A discussion on whether anaesthetic gel is required during catheterisation
A. Urethral catheterisation is a common nursing procedure with up to 13% of hospitalised and 4% of community adult patients having indwelling urethral catheters (Rew and Woodward, 2001). Both men and women find the procedure painful, with men finding it significantly more so than women.
Historically, urethral lubrication with an anaesthetic gel has been routinely used for men undergoing catheterisation, but it was not until a publication by de Courcy-Ireland (1993) that an anaesthetic gel for women undergoing catheterisation received serious consideration. It was believed until then that as the female urethra was so much shorter than in the male, anaesthesia or lubrication was unnecessary.
However, the female urethra has a flattened convoluted tube shape with epithelial folds that lie flat, making it prone to trauma during catheterisation. There is now consensus among most clinicians that a urethral gel should be routinely used for all male and female catheterisations to reduce pain and discomfort and minimise trauma.
Some literature suggests that the use of a lubricant gel can also aid visualisation of the female urethra (Woodward, 2005; Devine, 2003; de Courcy-Ireland, 1993).
Urinary tract infections
Catheter-associated urinary tract infections (CAUTIs) are widely recognised as a major source of healthcare-associated infection (HAI) (Harbath et al, 2003). The urinary tract has a natural ability to resist the intrusion of bacteria into the urethra and their subsequent bacterial colonisation. Bacteria are efficiently eliminated by the flushing mechanism of emptying the bladder of urine, the acidity of urine, osmolarity and high concentrations of urea. These all play a role in inhibiting bacterial adherence and colonisation.
The insertion of a catheter inhibits these natural defensive mechanisms. CAUTIs arise from trauma to the urethra during catheterisation and/or from the catheter itself providing a pathway for bacteria to enter the bladder. Such infections from CAUTIs can result in substantial costs to the healthcare system.
What is best practice?
Best-practice guidance supports the view that the procedure of urethral catheterisation requires sterile equipment using an aseptic technique (Pratt et al, 2007). Sterile, single-use urethral gels should also be used before catheterisation (Pratt et al, 2007; National Health Service Improvement Scotland, 2004; NICE, 2003). However, the advice given in these national guidelines is ambivalent on whether a lubricant gel or an anaesthetic gel should be used before catheterisation, leaving healthcare professionals in a quandary as to which method constitutes best practice.
The advent of the modern, fine calibre flexible cystoscope has replaced the rigid cystoscope, thus decreasing pain and making the experience more tolerable for the patient. This in turn has generated clinical research regarding the efficacy of urethral anaesthetic gel during flexible cystoscopy. Whether the results from cystoscopy studies can be extrapolated to urethral catheterisation is a matter of postulation.
Nevertheless, a meta analysis of this research concludes there is no evidence of a statistically significant difference in pain scores between lidocaine and plain lubricating gel instillation (Patel et al, 2008).
Furthermore, the pharmacodynamic profile of topical lidocaine demonstrates that peak absorption is not reached until 15–60 minutes after application, which suggests healthcare professionals should be waiting longer between applying a urethral anaesthetic gel and inserting the catheter. This in turn has a time implication, so perhaps the most cost-effective choice is a plain lubricating aqueous gel.
All healthcare professionals must promote patient comfort and reduce the risk of patients acquiring infection by using the correct product and aseptic technique. Similarly, they need to be cost aware. Whether a plain lubricating gel or an anaesthetic gel is the most efficacious in reducing discomfort and minimising trauma needs to be resolved by robust qualitative and quantitative research because only then will healthcare professionals have the necessary recommendation for practice.
Gaye Kyle, MA, BA, DipED, RGN, is honorary senior lecturer, Thames Valley University and recognised teacher, University of Ulster
de Courcy-Ireland, K. (1993) An issue of sensitivity: use of analgesic gel in catheterising women. ProfessionalNurse; 8: 11, 738–742.
Devine, A. (2003) Female catheterisation: what nurses need to know! Accident and Emergency Nursing; 11: 91–95.
Harbath, S. et al (2003) The preventable proportion of nosocomial infections: an overview of published reports.Journal of Hospital infection; 54: 258–266.
National Health Service Improvement Scotland (2004) Urinary Catheterisation and Catheter Care. Edinburgh: National Health Service Improvement Scotland.
NICE (2003) Infection Control: Prevention of Healthcare-associated Infection for Primary and Community Care. London: NICE.
Patel, A.R. et al (2008) Lidocaine 2% gel versus plain lubricating gel for pain reduction during flexible cystoscopy: a meta-analysis of prospective, randomised, controlled trials. The Journal of Urology;.179: 3, 986-990.
Pratt, R.J. et al (2007) epic2: National evidence-based guidelines for preventing healthcare-associated Infections in NHS Hospitals in England. The Journal of Hospital Infections; 65S: S1–S64.
Rew, M., Woodward, S. (2001) Trouble shooting common problems associated with long-term catheterisation. British Journal of Nursing; 10: 12, 764–774.
Woodward, S. (2005) Use of lubricant in female catheterisation. British Journal of Nursing; 14: 19, 1022–1023.