UUCI Health · Department of Neurology
APP Class II · Procedural Competency Series · 2026
●  Procedure 10·Bedside / standard·Standard tier
10.

Urinary Catheter

Insertion.

Straight in-and-out and indwelling Foley.
Chadwycke R. Smith, MSN, NP, AGACNP-BC
APP Education · Department of Neurology
Approving authority: Claire Henchcliffe, MD, DPhil · Chair, Department of Neurology
Version 2.0 · 2026-05-11
Urinary Catheter · UCI Neurology APP Class II
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UUCI · APP Class II
Procedure 10 · Urinary Catheter
02 · Why this matters
CAUTI share of all healthcare-associated infections
~12%
of all HAIs. NHSN-reportable. CMS will not pay for the hospital-acquired version. The dominant driver is not technique — it's indication discipline.
  • The majority of CAUTI episodes trace to catheters placed without a current indication, or left in beyond the indication window.
  • Daily indication review with prompt removal is the single highest-yield CAUTI-prevention intervention.
  • SHEA Compendium update reaffirms: limit insertion, ensure prompt removal.
  • Forced insertion against firm resistance is the dominant mechanism of urethral injury — a preventable, long-tail complication.
Gould CV et al. CDC HICPAC CAUTI Guideline 2009 (reaffirmed 2017)
Patel PK et al. Infect Control Hosp Epidemiol. 2023;44(8):1209–1231 · PMID 37620117
Urinary Catheter · Why this matters
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UUCI · APP Class II
Procedure 10 · Urinary Catheter
03 · Course objectives

What you'll leave with — six competencies.

01 · Cognitive

Indications & anatomy.

Differentiate CDC-accepted indications from inappropriate ones; describe female (~2 in) and male (~8 in, prostatic curve) urethral anatomy.

02 · Cognitive

Catheter selection.

Select straight vs. Foley; 14 Fr standard, 16 Fr hematuria, Coude for BPH; 10 mL balloon inflated with sterile water only.

03 · Psychomotor

Sterile technique.

Sterile field, fenestrated drape, meatal prep per institutional policy; catheter remains sterile throughout the advance.

04 · Psychomotor

Insertion · female + male.

Midline advance in the female; 90° → 45° two-phase angle in the male; advance to urine return, then 1–2 in further.

05 · Psychomotor

Urine return before inflation.

Confirm urine return BEFORE balloon inflation — every time. Inflate with 5–10 mL sterile water.

06 · Affective

Escalation & daily review.

Recognize BPH resistance, suspected stricture, blood at meatus — stop, escalate to urology. Daily necessity review & prompt removal.

Urinary Catheter · Course objectives
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UUCI · APP Class II
Section I of IV
I.
Section one

Anatomy & indication.

Female urethra ~2 in, nearly straight. Male urethra ~8 in, with a prostatic curve. Two anatomies, two techniques. The indication list is the same.
Objectives C-1 · C-2 · A-2 — slides 5–7
Urinary Catheter · Section I
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UUCI · APP Class II
Procedure 10 · Urinary Catheter
04 · Indications · the whole decision

The CDC list is the indication list.

CDC/HICPAC-accepted indications
  • Acute urinary retention (bladder scan ≥ 400 mL + symptoms)
  • Accurate strict I/O in critically ill / pressor-dependent patients (shock, aSAH, status, TTM)
  • Sacral / perineal pressure injury in an incontinent patient — wound healing threatened by urine
  • Prolonged immobilization with skin-integrity risk
  • Selected peri-operative — anticipated long case, large fluid shifts, anticipated post-op monitoring
  • Comfort at end-of-life per patient or surrogate preference
Inappropriate indications
  • Substitute for nursing care of an incontinent patient (without wound indication)
  • Urine specimen collection in a continent patient
  • Routine monitoring of a cooperative, ambulatory patient
  • Incontinence alone — without sacral / perineal wound
  • Prolonged post-operative use without ongoing need
Gould CV et al. CDC HICPAC CAUTI Guideline · 2009 (reaffirmed 2017)
Hooton TM et al. IDSA. Clin Infect Dis. 2010;50(5):625–63 · PMID 20175247
Urinary Catheter · Indications
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UUCI · APP Class II
Procedure 10 · Urinary Catheter
05 · Contraindications · cautions

When to defer — and to whom.

Suspected urethral injury · STOP
  • Blood at the meatus — most sensitive sign
  • Perineal hematoma or "butterfly" ecchymosis
  • High-riding or non-palpable prostate on rectal exam (male)
  • Pelvic ring fracture with any of the above
A catheter placed through a partially transected urethra can complete the transection. Defer to urology for retrograde urethrogram or suprapubic catheter placement.
Relative cautions · plan adjustments
  • Known urethral stricture history — Coude tip, lidocaine dwell, low threshold to call urology
  • Severe BPH or prior difficult male insertion — Coude tip, concave-up
  • Recent prostatic, urethral, or pelvic surgery — discuss with surgical team first
  • Latex allergy — silicone catheter; iodine allergy — chlorhexidine prep; lidocaine allergy — plain lubricant
Hooton TM et al. IDSA · 2010; PMID 20175247 · Marino, ICU Book, Ch 41
Urinary Catheter · Contraindications
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UUCI · APP Class II
Procedure 10 · Urinary Catheter
06 · Pre-procedure · time-out

Before you open the kit — verify the indication.

  • 01
    Indication verbalized. State the CDC-accepted indication aloud and write it in the procedure note. If you can't name an indication on the accepted list, don't place the catheter.
  • 02
    Consent & alternatives. Discuss risks, alternatives (condom catheter, external female wick / PureWick, straight-cath only), and right to decline. Offer chaperone where appropriate.
  • 03
    Allergy check. Latex · iodine · lidocaine · chlorhexidine. Cross-check kit contents against allergy list before opening.
  • 04
    Patient positioned. Female — supine, frog-leg, draped. Male — supine, legs extended, draped. Light source positioned.
  • 05
    Time-out called. Per TJC UP.01.03.01 — two identifiers, correct procedure, site (urethral vs. suprapubic), indication, allergies confirmed aloud.
TJC standard

UP.01.03.01

Pre-procedure verification, indication confirmation, formal time-out — the three-part protocol that exists to prevent placement decisions from happening on autopilot.
The Joint Commission. Universal Protocol UP.01.03.01.
TJC Hospital Accreditation Standards · 2024.
Urinary Catheter · Pre-procedure verification
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UUCI · APP Class II
Key fact · CAUTI
Daily indication review · the only intervention that moves the rate
~12%
of all healthcare-associated infections are CAUTI — NHSN-reportable, CMS non-payment for the hospital-acquired version. The fix is not antibiotics or irrigation. It is the daily question: does this catheter still need to be in?
01
Indication
at placement.
02
Sterile
insertion.
03
Closed drainage ·
bag below.
04
Daily
review.
05
Prompt
removal.
Patel PK et al. Infect Control Hosp Epidemiol. 2023;44(8):1209–1231 · PMID 37620117
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UUCI · APP Class II
Procedure 10 · Urinary Catheter
07 · Kit · catheter selection

Pick the right tube — sterile water only.

Kit checklist
  • 14 Fr Foley · standard adult
  • 16 Fr Foley · hematuria / clot risk
  • 12 Fr · delicate anatomy / pediatric
  • Coude tip · BPH or prior difficult male insertion
  • Straight-cath only · single-drainage indication
  • Sterile fenestrated drape · sterile gloves
  • Iodophor or chlorhexidine swabs (per policy)
  • 2% lidocaine jelly (urethral anesthetic)
  • Sterile water-based lubricant
  • 10 mL pre-filled sterile water syringe
  • Drainage bag with anti-reflux valve
  • StatLock or securement strap (medial thigh)
Labeled Foley catheter diagram showing inflation balloon, retention balloon port, and drainage port
Noda; Wayne · File:Foley catheter.png · WikimediaPublic domain
Balloon inflation: 5–10 mL sterile water for a 10 mL balloon. Never saline (crystallizes — blocks deflation channel). Never air (leaks — balloon won't seat). 30 mL balloons reserved for post-TURP or large-volume drainage only.
Urinary Catheter · Kit & catheter selection
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UUCI · APP Class II
Section II of IV
II.
Section two · female insertion

Midline.
Straight in.

Female urethra is ~2 in, nearly straight, meatus anterior to the vagina. Sterile setup, labial spread, midline advance, urine return, inflate.
Objectives P-1 · P-2 · P-3 · P-5 · P-7 — slide 11
Urinary Catheter · Section II.a
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UUCI · APP Class II
Procedure 10 · Urinary Catheter
08 · Female insertion

Frog-leg, drape, three swabs, midline advance.

  • 01
    Position & light. Supine, knees flexed and abducted (frog-leg), sterile fenestrated drape, light source aimed to illuminate the meatus.
  • 02
    Sterile field. Hand hygiene, sterile gloves, sterile drape. Open kit, pour iodophor or chlorhexidine, draw sterile water into pre-attached syringe (do not separate before testing balloon if institutional policy requires — many UCI kits ship pre-tested).
  • 03
    Labial spread & meatal prep. Non-dominant hand spreads the labia (now contaminated, remains in position). Three swabs front-to-back, one stroke per swab, center swab last.
  • 04
    Advance midline. With dominant sterile hand only, advance the lubricated catheter along the vertical midline. Urine returns at ~2–3 in. Advance another 1–2 in before balloon inflation.
  • 05
    Vaginal misplacement. If the catheter passes without urine return and without resistance, suspect vaginal misplacement. Leave it as a landmark and use a fresh sterile catheter in the correct tract — never reuse the contaminated catheter.
  • 06
    Inflate & seat. Inflate with 5–10 mL sterile water. Gentle traction until balloon seats at bladder neck. Attach closed drainage system.
Marino, ICU Book, Ch 41 · MGH HSM Foley protocol · Hooton TM et al. IDSA. Clin Infect Dis. 2010;50(5):625–63 · PMID 20175247
Urinary Catheter · Female insertion
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UUCI · APP Class II
Section II of IV · part b
II.b
Section two · male insertion

90° then 45°.

Male urethra is ~8 in with a prostatic curve. Lift the penis perpendicular to straighten penile + bulbar segments, then drop to ~45° to negotiate the prostatic curve. Patience over force.
Objectives P-1 · P-2 · P-4 · P-6 · P-7 · P-8 — slide 13
Urinary Catheter · Section II.b
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UUCI · APP Class II
Procedure 10 · Urinary Catheter
09 · Male insertion

Lift to 90°, lidocaine dwell, drop to 45° at the prostate.

  • 01
    Position & foreskin. Supine, legs extended, draped. In uncircumcised patients, retract the foreskin — and remember this for step 06. Grasp the shaft with the non-dominant hand (now contaminated) and lift the penis perpendicular (~90°) to straighten penile + bulbar urethra.
  • 02
    Meatal prep. Three swabs in concentric circles, center-out. Meatus first, then surrounding glans.
  • 03
    Lidocaine instillation. Instill 5–10 mL of 2% lidocaine jelly into the urethra. Dwell 5–10 minutes — meaningful difference at the prostatic curve. (Institutional norm per UCI Nursing Ed / Marino Ch 41.)
  • 04
    Advance at 90°. Steady gentle pressure. The penile and bulbar segments accept the catheter easily. Never force against firm resistance.
  • 05
    Drop to 45° at the prostate. When you feel the prostatic resistance, lower the penis to ~45° toward the feet. This aligns the catheter with the membranous and prostatic urethra. Urine returns at ~6–8 in. Advance another 1–2 in before balloon inflation.
  • 06
    Inflate · seat · return foreskin. Inflate with 5–10 mL sterile water. Gentle traction. Return the foreskin to its anatomic position — failure to do so causes paraphimosis, a urologic emergency.
Marino, ICU Book, Ch 41 · MGH HSM Foley · Gray's Anatomy 43rd ed., male urethra plate · NeuroICU Textbook, Ch 33
Urinary Catheter · Male insertion
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UUCI · APP Class II
Procedure 10 · Urinary Catheter · Critical checkpoint
Critical safety checkpoint · mandatory before balloon inflation

Confirm urine return
before you inflate.

Rule 01 · never inflate without return

Inflating in the urethra creates a false passage at minimum and a long-term stricture at worst. If you've advanced to the hub with no urine return, withdraw, re-prep, fresh catheter.

Rule 02 · never force against firm resistance

Firm resistance + BPH or stricture history = call urology. Adjunct steps first: lidocaine jelly 5–10 min dwell, Coude tip concave-up. Urology after one failed retry.

Three nevers
NEVER force · NEVER inflate without return ·
NEVER leave the foreskin retracted.
Balloon-in-urethra inflation is the single most preventable
urethral injury we see in this institution.
Urinary Catheter · Urine-return checkpoint
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UUCI · APP Class II
Procedure 10 · Urinary Catheter
10 · Securement · CAUTI bundle

Medial thigh, bag below, daily review.

Securement & drainage
  • Secure to the medial thigh in all adults (current SHEA/IDSA practice — Patel 2022)
  • StatLock or equivalent securement device · tape slides
  • Drainage bag below the level of the bladder at all times · no dependent loops
  • Closed drainage system — never disconnect for sampling
  • Daily perineal care with soap and water · no antimicrobial agents needed
CAUTI bundle · highest yield
  • No routine irrigation
  • No routine prophylactic antibiotics
  • No routine catheter exchange
  • Yes — daily indication review with prompt removal
Cross-sectional schematic of indwelling urinary catheter seated in the bladder with inflated retention balloon at the bladder neck
NIDDK/NKUDIC · File:Foley catheter in place.png · WikimediaPublic domain
Patel PK et al. Infect Control Hosp Epidemiol. 2023;44(8):1209–1231 · PMID 37620117 · Septimus EJ et al. Open Forum Infect Dis. 2026;13(2):ofag060 · PMID 41725706
Urinary Catheter · Securement & bundle
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UUCI · APP Class II
Section III of IV
III.
Section three

Recognize.
Escalate.

CAUTI is the high-volume complication. Urethral injury, balloon misplacement, and paraphimosis are the high-stakes ones — all preventable.
Objectives C-5 · C-6 · C-7 · A-3 · A-4 — slides 17–18
Urinary Catheter · Section III
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UUCI · APP Class II
Procedure 10 · Urinary Catheter
11 · Complications — immediate & delayed

Eight events you diagnose on sight.

01 · Delayed

CAUTI.

Risk rises ~3–7% per day of dwell. NHSN-reportable. Bundle adherence + prompt removal are primary prevention.

02 · Immediate

Urethral injury.

Forced insertion against firm resistance is the dominant mechanism. Blood at meatus = stop. Urology consult.

03 · Immediate

False passage.

Premature balloon inflation in urethra or repeated forced attempts. Risks long-term stricture. Cystoscopic / IR retrieval.

04 · Immediate

Paraphimosis.

Unreturned foreskin in uncircumcised male = urologic emergency. Manual reduction or surgical release.

05 · Immediate

Bladder spasm.

Usually self-limited. Anticholinergics if severe. Re-check catheter not too small / over-inflated.

06 · Delayed

Meatal pressure ulcer.

From tight or kinked securement. Re-secure, off-load skin, daily perineal care.

07 · Delayed

Balloon rupture.

On removal — retained fragment. Cystoscopic retrieval. Document fragment count.

08 · Never event

Catheter w/o indication.

A catheter placed without an accepted indication is the dominant driver of CAUTI. Indication discipline is the fix.

Urinary Catheter · Complications
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UUCI · APP Class II
Procedure 10 · Urinary Catheter
12 · Pitfalls

Four errors we see — repeatedly.

01

Forcing against firm resistance.

The dominant mechanism of urethral injury we see. Stop, lidocaine jelly dwell, Coude tip — and then urology after one failed retry. Never force.

02

Inflating before urine return.

A near-miss that becomes a stricture when missed twice. If catheter is at the hub with no return — withdraw, fresh catheter. Never inflate on hope.

03

Leaving the foreskin retracted.

Paraphimosis is a urologic emergency and is 100% preventable. The last step of male catheterization is always: return the foreskin.

04

No daily necessity review.

The pitfall that drives the institutional CAUTI rate. Ask every day: does this still need to be in? Pull the day the indication resolves.

Urinary Catheter · Pitfalls
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UUCI · APP Class II
Procedure 10 · Urinary Catheter
13 · UCI FPPE · OPPE

Your competency pathway.

StageTriggerScope
FPPEBoard approval of urinary catheter privilegeFirst 3 independent cases · per-case review within 30 d · aggregate at 3 · closed within 6 mo
OPPEContinuous baselineEvery 6 mo · 10% sample (min 2, max 10) · 100% review on complication or CAUTI event
Ad-hoc FPPEUrethral injury · paraphimosis · CAUTI w/ bacteremia · non-indicated pattern3 subsequent cases reviewed; outcome a / b / c
Reinstatement< 3 independent cases over 24 moPhantom skills checklist + 1 proctored live case (lapse is rare — high-volume procedure)
Tracked OPPE indicators
  • CAUTI rate < 1 / 1,000 catheter-days (UCI target)
  • First-attempt success ≥ 80%
  • Appropriate-indication rate 100%
  • Daily-indication-review rate ≥ 95%
  • Urethral injury / false passage rate — 100% per-case review on any occurrence
  • Paraphimosis events — 100% per-case review, target zero
  • Procedure-note completeness 100%
Standard tier Sim center optional · triggered only on bench gap.
Urinary Catheter · FPPE / OPPE pathway
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UUCI · APP Class II
Procedure 10 · Urinary Catheter
14 · References & acknowledgments

Sources of truth.

  1. 01Gould CV, Umscheid CA, Agarwal RK, et al. Guideline for prevention of catheter-associated urinary tract infections. CDC HICPAC. 2009 (reaffirmed 2017).
  2. 02Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated UTI in adults: 2009 IDSA international clinical practice guidelines. Clin Infect Dis. 2010;50(5):625–63. PMID 20175247.
  3. 03Patel PK, Advani SD, Kofman AD, et al. Strategies to prevent catheter-associated urinary tract infections in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol. 2023;44(8):1209–1231. PMID 37620117.
  4. 04Septimus EJ, Arya LA, Crapanzano-Sigafoos R, et al. Prevention strategies for all hospital-onset urinary tract infections: best practice consensus recommendations. Open Forum Infect Dis. 2026;13(2):ofag060. PMID 41725706.
  5. 05Scruggs-Wodkowski E, Kidder I, Meddings J, Patel PK. Urinary catheter-associated infections. Infect Dis Clin North Am. 2024;38(4):713–729. PMID 39261137.
  6. 06Marino PL. Urinary catheters. In: The ICU Book, 4th ed. Lippincott Williams & Wilkins; Ch 41.
  7. 07Torbey MT, ed. Neurocritical Care, 2nd ed. Cambridge University Press; Ch 33 (bedside procedures).
  8. 08Bigelow Medical Service. Massachusetts General Hospital Handbook of Internal Medicine — Foley protocol. 2024–25 ed.
  9. 09The Joint Commission. Universal Protocol UP.01.03.01. TJC Hospital Accreditation Standards; 2024.
  10. 09aThe Joint Commission. Universal Protocol UP.01.01.01 — preprocedure verification; use a standardized list (H&P, signed consent, nursing & preanesthesia assessment, labeled imaging, required equipment/devices). National Patient Safety Goals (HAP); effective January 2025.
  11. 09bThe Joint Commission. NPSG.01.01.01 EP 1 — use at least two patient identifiers (room number is not an identifier) before any treatment or procedure. National Patient Safety Goals (HAP); effective January 2025.
  12. 09cThe Joint Commission. NPSG.07.01.01 EP 1 — implement CDC and/or WHO hand-hygiene categories IA, IB, IC. National Patient Safety Goals (HAP); effective January 2025.
  13. 09dThe Joint Commission. NPSG.03.04.01 — label all medications, medication containers, and solutions on and off the sterile field (name, strength, amount, diluent, expiration). EP 4 requires two-individual verification when preparer ≠ administrator. National Patient Safety Goals (HAP); effective January 2025.
  14. 10The Joint Commission. HR.01.06.01 (competence verified before care) · MS.08.01.01 / MS.08.01.03 (FPPE / OPPE). 2024.
  15. 11UCI APP Class 2 Training Plan Process. Department of Neurology, University of California, Irvine. April 2026.
  16. 12UCI Nursing Education. Aseptic technique & CAUTI-prevention modules. UCI Health; 2025.
Urinary Catheter · References
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UUCI · APP Class II
Procedure 10 · Urinary Catheter
End of module · Procedure 10

Now —
the post-test.

Stream A
13-item post-test
≥ 11/13
Stream B
19-item skills
female + male phantom
Stream C
Sim — optional
triggered on bench gap
Live
3 proctored cases
female + male mix
Routing: IDPC → Department Chair → APP Director per UCI Medical Staff Bylaws.
Approving authority: Claire Henchcliffe, MD, DPhil · Chair, Department of Neurology.
UCI Health · APP Education
Version 2.0 · 2026-05-11
Urinary Catheter · End
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