Female urinary catheters causing trauma to adult males

The National Reporting and Learning Service received 114 incident reports between 1 January 2006 and 17 December 2008 where female catheters were inserted into male patients. If this happens, the ‘balloon’ inflated with sterile water to retain the catheter will be within the urethra, rather than the bladder, and can cause severe trauma.

 All reported incidents appeared to cause significant pain, plus haematuria, penile swelling, or retention. Seven caused significant haemorrhages, two were believed to have led to acute renal failure, and two to impaired renal function.

 All acute, mental health and primary care organisations in the NHS and independent sector should:

• Distribute this report to all staff who insert urinary catheters in teenage or adult male patients, and to community pharmacists who dispense them.
• Review current supply systems for female length catheters, with the aim of limiting access where appropriate.
• Display a warning notice close to the stock of female length catheters, in any setting where teenage or adult males are also treated.
• Attach warning labels to female length catheters before these are distributed to individual clinical areas or community staff bases.
• Review training for urinary catheter insertion.
• Give preference to purchasing urinary catheters which are clearly labelled (your NHS Supply Chain manager will be able to give you details of the companies with highly visible labels).

Although the deadline for actions has passed, this guidance remains best practice. It should be followed to prevent future patient safety incidents.

Read the guidance in full.

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