using a 10ml syringe
Ask patient to breathe in and out and when they exhale withdraw the catheter.
Clean the meatus and make the patient comfortable.
Post Catheter removal – Ward Care
Catheters are either removed at midnight so the patient goes to the toilet on waking or early
morning so that problems can be dealt with during the day.
Ensure the patient can get to the toilet when needed and give a supply of liners, ask the
patient to use a separate one each time they pass urine.
Encourage fluid intake and ensure urine passed is documented on the fluid balance chart.
Ensure the patient is passing urine easily and in good volumes (above 100mls each time).
If patient is having difficulty use a bladder scanner to assess residual urine.
Document care given in patients notes.
Mid-stream Specimen of Urine (MSU) & Urinalysis
Introduction
The Mid-stream urine (MSU) test is carried out to check for infections. Infections can cause
a lot of bladder problems so it is important that these are ruled out first.
Background Physiology
The kidneys filter approximately 180 litres of plasma per day.
The final volume of urine produced is approximately 1 – 1.5 litres.
The processes of ultrafiltration, tubular reabsorption and tubular secretion ensure that vital
substances such as glucose, amino acids and electrolytes are conserved as required and
waste products such as urea and creatinine are excreted.
Water maybe conserved or excreted as required.
Normal Urine
Urine is a straw-coloured clear fluid.
When urine is becoming concentrated, it becomes darker and more yellow.
Urine may have no smell or may have a slight aroma. This may alter as a result of disease,
concentration or length of time it has been stored in the bladder.
Urine is slightly acidic – pH 5 – 6.
Urine’s normal composition includes water, urea, creatinine, sodium, potassium, protein,
small traces of protein and glucose and cellular components.
Urinalysis (Point of care analysis)
Introduction
Urinalysis is used as a screening and/or diagnostic tool because it can detect different
metabolic and kidney disorders. Often, substances such as protein or glucose will begin to
appear in the urine before patients are aware that they may have a problem. It is used to
detect urinary tract infections (UTI) and other disorders of the urinary tract.
Basic urinalysis should include observing the urine’s colour and consistency.
Any cloudiness or debris may indicate presence of abnormal cells or disease.
The aroma of the urine should be documented. A ‘fishy’ aroma may indicate infection
whereas a ‘pear drop’ aroma may indicate the presence of ketones.
All of the above should be considered in the context of the patient’s clinical condition, urine
output and fluid balance records.
Reagent Sticks
Reagent sticks are plastic or paper strips impregnated with chemicals.
These should be immersed in the urine sample and read against the reference guide
supplied to provide an indication of the presence of a certain substance.
Reagent sticks or dipsticks are useful in preliminary patient assessment.
A common range of tests form part of general urinalysis. These tests may include:

Blood / haemoglobin – the presence of which may indicate trauma

Erythrocytes – presence of this may indicate bleeding in the genitor-urinary tract, kidney
stones or infection

White blood cells – this may indicate infection

pH

Glucose

Ketones – presence may indicate keto-acidotic states or starvation

Protein – may indicate, hypertension, kidney or heart dysfunction or infection
Equipment required for urinalysis
Urine dipsticks
Gloves
Sterile receiver
Disposable towel
Apron
The Procedure
Obtain verbal informed consent
Check manufacturers instructions and check expiry date of reagent sticks
Wash hands, put on gloves and apron
Collect an MSU or catheter specimen from the patient using a sterile receiver
Remove reagent stick from container and immediately replace cap
Immerse the reagent stick into the urine, the duration of immersion will vary according to
manufacturer’s instruction
Wipe the edge of the reagent stick on the rim of the receiver to remove any excess urine.
Dab the back of the test strip on an absorbent towel
Read the reagent strip against the reference guide provided.
Dispose of urine and reagent strip appropriately
Remove gloves and apron and wash hands
Document results in patient notes and obtain sample for microbiological analysis if required
Mid-stream Specimen of Urine (MSU)
The MSU must be:

Appropriate to the patient’s clinical presentation

Collected at the right time

Collected in a way that minimises contamination

Collected to minimise risk to all staff (including laboratory staff)

Documented clearly

Transported appropriately
Urine Samples
Urine is frequently collected for microbiological and/or biochemical investigation.
It is commonly collected for testing levels of particular metabolites or presence of particular
drugs or drug metabolites and toxicology screens. Microbial culture and antimicrobial
sensitivity.
Where a sample is to be microbiologically tested, an MSU is required. This involves taking
a ‘middle’ sample whilst urine is being voided. This avoids the initial and end stages of the
void which reduces the risk of contamination of the sample from bacteria that colonises the
distal urethra as these bacteria are washed away with the initial urine flow.
Advice to Patients requiring MSU
MSU is indicated in adults and children who are continent and can empty their bladder on
request (Gilbert, 2006).
Most patients require advice beforehand to ensure that a ‘middle’ sample is collected.
Hygiene advice must be given to reduce risk of contamination from hands or the genital
area.
Uncircumcised men should retract their foreskin before micturition.
Women should be advised to part the labia.
It is widely agreed that a strong urine flow will clear bacteria from the urethral meatus
therefore it is suggested that a sample be obtained when the bladder is full to result in the
least contaminated sample.
Equipment required for MSU
Soap and water
Sterile specimen pot
Gloves
Apron
Appropriate investigation request form
The Procedure
Obtain patient informed consent and assess the level of assistance the patient may require
Instruct or assist patient to wash hands and attend to genital hygiene
Provide information on retracting the foreskin / parting the labia
Instruct the patient to direct the first part of the void into the toilet
Ask the patient to collect the middle part in the sterile pot
Ask the patient to void the remaining urine into the toilet
Instruct the patient to wash hands
Label the sample, complete request from and document in the patient notes
Pregnancy Testing
Introduction
A pregnancy test attempts to determine whether or not a woman is pregnant. Modern
pregnancy tests look for chemical markers associated with pregnancy. These markers are
found in urine and blood, and pregnancy tests require sampling one of these substances.
The first of these markers to be discovered, human chorionic gonadotropin (hCG), was
discovered in 1930 to be produced by the trophoblast cells of the fertilised ovum
(blastocyst). While hCG is a reliable marker of pregnancy, it cannot be detected until after
implantation this results in false negatives if the test is performed during the very early
stages of pregnancy. Most chemical tests for pregnancy look for the presence of the beta
subunit of hCG in blood or urine. hCG can be detected in urine or blood after implantation,
which occurs six to twelve days after fertilization. Quantitative blood (serum beta) tests can
detect hCG levels as low as 1 mIU/mL, while urine tests have published detection
thresholds of 20 mIU/mL to 100 mIU/mL, depending on the brand.
Radiology
Prior to a diagnostic imaging procedure, it is essential that any female of reproductive age
(between 12 and 55 years although local trust policy and guidance may differ) presenting
for an examination involving exposure of the pelvic area or the administration of
radioisotopes is asked if she might be pregnant.
Where possible, an examination should be scheduled within 28 days of the onset of the last
menstrual period.
Where a high dose procedure is proposed, for example a pelvic CT or barium study, local
policy may require the procedure to be completed within 10 days of the onset of the
menstrual period.
If the woman cannot exclude the possibility of pregnancy then it should be ascertained if
her period is overdue.
Advice should be sought from the clinician authorising the investigation as to whether the
investigation is justified by being of indirect benefit to an unborn child, for example an
emergency procedure.
If the period is not overdue (within 28 days of the onset of the last menstrual period) then a
urine or serum test for pregnancy may be performed prior to the examination. These tests
are highly sensitive.
The Equipment
Please refer to local arrangements.
At GEH a Clearview hCG II Pregnancy detection test is used.
The Procedure
Pregnancy Tests are to be carried out following the manufacturers’ instructions. For
Clearview hCG, see below.
References
Bardsley, A. (2005) Use of lubricant gels in urinary catheterisation. Nursing Standard. 20, 8
BAUN (British association of urological nurses) (2000/2001) Guidelines for female urethral
catheterisation using 2% lignocaine gel (Instillagel) Printed by CliniMed Limited.
Bruck, L., Donofrio, J., Munderi, J., Thompson, G. (nk) Anatomy and Physiology made
incredibly easy. London: Lippincott Williams and Wilkins.
Dougherty, L. Lister, S (2004) The Royal Marsden Hospital manual of Clinical Nursing
Procedures. Oxford: Blackwell Publishing.
Gilbert, R. (2006) Taking a midstream specimen of urine. Nursing Times; 101: 18, 22-23.
Graham, J.C, Galloway, A. (2001) The laboratory diagnosis of urinary tract infection.
Journal of Clinical Pathology; 54: 911-919
Higgins, C. (2000) Microbiology testing. In: Understanding Laboratory Investigations.
Oxford: Blackwell Science.
Leaver, R.B. (2007) The evidence for urethral meatal cleansing. Nursing Standard; 21: 41,
39-42.
NHS Quality Improvement Scotland (2004) Best Practice Statement. Urinary
Catheterisation and Catheter Care. www.nhshealthquality.org
Pratt, R.J. (2007) Epic 2: National evidence-based guidelines for preventing healthcare
associated infections in NHS hospitals in England. Journal of Hospital Infection; 65 suppl 1;
s1-64
RCN (2005) Good practice in Infection Prevention and Control: Guidance for Nursing Staff.
London: RCN.
RCN (2006) Best Practice Guidance on Pregnancy Testing prior to diagnostic imaging.
http://www.rcn.org.uk/__data/assets/pdf_file/0011/78707/003063.pdf accessed March 2010
RCN (2008) Catheter Care. RCN Guidance for Nurses. London RCN
Richardson M. (2006) The Urinary System. Part 4 – Bladder control and micturition.
Nursing Times. 102, 43
Royal Marsden NHS Foundation Trust (2004) Royal Marsden Hospital Manual of Clinical
Nursing Procedures. Sixth Edition. Eds Dougherty, L., Lister, S. London: Royal Marsden
NHS Foundation Trust / Blackwell Publishing
Skills for Health. www.tools.skillsforhealth.org - accessed March 2010. CHS 7 Obtain
and test specimens from individuals
Skills for Health / RCN (2008) www.tools.skillsforhealth.org - accessed March 2010.
Continence Care – National Occupational Standards (NOS).
Tew, L. et al (2005) Infection risks associated with urinary catheters. Nursing Standard. 20,
7