How To Catheterize the Bladder in a Female Child

Bladder catheterization can be done for diagnosis and/or treatment.

The main reason to insert a bladder catheter in female children is to

• Collect a sterile urine sample for testing in very young children who cannot void on command

Less common reasons include

• Relief of acute or chronic urinary retention (obstructive uropathy)

• Intermittent catheterization of a neurogenic bladder

• Instillation of contrast agent for cystourethrography

• Bladder irrigation

• Instillation of a medicine

• Monitoring of urine output in certain hospitalized patients (indwelling catheter; not discussed here)

Absolute contraindications

• Suspected lower urinary tract disruption from recent trauma

In trauma patients, lower urinary tract disruption (suggested by perineal hematoma, bleeding from the meatus, or pelvic bone injury) should be ruled out by retrograde urethrography or vaginal examination (and sometimes cystoscopy) before doing bladder catheterization.

Relative contraindications

• Known major abnormalities of the lower urinary tract

• History of urethral strictures

• Prior urethral or bladder neck reconstruction

• History of difficult catheter placement

Complications include

• Superficial urethral or bladder injury with bleeding (common)

• Urinary tract infection (UTI; common)

• Creation of false passages

• Scarring and strictures

• Bladder perforation (rare)

Sometimes prepackaged kits are available; if not, equipment required typically includes

• Sterile drapes and gloves

• An absorbent underpad

• Sterile cup for collecting urine specimen

• Urethral catheter size varies with age: neonate (full term) to 6 months—5 to 6 French (Fr); infant or toddler—6 to 8 Fr; prepuberal child—10 to 12 Fr; adolescent—12 to 14 Fr

• Washcloth for removing antiseptic solution after the procedure

• Sterile technique is necessary to prevent a lower UTI. 

• If doing multiple procedures, do bladder catheterization first, as the child may void during the other procedures.

• The pediatric female anatomy is similar to the adult's, with a difference in size.

• The female urethral meatus is the first opening below the clitoris and is located above the vaginal opening. It can be difficult to visualize if it appears closed. Also, young girls may have labial adhesions, which can make visualization of the meatus more difficult.

• The urethra is short and straight and thus easy to catheterize.

• Place the patient in a supine, frog position (hips and knees partially flexed, heels on the bed, hips comfortably abducted).

• An assistant should hold the legs or knees.

The in-and-out insertion of a catheter is described here.

• Allow one or both parents or caretakers to remain present to comfort the child. Having them hold the child's hand, provide a stuffed animal for the child to play with, or engage in other distraction techniques can help. Occasionally sedation is needed.

• Place all equipment within easy reach on an uncontaminated sterile field on a bedside tray.

• Open the prepackaged kit, taking care not to contaminate the contents.

• Place the absorbent underpad with the plastic side down beneath the buttocks.

• Remove diaper if present and clean the area with a wet washcloth using soap and water. Dry the area with a dry towel. Then wash your hands with soap and water.

• Put on gloves using sterile technique.

• Apply the sterile lubricant to the end of the catheter and place on the sterile field.

• Place the sterile fenestrated drape over the pelvis so that the vulva is exposed.

• With your nondominant hand, separate the labia to expose the meatus.

• Hold the catheter in your dominant free hand. Separate the labia with your nondominant hand. If the meatus is difficult to see, gently pull the vaginal introitus mucosa downward.

• Advance the catheter gently through the urethra just until urine is obtained. Do not poke repeatedly or force the catheter. Urine should flow freely.

• If the catheter has entered the vagina, leave that catheter in place as a landmark and obtain another catheter.

• Collect urine in the specimen container. If the volume is insufficient, gently massage the lower abdomen over the bladder (suprapubic area).

• Remove the catheter by pulling out gently.

• Remove the drapes.

• To prevent causing a UTI, maintain strict sterile technique during the procedure.

• To prevent causing blind passages and urethral injury, do not use excessive force during insertion.

• Do not proceed with continued attempts at catheter placement if significant resistance is met or if the catheter feels as if it is buckling inside and not advancing.

• If the catheter appears to be in the correct position but urine does not return, lubricant may be obstructing the drainage of urine. With the catheter held in the current position, flush the catheter with normal saline to dislodge the lubricant and see if urine returns prior to proceeding with the remaining steps.

• If the catheter appears to be in the correct position but urine does not return and there is the possibility of anuria due to dehydration, consider providing hydration (appropriate to the patient's clinical condition) before the procedure is attempted again.

• If the catheter appears to be in the vaginal opening, leave the catheter in temporarily. Reattempt catheterization of the urethral opening with a fresh sterile catheter; the previously placed vaginal catheter will prevent you from entering the incorrect orifice. Once urethral catheterization is complete, remove the vaginal catheter.

• Consult a urologist for any issues with catheter placement or guidance on catheter size and style in select clinical scenarios. In certain situations where a catheter cannot be placed, a suprapubic percutaneous aspiration may be indicated.