Microbiology - Urine sample (catheter)

Indications

Symptoms of a urinary tract infection, which are:

Fever

Acute change in mental status

New dysuria, frequency, urgency, incontinence or suprapubic pain

Flank or costovertebral tenderness

Gross haematuria

and

Patient incontinent or unable to void on request for clinician-collected midstream urine

Contraindications (absolute in bold)

None

Alternatives

Treat empirically without urine collection

Mid-stream urine collection by patient or clinician

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Pain

Failure (contamination of sample, creation of a false passage)

Allergy

Urethral trauma and haemorrhage

Paraphimosis (male only, from unreduced foreskin)

Urinary tract infection

Urethral stricture

Procedural hygiene

Standard precautions

Aseptic non-touch technique

PPE: sterile gloves, plastic apron, protective eyewear or shield

Area

Any adequately private bed space with good lighting

Staff

Procedural clinician and assistant

Equipment

Clean intermittent self-catheterising catheter or standard urethral catheters (non-latex)

Extra sheet or towel placed under patient

Sterile tray, gauze squares and cotton balls (cleaning tray)

0.9% sodium chloride (for cleaning) and forceps for application

Sterile tray (drainage)

Fenestrated drape (male only)

Lubricant (lignocaine gel)

Positioning

Semi-recumbent on the bed (male) or

Supine position with the knees flexed and separated and feet flat on the bed, about 60cm apart (female)

Medication

5ml of 2% lignocaine gel (lubricant)

Sequence (abbreviated, see insertion of male or female urinary catheter for detail)

Clean urethral meatus with gauze soaked with 0.9% sodium chloride

Inject lignocaine gel into the urethra clamping the urethra for 2-3 minutes (male only)

Place tray for drainage between patient’s legs on the fenestrated drape

Remove catheter from plastic sleeve, ensuring to maintain sterility of the catheter (non-touch technique)

Lubricate sterile catheter and insert into urethral meatus

Collect sterile specimen in kidney dish then remove catheter

Transfer specimen to sterile jar

Post-procedure care

Process sample (point-of-care urine dipstick and send for culture)

Document time and reason for collection

Tips

In-out catheter sampling is required if the patient is incontinent or unable to assist midstream urine collection

Asymptomatic bacteriuria is common in aged care facility residents (routine screening is not recommended)

Discussion

The ideal voided urine sample for evaluation of UTI is one that accurately represents the bladder bacterial count with minimised contamination by bacteria colonising the distal urethra and genital mucosa.

Good technique includes minimising contact with the mucosa by spreading the labia in females or pulling back the foreskin in uncircumcised males, as well as discarding the initial stream which flushes urethral contaminants.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

NSW Agency for Clinical Innovation. Orthopaedic/musculoskeletal. Sydney: ACI; 2020. Available from https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical-tools/orthopaedic-and-musculoskeletal

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

eTG complete. Melbourne: Therapeutic Guidelines; 2019 Apr. Acute cystitis in adults. Available from: https://tgldcdp.tg.org.au/viewTopic?topicfile=acute-cystitis-adults

eTG complete. Melbourne: Therapeutic Guidelines; 2019 Apr. Urinary tract infection in aged care facilities. Available from: https://tgldcdp.tg.org.au/viewTopic?topicfile=urinary-tract-infection-aged-care

Meyrier A. Sampling and evaluation of voided urine in the diagnosis of urinary tract infection in adults. In: UpToDate. Waltham (MA): UpToDate. 2019 July 1. Available from: https://www.uptodate.com/contents/sampling-and-evaluation-of-voided-urine-in-the-diagnosis-of-urinary-tract-infection-in-adults

Frazee BW, Frausto K, Cisse B, White DE, Alter H. Urine collection in the emergency department: what really happens in there?. West J Emerg Med. 2012;13(5):401-405. doi:10.581/westjem.2012.1.6855

Chung C, Chu M, Paoloni R, O'Brien MJ, Demel T. Comparison of lignocaine and water-based lubricating gels for female urethral catheterization: a randomized controlled trial. Emerg Med Australas. 2007;19(4):315-319. doi:10.1111/j.1742-6723.2007.00961.x

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