Catheters and Urine Samples

Are catheters safe for intact (not circumcised) infants and children?

In theory, a catheter is no more invasive for a child with an intact penis than it is for a child with a circumcised penis. The issue lies with the lack of education that many United States healthcare providers have about the foreskin of children — specifically, that the foreskin is typically fused to the glans (head of the penis) until 10 years of age on average. [1-4] When a healthcare provider wants to insert a catheter into an intact child, they may insist on retracting the foreskin, which can be damaging and painful. Worse yet, they may leave the foreskin retracted, leading to paraphimosis, a painful emergency condition that can result in amputation of the glans. In addition, U.S. healthcare providers on average seem more eager than doctors in other countries to jump to catheter insertion for an intact child versus a circumcised child, when less invasive testing may be available and suitable. 

We highly recommend you print this journal article and take it with you if you have a situation in which your son/child may need a catheter. 

How can a catheter be safely inserted into an intact infant or child?

Both of these methods are described in Dr. Adrienne Carmack and Marilyn Fayre Milos, RN's article, "Catheterization Without Foreskin Retraction," published in the March 2017 issue of the journal Canadian Family Physician.

Inserting by Feel (No Retraction)

It is possible for some healthcare providers to insert a catheter by feel without manipulating the foreskin at all. This can most likely be done by someone who is familiar with the intact penis and who has experience with catheters in general. As Carmack and Milos explain, "The catheter can . . . be lubricated and gently inserted through the foreskin opening and guided into the meatus, much like an intravenous catheter is guided into a vein by feel." Encouraging a healthcare provider to insert a catheter by feel if they are uncomfortable with the idea may cause more harm than good, as the catheter will be poking the child's glans under their foreskin with each failed attempt.

Inserting by Visualization (No Retraction)

It is also possible for any and all healthcare workers to insert a catheter without retracting by gently manipulating the tip of the foreskin in order to visualize the entrance the urethra. You as the parent must be diligent in ensuring that the healthcare provider knows the difference between retracting the foreskin and gently manipulating the tip. As Carmack and Milos explain, "If the foreskin can be gently moved such that the glans and meatus can be seen, catheterization can be performed under direct vision using a sterile technique." [5]

Should I ask for a clean-catch or a catch bag before a catheter?

Is your child’s health issue life-threatening?

Yes, the health issue is life-threatening. If yes, and your physician is recommending a catheter, then a catheter or suprapubic bladder aspiration (SPA) are most likely the best methods for diagnosing your child. In this situation, we advise that you ensure your child's healthcare provider can either insert a catheter by feel or by visualization WITHOUT RETRACTING. 

If your healthcare provider says they cannot do either of these things, then you may want to discuss SPA as a safer and less invasive option for obtaining a reliable urine sample. The European Association of Urology (EAU) states that, "SPA should be the method of choice"  for "children </=6 mo of age and uncircumcised boys." The EAU continues, "Bladder catheterisation may be an alternative to SPA, although the rates of contamination [for bladder catheterisation] are higher . . . The risk factors for a high contamination rate [for bladder catheterisation] are patients <6 mo of age, difficult catheterisation, and uncircumcised boys." [6]

No, the health issue is not life-threatening. If your child is stable, non-toxic, and low risk, then you may discuss a clean catch or catch-bag (depending on your child’s age/ability to void voluntarily) with your physician as a starting point. Note: If the results are contaminated (contamination rates for catch bags are higher), a catheter or SPA will most likely be recommended as the next step.

Terms to Know

Catch bag: Used for a person who is not old enough to voluntarily void. Catch bags have a high contamination rate and are generally not a good option if your child is experiencing life-threatening health issues. According to the EAU catch bags are "the technique used most often in daily practice. It is helpful when the culture result is negative." In other words, a negative result can rule out an UTI. The EAU also notes that catch bags have a "high incidence of false-positive results" due to contamination. [6] Therefore, if a catch bag gives a read of "positive" for a UTI, further testing would be needed to confirm this diagnosis.  

Clean-catch: Used for a person who is old enough to voluntarily void.** Like a catch bag, a negative result can rule out a UTI. According to the EAU, the contamination rate for a clean-catch is 26%. [6] As the EAU states, "In toilet-trained children, a clean voided midstream urine sample has a good rate of accuracy." [6]

Suprapubic bladder aspiration: Collects urine from the bladder using a needle. According to the EAU, the contamination rate for SPA is 1%. [6]

In Summary

Many U.S. doctors consider catheters to be the most reliable and least invasive diagnostic tool for infants and children with life-threatening illnesses. However, an SPA may be an option if your healthcare provider is unable or unwilling to insert a catheter in a way that is safe for your intact child's penis and foreskin. A catheter can safely be inserted into an intact infant or child, but YOU must ensure that the healthcare provider can either insert by feel or TRULY knows how to manipulate the tip of the foreskin to visualize the urethra entry WITHOUT retracting.

If your child's illness is not life-threatening (for example, you've taken them to the ER because of a fever with no other symptoms), then discussing a less invasive first step, such as a clean-catch or catch bag, is reasonable.

[1] Oster, J. (1968, April). Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child, 43(228), 200-3. Retrieved from here. 
[2] Thorvaldsen, M.A., & Meyhoff, H. (2005, April 25). Patologisk eller fysiologisk fimose? Ugeskr Læger, 167(17), 1858- 62. Translation retrieved from here.
[3] Ishikawa, E., & Kawakita, M. (2004, May). Preputial development in Japanese boys. Hinyokika Kiyo, 50(5), 305-8. Retrieved from here.
[4] Kayaba, H., Tamura, H., Kitajima, S., Fujiwara, Y., Kato, T., & Kato, T. (1996, November). Analysis of shape and retractability of the prepuce in 603 Japanese boys. Journal of Urology, 156(5), 1813-5. Retrieved from here.
[5] Carmack, A., & Milos, M.F. (2017, March). Catheterization without foreskin retraction. Canadian Family Physician, 63(3), 218–20. Retrieved from here.
[6] European Association of Urology. (2014). "Urinary Tract Infections in Children: EAU/ESPU Guidelines." Retrieved from here. 

* The EAU also notes, regarding bladder punctures used for SPA, that they "caused more pain that catheterisation in infants <2 mo of age." They do also note a topical mixture that can be applied to reduce pain. 

** A clean-catch could, in theory, be used for an infant, as the EAU explains, a sterile foil bowl would need to be placed under the infant's genitalia, which is "time consuming and requires careful instructing of the parents."