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Practice question

Should lidocaine gel or lubricating gel be used for catheter insertion?

  • 3 Comments

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. 

 

Urethral lubrication

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.

 

Conclusion

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


  • 3 Comments

Readers' comments (3)

  • One of continence and urology's long running debates. Each new article seems to pose new answers and opens up new questions. After years working in this area and keeping patient (and staff) safety as paramount I can only add a little to the debate.
    We ask - what are we trying to achieve?
    Pain free and lowest possible risk of catheter related UTI.
    Plain lubricant the surface appears to achieve an outcome.
    If we add anaesthetic, how long do we wait? 3 - 5 minutes - Honestly! Always?
    We seem to have managed almost for ever with anaesthetic and lubricant, BUT managing, is that really good enough?
    Research/Evidence based practice is ideal but this one seems to be hard to get a perfect answer to.

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  • From my experience, instilling the lidocaine gel AND waiting has always achieved the best outcome. if the guidelines change now and turn us back to lubricating gel only I think we will not be giving the best care possible. Where research is not conclusive I guess we need to stick to common sense until research conclusively advises otherwise.

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  • Well I do not disagree with anonymous above. My experience would suggest the same. Unfortunately we are being challenged more and more to prove best practice. Whilst common sense does imply local anaesthetic + lubricant should be best (and I don't have a problem with this) the highest risk area, especially in male catheterisation will be in the area of bladder neck/prostrate and by the time any gelled catheter reaches here most of the gel, anaesthetic or otherwise will/may be lost. That's the dilemma! Thank goodness we have really clever people who sometime in the next 50 years will be able to make an absolute decision for us. It's only taken 3000 years to get this far so 50 years isn't too long to wait! And in the meantime? Anonymous must be headed, common sense must apply. A final word, IF you or your Trust has to answer to the WHY? Why you chose this or that, have an answer ready that will stand up to scrutiny.

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