Urethral catheterization: indications, technique, complications, care, and modern rules for safe use

Urethral catheterization is the insertion of a catheter through the urethra into the bladder for temporary or longer-term urinary drainage, urine output control, acute urinary retention, or other clinical purposes. The procedure appears simple and routine, but current guidelines consider it an intervention with real risks, rather than a neutral, routine procedure. [1]

The main reason for this revision is simple: the longer a catheter remains in the bladder, the higher the risk of complications. The US Centers for Disease Control and Prevention (CDC) notes that indwelling urinary catheters are rapidly colonized by microorganisms, with bacteriuria rates ranging from approximately 3-7% per day to approaching 100% after 1 month. [2]

Bacteriuria and clinical infection are not the same thing. The presence of bacteria in the urine of a patient with a catheter often reflects colonization and biofilm, rather than a definitive infection requiring antibiotics. This is why modern urethral catheterization is based on three principles: avoid catheter placement without a clear indication, use it for as short a time as possible, and maintain it according to strict guidelines. [3]

Urethral trauma is a separate issue. A 2024 study found that traumatic urethral catheterization is associated with a greater need for additional interventions, a higher risk of catheter-associated urinary tract infection, and a longer drainage period. This is an important signal: an error during catheter insertion can be just as significant as an infection. [4]

Therefore, today, urethral catheterization is more than just a tube insertion technique. It's a clinical decision that requires an understanding in advance of whether a catheter is needed at all, which catheter to choose, how to insert it with minimal trauma, and when to remove it without waiting for unnecessary problems. [5]

Table 1. What is important to understand about urethral catheterization from the start

Question	Practical answer
What is this?	Insertion of a catheter through the urethra into the bladder
The main goal	Urinary diversion, elimination of retention, monitoring of diuresis, assistance in individual clinical situations
The main risk	Infection, biofilm, urethral trauma, pain, leakage, obstruction
The most important risk factor for infection	Duration of catheter instillation
The main modern principle	Place only as indicated and remove as soon as possible.
A common mistake	Use a catheter as a substitute for incontinence care or "just in case"

Source: [6]

When is a catheter really necessary, and when is it better to avoid it?

Not every urinary disorder requires a urethral catheter. The US Agency for Healthcare Research and Quality classifies appropriate indications as acute urinary continence or obstruction, precise urine output control in critically ill patients, certain surgical situations, strict immobilization, palliative care, and promoting healing of severe perineal and sacral wounds in patients with incontinence. [7]

On the contrary, current guidelines explicitly recommend avoiding indwelling catheters as a substitute for routine incontinence care. The US Centers for Disease Control and Prevention classifies the use of a catheter instead of nursing care as inappropriate, as is placement solely for urine collection in a patient who can void spontaneously. [8]

Postoperative care is also crucial. For surgical patients, a catheter is not needed routinely, but only when there is a genuine reason. If there is an indication, it is recommended to remove it as soon as possible after surgery, preferably within 24 hours, unless there is a compelling reason to continue drainage. [9]

If the problem is not short-term urinary retention, but chronic bladder emptying dysfunction, the modern approach often favors intermittent catheterization. The US Centers for Disease Control and Prevention explicitly states that intermittent catheterization is preferable to an indwelling urethral or suprapubic catheter for bladder emptying dysfunction. [10]

There are also intermediate options. For cooperative men without urinary retention or bladder outlet obstruction, external catheters can be considered as an alternative to an indwelling urethral catheter. This is important, because modern complication prevention begins with the question not "how best to insert a catheter," but "is there another method available?" [11]

Table 2. When urethral catheterization is appropriate and when it is not

Situation	Urethral catheterization
Acute urinary retention	Usually shown
Accurate measurement of urine output in a critically ill patient	Shown
Selected urological and major surgeries	May be shown
Comfort at the end of life	It may be justified
Urinary incontinence without other causes	Not usually shown
Urine collection for analysis from a patient who can urinate independently	Not shown
Chronic bladder emptying disorder with the possibility of patient education	Intermittent catheterization is often better.
A man without urinary retention and without obstruction needs urine collection	An external catheter may be considered.

Source: [12]

When a procedure is contraindicated or requires special caution

Catheterization cannot be considered absolutely safe, even when indicated. A StatPearls review lists contraindications as blood at the urethral orifice, severe macrohematuria, signs of urethral infection, pain along the urethra, low bladder capacity or poor bladder compliance, and patient refusal. In practice, the first point is particularly important, as it may indicate urethral injury. [13]

In traumatology, suspected urethral injury requires a separate approach. The European Association of Urology, in its 2025 guidelines for urological trauma, states that blood at the urethral meatus is the most important clinical sign requiring further investigation. The American Urological Association also emphasizes that blood at the meatus after trauma should be considered for urethral injury and appropriate evaluation should be performed first. [14]

Clinically, this implies an important rule: if there is reason to suspect urethral injury, do not force the catheter through. Blind insertion in such a situation can aggravate the injury and turn a partial rupture into a more severe one. This principle is repeatedly reiterated in trauma manuals and reviews. [15]

Caution is also necessary in cases of known urethral stricture, severe benign prostatic hyperplasia, recent urological interventions, and complex anatomy following surgery or radiation therapy. In these cases, multiple repeated attempts are particularly dangerous because they increase the risk of false prolapse and iatrogenic injury. [16]

If standard catheterization fails, modern logic discourages a series of crude attempts. Failure after a reasonable attempt is not a reason to increase pressure, but rather a reason to stop, reassess the situation, and, if necessary, involve a urologist or choose an alternative drainage method. [17]

Table 3. Signs that indicate routine catheterization should be stopped and re-evaluated.

Sign	Why is this important?
Blood at the external opening of the urethra	Possible damage to the urethra
Severe pain when advancing the catheter	Possible injury or obstruction
Severe macrohematuria	The cause needs to be re-evaluated.
Known urethral stricture	Higher risk of false move and injury
Multiple unsuccessful attempts	The risk of iatrogenic injury increases
Patient refusal	The procedure should not be carried out forcibly without reason and discussion.

Source: [18]

How the procedure is performed according to modern rules

Good catheterization begins with preparation, not the insertion itself. The U.S. Centers for Disease Control and Prevention recommends performing hand hygiene immediately before and after inserting a catheter or handling it, and entrusting the procedure only to people trained in proper aseptic technique for insertion and care. [19]

In a hospital setting, indwelling urethral catheter placement requires aseptic technique and sterile equipment. Sterile gloves, a sterile drape, sterile swabs, a suitable antiseptic or sterile periurethral solution, and a disposable lubricant pack are recommended. However, the routine use of antiseptic lubricating gels is not considered necessary. [20]

The importance of adequate lubrication is emphasized. The 2025 National Health Service of Scotland guidelines for adults note that an adequate amount of anaesthetic gel helps reduce urethral trauma; the document provides typical volume guidelines for men and women and recommends waiting 2-5 minutes after gel insertion. This is a practical, not decorative, step, especially in men. [21]

Once the catheter is inserted, it must be securely secured. The US Centers for Disease Control and Prevention recommends properly securing an indwelling catheter after insertion to reduce movement and traction on the urethra. They also recommend using the smallest catheter diameter sufficient for normal urine flow to reduce trauma to the bladder neck and urethra. [22]

Technical details vary between men and women. A practical review of StatPearls in men emphasizes the need for generous lubrication and full advancement of the catheter until it is firmly positioned in the bladder before inflating the balloon. In women, it is important to clearly visualize the external urethral opening; if the catheter accidentally enters the vagina, it is recommended to leave it there as a landmark and use a new sterile catheter for proper insertion. [23]

Table 4. Modern algorithm for safe urethral catheterization

Step	What are they doing?	Why is this necessary?
1	Check the indications and contraindications	To avoid performing an unnecessary or dangerous procedure
2	Wash your hands and prepare a sterile kit.	To reduce the risk of infection
3	Perform periurethral treatment and use a disposable lubricant.	To ensure asepsis and reduce trauma
4	The minimum sufficient catheter size is selected	To reduce trauma to the urethra
5	The catheter is inserted without force and without repeated rough attempts	To prevent false stroke and damage
6	After installation, the catheter is fixed	To reduce traction and pain
7	Connect a closed drainage system	To reduce the risk of infection
8	Document the date, indication, and removal plan.	To control catheter days and timely removal

Source: [24]

Which catheter to choose and how does continuous catheterization differ from intermittent catheterization?

From a practical standpoint, the drainage strategy, rather than the type of material, should be the first consideration. For patients with bladder emptying dysfunction, intermittent catheterization is generally preferred over continuous catheterization if feasible. This is reflected in both the US Centers for Disease Control and Prevention guidelines and more recent clinical reviews and quality of life surveys. [25]

Infection isn't the only factor. In a 2025 study of over 3,000 patients on long-term drainage, intermittent catheterization was associated with the best satisfaction and quality of life scores. Indwelling catheters, both urethral and suprapubic, were associated with worse scores on these parameters after adjusting for confounding factors. [26]

However, intermittent catheterization is not suitable for everyone. Self-administration requires sufficient manual dexterity, strength, vision, understanding of the procedure, and, often, training. If the patient is physically or cognitively unable to perform it independently and there is no assistant, then an indwelling catheter may be the only realistic option. [27]

Regarding the catheters themselves, current guidelines do not support the idea that "the thicker, the better." The US Centers for Disease Control and Prevention recommend choosing the smallest possible diameter that ensures good drainage. For long-term use, the material and coating are selected based on the clinical objective and tolerability, not on the patient's habits. [28]

Coated catheters are a separate issue. The European Association of Urology, in its 2025 update, supports the use of hydrophilic coatings to reduce the risk of catheter-associated urinary tract infections, particularly in the context of intermittent catheterization. The same document notes that silver-containing catheters have not shown a convincing statistically significant reduction in such infections in systematic reviews. [29]

Table 5. Comparison of the main bladder drainage strategies

Option	Pros	Cons	When is it more suitable?
Indwelling urethral catheter	Fast, simple, available almost everywhere	Higher risk of infection, injury, discomfort, biofilm	Short-term drainage when other options are not feasible
Intermittent catheterization	Generally better for quality of life and often preferred by current guidelines	Requires training, dexterity and regularity	Chronic bowel movement disorder with the possibility of independent or assisted bowel movement
External catheter in men	No invasion of the urethra	Not suitable for urinary retention and obstruction	Cooperative men without urinary retention
Suprapubic catheter	It comes out of the urethra and may be more convenient for long-term situations.	Requires a separate procedure and care for the injection site	When a long-term urethral catheter is undesirable and there are indications

Source: [30]

Complications: What happens most often and how to prevent them

The most well-known complication is catheter-associated urinary tract infection, but this is not the only problem. Pain, traction injury, false passage, urethral bleeding, leakage past the catheter, obstruction, bladder spasms, paraphimosis in uncircumcised men, and decreased quality of life with prolonged use are equally significant in clinical practice. [31]

Infections are not limited to insertion errors. Once inserted, a biofilm quickly forms on the catheter surface, making microorganisms difficult to eliminate even with antibiotics. Therefore, prevention focuses on avoiding unnecessary catheters, maintaining a closed system, and reducing the duration of use, rather than relying on prophylactic antibiotics. [32]

Current guidelines are quite strict regarding unnecessary antimicrobial prophylaxis. The European Association of Urology recommends against the use of prophylactic antimicrobials to prevent catheter-associated urinary tract infections and against their routine use after removal of a urethral catheter. The same document recommends against applying topical antiseptics or antimicrobials to the catheter, urethra, or external opening. [33]

Mechanical prophylaxis is equally important. The US Centers for Disease Control and Prevention recommend maintaining a closed system, preventing kinks in the tubing, keeping the bag below the bladder and off the floor, and not changing the catheter or drainage bag on a rigid schedule without a clinical reason. Replacement is necessary in the event of infection, obstruction, or loss of closure. [34]

Routine care has also changed compared to previous concepts. Routine antiseptic treatment of the external urethral opening during catheterization is not recommended. Instead, routine hygiene during daily washing is sufficient. Routine bladder irrigation with antimicrobial solutions and the routine insertion of antiseptics into the drainage bag are also not recommended. [35]

Multiple, forceful attempts to insert a catheter while resisting are extremely dangerous. Research from 2024 on traumatic catheterization shows that such injuries lead to additional interventions and increase the risk of infection. From a practical standpoint, this means a simple rule: the catheter should not be inserted by force. [36]

Table 6. Main complications and preventive measures

Complication	How does it manifest itself?	How to reduce the risk
Catheter-associated urinary tract infection	Fever, pain, new symptoms of urinary tract infection	Minimization of catheter days, closed system, early removal
Bacteriuria without symptoms	Bacteria in urine without clinical infection	Usually they don't treat with antibiotics, they evaluate the symptoms
Urethral trauma	Pain, blood, resistance during injection	Do not force the injection, avoid multiple attempts
Catheter obstruction	Poor drainage, overflow, leakage	Monitor for kinks and change as needed
Traction pain and discomfort	Aching pain, irritation	Secure fixation of the catheter
Bladder spasms and leakage	Pain, urine passing through the catheter	Check the patency, size, and cause of irritation.
Paraphimosis	Swelling and constriction of the foreskin	After manipulation, return the foreskin to its place

Source: [37]

Post-insertion care and when to remove the catheter

The work doesn't end after placement. One of the key modern guidelines is daily reassessment of the need for a catheter. The StatPearls review and the US Centers for Disease Control and Prevention guidelines emphasize that the need for a catheter should be reassessed daily, and removal should occur as soon as the need for a catheter has disappeared. [38]

The integrity of the closed system is essential for preventing complications. If a leak, disconnection, or breach of asepsis occurs, the US Centers for Disease Control and Prevention recommend replacing the catheter and collecting system using sterile technique and sterile equipment. This is more important than cosmetic cleaning of the external portion of the system. [39]

Catheters and drainage bags should also not be changed on a fixed schedule without a reason. The US Centers for Disease Control and Prevention recommends doing this only when clinically indicated, such as in the case of infection, obstruction, or compromise of the closed system. This approach avoids the need for unnecessary procedures. [40]

In terms of lifestyle and quality of life, modern data have become much more sensitive to the patient experience. A 2025 national survey showed that patients on long-term permanent drainage, on average, rate their well-being and satisfaction lower than those on intermittent catheterization. Therefore, with long-term drainage requirements, the question should be asked not only about "technical performance," but also about tolerability, independence, and everyday consequences. [41]

From a clinical perspective, the ideal catheter is one that is removed promptly. The most effective way to reduce the incidence of catheter-associated urinary tract infections, according to current guidelines and implementation documents, is to avoid placing an indwelling catheter without strict criteria and to minimize the duration of its indwelling. [42]

Frequently asked questions

Is inserting a urethral catheter painful?
The procedure can cause burning, pressure, and discomfort, especially in men. Adequate lubrication, anesthetic gel, and careful technique reduce pain and the risk of injury. [43]

Should I take an antibiotic "prophylactically" if I have a catheter in place for a long time?
Routinely, no. Current guidelines do not recommend prophylactic antimicrobials to prevent catheter-associated urinary tract infection in most patients with a catheter. [44]

Is it true that almost everyone eventually develops bacteria in their urine?
Yes. With an indwelling catheter, bacteriuria develops very frequently: approximately 3-7% per day, and after a month, it occurs in almost everyone. But this does not always indicate a clinical infection. [45]

Which is better for long-term use: an indwelling catheter or intermittent catheterization?
If a person can perform intermittent catheterization themselves or with the help of a trained assistant, this option is generally considered preferable. It is more consistent with current guidelines and often results in a higher quality of life. [46]

Can the catheter be changed on a schedule, such as every few days, to prevent infection?
No, routine replacement at a fixed interval without a clinical reason is not recommended. Infection, obstruction, or disruption of the closed system are considered grounds for replacement. [47]

What should you do if the catheter doesn't move and resistance is felt?
Do not force it forward. Repeated, forceful attempts increase the risk of a false passage and urethral injury. In this situation, reassessment and, often, the help of a urologist are required. [48]

When should conventional catheterization not be attempted?
Blood at the external urethral opening following trauma is especially dangerous. In this case, urethral injury should be ruled out first, rather than attempting standard catheterization. [49]

Is it necessary to constantly treat the external urethral opening with an antiseptic while the catheter is in place?
No. Routine antiseptic treatment of the external urethral opening is not recommended for infection prevention. Regular daily hygiene is sufficient. [50]

Key points from experts

Anne Pelletier Cameron, MD, professor of urology at the University of Michigan, vice chair for academic affairs, and director of the urology clinical service, specializes in neurogenic bladder, female urethral disease, and reconstructive urology. A practical implication of the current urologic approach, which aligns well with her area of expertise, is that patients with long-standing bladder emptying dysfunction should seek strategies that preserve independence and quality of life, rather than automatically resorting to an indwelling urethral catheter. [51]

Sanjay Saint, MD, MPH, professor of internal medicine at the University of Michigan and chief of internal medicine at the Veterans Affairs Hospital in Ann Arbor, has worked for many years in the field of patient safety and hospital complication prevention. His research consistently emphasizes the same principle: the best way to reduce harm from urinary catheters is to avoid them unless strictly indicated and to reduce the duration of their use. [52]

Peter Tenke, MD, PhD, PhD, a urologist and specialist in urologic infections, has been working on catheter-associated urinary tract infections for many years. His professional profile and long-standing publications in this field well reflect the modern idea: the fight against infections begins not with a “stronger antibiotic,” but with proper patient selection, high-quality technique, a closed system, and minimizing catheter days. [53]

Conclusion

Urethral catheterization remains a necessary and often vital procedure, but modern medicine no longer views it as a harmless, default procedure. Each catheter inserted increases the risk of colonization, and prolonged catheter placement increases the likelihood of infection, discomfort, and mechanical complications. [54]

Therefore, the main modern standard is very simple in formulation, but strict in meaning: the catheter must be justified, correctly placed, securely fixed, maintained according to the rules of a closed system, and removed immediately as soon as it is no longer needed. In a real-life clinic, this sequence is more beneficial than any attempt to "compensate" for unnecessary catheterization by subsequent treatment of complications. [55]