[Skip to content]

NHS
Loading
.

Female urinary catheters causing trauma to adult males

Female urinary catheters causing trauma to adult males
Reference number
1075
Central Alert System (CAS) reference
NPSA/2009/RRR02
Issue date30 April 2009
Action date (if applicable) (date field)01 September 2009
DH Gateway reference
11515
TypeAlert

This Rapid Response Report alerts healthcare organisations to the risk of trauma to adult males if female length catheters are used.

 

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:

  1. Distribute this report to all staff who insert urinary catheters in teenage or adult male patients, and to community pharmacists who dispense them.
  2. Review current supply systems for female length catheters, with the aim of limiting access where appropriate.
  3. Display a warning notice close to the stock of female length catheters, in any setting where teenage or adult males are also treated.
  4. Attach warning labels to female length catheters before these are distributed to individual clinical areas or community staff bases.
  5. Review training for urinary catheter insertion.
  6. 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.
Female urinary catheters - Rapid Response Report:
Female urinary catheters - Rapid Response Report: - 53 KB 1075 - Female urinary catheters - Rapid Response Report: 2009-04-30 - V1
Female urinary catheters - Rapid Response Report supporting information
Female urinary catheters - Rapid Response Report supporting information - 104 KB 1075A - Female urinary catheters - Rapid Response Report supporting information - 2009-04-30 - V1
Female urinary catheters warning poster A4
Female urinary catheters warning poster A4 - 116 KB 1075B - Female urinary catheters warning poster A4 - 2009-04-30 - V1
Female urinary catheters warning poster A3
Female urinary catheters warning poster A3 - 114 KB 1074C - Female urinary catheters warning poster A3 - 2009-04-30 - V1
Label templates: Female urinary catheters causing trauma to adult males- RRR
Label templates: Female urinary catheters causing trauma to adult males- RRR - 886 KB 1075 D | Label templates | Female urinary catheters causing trauma to adult males | RRR