By Danelle Day, Ph.D. © 2011
We receive two common types of forced retraction reports from parents: those that happen at well-baby checkups in the United States, often before a parent even knows what is happening, and those that happen when a parent ends up in the hospital with a baby who is catheterized (due to illness or surgery).
Before we address catheterization specifically, and the correct way to catheterize an intact male baby or child, it should be noted that frequently there is truly not a need for catheterization in the first place. With some surgeries, and post-op recovery, it is going to be necessary. However, often, in surgical cases for babies and toddlers, simply wearing a diaper and having another couple ready for change during and/or post-OR, is another option, especially if the toddler will be under general anesthesia for less than 4 hours.
Urinary Tract Infection
Besides surgery, the most common reason for catheterization is to check for the existence of a urinary tract infection (UTI). UTIs occur with much more frequency in girls than they do in boys due to the short urethra and proximity to the anus (contamination with fecal matter or bacteria from the hands of a care-taker are the two biggest causes of UTIs). UTIs are easily treated with antibiotics, but they should not be ignored or left untreated because bacteria can quickly spread up the urinary tract, through the bladder, into the kidneys, and do serious or permanent damage. UTIs are bacterial infections and once they have taken hold, merely drinking cranberry juice will not kill off bacteria, as some pop parenting reports suggest. Regularly consuming 100% cranberry extract capsules (a much higher concentration than you would get from cranberry juice) for older children and adults can reduce the likelihood of UTIs in the future by priming the health of the urinary tract, but it cannot 'cure' an already established bacterial infection. Even if symptoms disappear, the strongest bacterial strains may remain, causing future kidney problems. Therefore, if you suspect UTI, do not wait, and do not mess around with treatment if a UTI is confirmed. If antibiotics are prescribed for a UTI, be sure your baby or child takes the full does, on time, and does not miss any days or stop early (which can also lead to the most powerful bacteria lingering on when the child is asymptomatic).
There are some children (girls especially) who seem overly susceptible to contracting UTIs and may have a bout with several each year until they are older, out of diapers, without parents' hands helping them to wipe, and always wiping themselves 'front to back.' While it is not a subject regularly brought up at the physician's office, self-touching or exploration of the genitals (masturbation) with hands that have not yet been washed and have fecal particles on them is another way that UTIs can be contracted - again, especially among girls whose urethra is shorter and less protected. This does not make masturbation 'wrong' or 'dirty' -- it merely is a reality that we need to wash our hands before and after changing or wiping babies or toddlers, and encourage them to do the same before they touch their own bodies. This is also one of the reasons masturbation and circumcision became intertwined in U.S. history in the first place -- it was theorized that if we remove the prepuce (which houses the most nerves of any male body part, and a relatively equal number to the female clitoris) we would thereby diminish boy's and men's sexual desire to masturbate, and in turn, we'd also see fewer UTIs (among other illnesses previously blamed on masturbation).
In reality, when forced retraction is not part of the picture, UTIs are no more common in intact baby boys (boys who have their full, intact prepuce and penis) than in circumcised boys. The prepuce, in fact, serves to protect against UTIs. Additionally, breastfeeding reduces the rate of urinary tract infection for both male and female babies, as human milk is powerfully charged with antibodies and white blood cells, among other protective, immunological features.
Urine Sampling
Today, the two most commonly used methods of collecting a urine sample from non-toilet using babies and children in U.S. emergency rooms are the "clean catch" and "bag specimen." Neither method is done without contamination of sample, but research suggests that between the two, clean catch is the way to go. (1, 2) Note: Studies do show that there is no significant variation between clean catch versus a standard urine sample obtained through other means for older children and adults who can urinate into a sterile cup on their own. (3, 4, 5, 6, 7)
A clean catch works by wiping down the genitals of an infant or child with sanitizing wipes (provided by the clinic), and holding a sterile specimen bottle under the stream of urine - after the baby/child has started to urinate. This is considered to be the 'gold standard' of non-invasive urine sampling, but is more difficult to time with babies. Breastfeeding may help to fill and release the bladder.
For older children who can tell you when they need to go, a clean catch can be done at home. Wipe down the outside of the genitals and the perineum (between the urethra and rectum) with a wet cloth. Have your child drink a lot of liquid or nurse, and stand by or sit on the toilet with the faucet water running (this helps to psychologically induce 'flow'). Your child may also want to stand over a cup in the bathtub if he is more comfortable with this. Write your child's name, date of birth, and the date and time the sample was taken on the outside of the cup. Take it to your local urgent care or emergency room within 2 hours of the time it was taken (if more time has passed, it is likely they will ask you to repeat the sample). If your child truly has a UTI, it may be difficult for them to push out urine even when they feel the intense urge to 'go.' This urgency and frequency, coupled with being unable to eliminate urine, is a key indicating factor that there is indeed a UTI present, and a full round of antibiotics are justified. Babies who cannot tell you that they desperately need to go, but cannot, and that it constantly hurts, and stings when they try, are those who we are especially concerned with - their cry of discomfort, fever to fight infection, and possible reduction in wet diapers, are the only indications we often have of a UTI.
The National Institute for Health and Clinical Excellence (NICE) suggests that the use of urine collection pads is the next best method of urine collection in a non-toilet using baby or child. This is a special pad made specifically for collecting urine that is placed into a baby's diaper after a wipe-down with a sanitizing wipe. The pad needs to be changed every 30-40 minutes (whether the child wets or not) so as to reduce the rate of contamination. (8) One reason that we see higher rates of UTIs in the first place during the first year of life is due to the diapering of our babies - a situation that helps to move fecal bacteria from the anus to the meatus (urethral opening). The same is true for collection pads - it is merely contact with the perineal area that increases contamination of sample - so change often. (9)
Another form of urine collection (which sees no less contamination of sample than the urine collection pad, and is more cumbersome, so may not be the method of choice) is the urine collection bag. The bag has a U shaped sticky area (similar to a bandaid, but with less adhesive) on the round opening that is placed over the genitals after they are wiped down. The bag lays out of the way (to the top or bottom of baby's genitals) as urine is collected. A diaper can be put on over the the collection bag. If being used at home, the urine from the collection bag can then be transferred to a sterile collection cup and submitted to your local urgent care or emergency room within 2 hours, just as it would be with a clean catch. A 2009 study published in the Journal of Pediatrics found that bag-obtained specimens produced a significantly higher number of false-positive results (parents were told their child had a UTI, when in fact, he did not). In addition, there was a higher number of false-negatives (parents were told their child did not have a UTI, when he in fact did). (10)
Neither pads or bags may be left on a baby for more than 40 minutes or it will increase the likelihood of a bacterial infection even if your baby does not already have an infection. Leaving babies in diapers all day also increases infection potential - so give your little one some 'diaper free' time whenever you are able. Babies who are not yet crawling can do tummy time on a waterproof mat with a towel or cloth diaper laid out under him/her. Many parents today incorporate 'elimination communication' into their routine as well, which also reduces time in diapers.
We receive two common types of forced retraction reports from parents: those that happen at well-baby checkups in the United States, often before a parent even knows what is happening, and those that happen when a parent ends up in the hospital with a baby who is catheterized (due to illness or surgery).
Before we address catheterization specifically, and the correct way to catheterize an intact male baby or child, it should be noted that frequently there is truly not a need for catheterization in the first place. With some surgeries, and post-op recovery, it is going to be necessary. However, often, in surgical cases for babies and toddlers, simply wearing a diaper and having another couple ready for change during and/or post-OR, is another option, especially if the toddler will be under general anesthesia for less than 4 hours.
Urinary Tract Infection
Besides surgery, the most common reason for catheterization is to check for the existence of a urinary tract infection (UTI). UTIs occur with much more frequency in girls than they do in boys due to the short urethra and proximity to the anus (contamination with fecal matter or bacteria from the hands of a care-taker are the two biggest causes of UTIs). UTIs are easily treated with antibiotics, but they should not be ignored or left untreated because bacteria can quickly spread up the urinary tract, through the bladder, into the kidneys, and do serious or permanent damage. UTIs are bacterial infections and once they have taken hold, merely drinking cranberry juice will not kill off bacteria, as some pop parenting reports suggest. Regularly consuming 100% cranberry extract capsules (a much higher concentration than you would get from cranberry juice) for older children and adults can reduce the likelihood of UTIs in the future by priming the health of the urinary tract, but it cannot 'cure' an already established bacterial infection. Even if symptoms disappear, the strongest bacterial strains may remain, causing future kidney problems. Therefore, if you suspect UTI, do not wait, and do not mess around with treatment if a UTI is confirmed. If antibiotics are prescribed for a UTI, be sure your baby or child takes the full does, on time, and does not miss any days or stop early (which can also lead to the most powerful bacteria lingering on when the child is asymptomatic).
There are some children (girls especially) who seem overly susceptible to contracting UTIs and may have a bout with several each year until they are older, out of diapers, without parents' hands helping them to wipe, and always wiping themselves 'front to back.' While it is not a subject regularly brought up at the physician's office, self-touching or exploration of the genitals (masturbation) with hands that have not yet been washed and have fecal particles on them is another way that UTIs can be contracted - again, especially among girls whose urethra is shorter and less protected. This does not make masturbation 'wrong' or 'dirty' -- it merely is a reality that we need to wash our hands before and after changing or wiping babies or toddlers, and encourage them to do the same before they touch their own bodies. This is also one of the reasons masturbation and circumcision became intertwined in U.S. history in the first place -- it was theorized that if we remove the prepuce (which houses the most nerves of any male body part, and a relatively equal number to the female clitoris) we would thereby diminish boy's and men's sexual desire to masturbate, and in turn, we'd also see fewer UTIs (among other illnesses previously blamed on masturbation).
In reality, when forced retraction is not part of the picture, UTIs are no more common in intact baby boys (boys who have their full, intact prepuce and penis) than in circumcised boys. The prepuce, in fact, serves to protect against UTIs. Additionally, breastfeeding reduces the rate of urinary tract infection for both male and female babies, as human milk is powerfully charged with antibodies and white blood cells, among other protective, immunological features.
Urine Sampling
Today, the two most commonly used methods of collecting a urine sample from non-toilet using babies and children in U.S. emergency rooms are the "clean catch" and "bag specimen." Neither method is done without contamination of sample, but research suggests that between the two, clean catch is the way to go. (1, 2) Note: Studies do show that there is no significant variation between clean catch versus a standard urine sample obtained through other means for older children and adults who can urinate into a sterile cup on their own. (3, 4, 5, 6, 7)
A clean catch receptacle designed by UriAid especially for use with children, women, or little ones who may be laying down during urine sample collection.
A clean catch works by wiping down the genitals of an infant or child with sanitizing wipes (provided by the clinic), and holding a sterile specimen bottle under the stream of urine - after the baby/child has started to urinate. This is considered to be the 'gold standard' of non-invasive urine sampling, but is more difficult to time with babies. Breastfeeding may help to fill and release the bladder.
For older children who can tell you when they need to go, a clean catch can be done at home. Wipe down the outside of the genitals and the perineum (between the urethra and rectum) with a wet cloth. Have your child drink a lot of liquid or nurse, and stand by or sit on the toilet with the faucet water running (this helps to psychologically induce 'flow'). Your child may also want to stand over a cup in the bathtub if he is more comfortable with this. Write your child's name, date of birth, and the date and time the sample was taken on the outside of the cup. Take it to your local urgent care or emergency room within 2 hours of the time it was taken (if more time has passed, it is likely they will ask you to repeat the sample). If your child truly has a UTI, it may be difficult for them to push out urine even when they feel the intense urge to 'go.' This urgency and frequency, coupled with being unable to eliminate urine, is a key indicating factor that there is indeed a UTI present, and a full round of antibiotics are justified. Babies who cannot tell you that they desperately need to go, but cannot, and that it constantly hurts, and stings when they try, are those who we are especially concerned with - their cry of discomfort, fever to fight infection, and possible reduction in wet diapers, are the only indications we often have of a UTI.
Urine collection pad kit.
The National Institute for Health and Clinical Excellence (NICE) suggests that the use of urine collection pads is the next best method of urine collection in a non-toilet using baby or child. This is a special pad made specifically for collecting urine that is placed into a baby's diaper after a wipe-down with a sanitizing wipe. The pad needs to be changed every 30-40 minutes (whether the child wets or not) so as to reduce the rate of contamination. (8) One reason that we see higher rates of UTIs in the first place during the first year of life is due to the diapering of our babies - a situation that helps to move fecal bacteria from the anus to the meatus (urethral opening). The same is true for collection pads - it is merely contact with the perineal area that increases contamination of sample - so change often. (9)
Pediatric urine collection bag.
Another form of urine collection (which sees no less contamination of sample than the urine collection pad, and is more cumbersome, so may not be the method of choice) is the urine collection bag. The bag has a U shaped sticky area (similar to a bandaid, but with less adhesive) on the round opening that is placed over the genitals after they are wiped down. The bag lays out of the way (to the top or bottom of baby's genitals) as urine is collected. A diaper can be put on over the the collection bag. If being used at home, the urine from the collection bag can then be transferred to a sterile collection cup and submitted to your local urgent care or emergency room within 2 hours, just as it would be with a clean catch. A 2009 study published in the Journal of Pediatrics found that bag-obtained specimens produced a significantly higher number of false-positive results (parents were told their child had a UTI, when in fact, he did not). In addition, there was a higher number of false-negatives (parents were told their child did not have a UTI, when he in fact did). (10)
Infant with urine collection bag in place.
Neither pads or bags may be left on a baby for more than 40 minutes or it will increase the likelihood of a bacterial infection even if your baby does not already have an infection. Leaving babies in diapers all day also increases infection potential - so give your little one some 'diaper free' time whenever you are able. Babies who are not yet crawling can do tummy time on a waterproof mat with a towel or cloth diaper laid out under him/her. Many parents today incorporate 'elimination communication' into their routine as well, which also reduces time in diapers.
Catheters
Occasionally, medical staff will suggest they need to collect an uncontaminated sample, or verify the results of a sample previously obtained through non-invasive means, with catheterization.
There are two types of catheters that are most commonly used with infant or young boys: the Foley catheter and the intermittent or Robinson catheter. The Foley catheter is used most often during surgery when the instrument needs to stay in place. This is done with a small balloon at the tip of the catheter that is inflated with sterile water once inside the bladder. The intermittent/Robinson catheter is a flexible catheter that is used most often when medical staff are checking for urinary tract infection. It is designed for the brief drainage of urine - to obtain a quick sample - and cannot stay in place without being held.
When an intact male baby or child is catheterized, retraction of the prepuce (foreskin) is not necessary or indicated.
In the United States there is quite a well founded concern that forced retraction will come into play when an intact male child is catheterized. However, it is the female patient for whom catheterization is actually more diverse and confounding. Age, weight, childbirth, past surgeries, female genital cutting, and many natural variations in the female body make catheterization of a girl or woman much more complex than catheterization of a boy or man, intact or otherwise. In general (unless hypospadias is a factor) the meatus (urinary opening) is going to be somewhat centrally located directly behind the opening to the prepuce, and fairly easy to 'hit on feel.'
The prepuce will typically be tightly adhered to the glans (penis head) of a baby or young toddler with little slack or room for movement, as seen in the photograph below. Even in boys as old as 10 years, many will still not have a retractible prepuce. In Pediatrics, Rudolph and Hoffman note, "The prepuce, foreskin, is normally not retractile at birth. The ventral surface of the foreskin is naturally fused to the glans of the penis. At age 6 years, 80 percent of boys still do not have a fully retractile foreskin. By age 17 years, however, 97 to 99 percent of uncircumcised males have a fully retractile foreskin." The average age of retraction is 10 1/2 years -- some will retract naturally, on their own, sooner, and some later. Each is within the range of normal, but no one should retract a baby or child except for the boy himself when he chooses to do so.
In their bulletin, Care of the Uncircumcised Penis, the American Academy of Pediatrics stresses, "...foreskin retraction should never be forced. Until natural separation occurs, do not try to pull the foreskin back - especially an infant's. Forcing the foreskin to retract before it is ready may severely harm the penis and cause pain, bleeding and tears in the skin."
Simply put, there is never a reason to forcibly retract the prepuce. Writes Doctors Opposing Circumcision in their article, Forced Retraction of Intact Boys: An Epidemic:
If retraction of intact boys is not going to take place for catheterization, how then should it be done? By feel alone.
Nurse K. at Johns Hopkins Hospital in Baltimore, Maryland (top ranked urology hospital in the nation), writes,
Because the prepuce on an infant boy is typically quite stationary and non-mobile, there is not much prepuce slack, and there are not many places to 'go' with the catheter. If the first try does not work, a mere glance to the right or left, up or down, will. In an older, retracting child, after separation from the glans has started to occur naturally, he may wish to retract his foreskin enough on his own for a catheter to be inserted directly into the meatus (if he is awake during the procedure). But even for older children, simply holding the penis steady with one hand, while gliding the catheter into the prepuce opening, until it touches the glans where it can be pressed into the urethra, works quite well and uneventfully. If your practitioner is not willing to take the extra moment to catheterize without forced retraction, ask to see another staff member, or request a set of sterile gloves, while you take your son's penis, and his health, into your own hands.
For additional resources on raising intact boys see: How to Care for Your Intact Son
Medical Professionals for Genital Autonomy
Catheterization Without Retraction in Canadian Family Physician. 2017 Mar; 63(3): 218–220. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5349724/ • FULL TEXT
1) Hardy JD, Furnell PM & Brumfitt W. Comparison of sterile bag, clean catch and suprapubic aspiration in the diagnosis of urinary tract infection in early childhood. British Journal of Urology1976;48(4):279-83.
2) Alam MT, Coulter JB, Pacheco J, Correia JB, Ribeiro MG, Coelho MF & Bunn JE. Comparison of urine contamination rates using three different methods of collection: clean-catch, cotton wool pad and urine bag. Annals of Tropical Paediatrics. 25(1):29-34, 2005 Mar.
3) Lohr JA, Donowitz LG & Dudley SM. Bacterial contamination rates for non-clean-catch and clean-catch midstream urine collections in boys. Journal of Pediatrics 1986; 109:659-660.
4) Lohr JA, Donowitz LG & Dudley SM. Bacterial contamination rates in voided urine collections in girls. Journal of Pediatrics 1989;114:91-93
5) Bradbury SM. Collection of urine specimens in general practice: to clean or not to clean? J R Coll Gen Pract [Occas Pap] 1988;38:363-365.
6) Morris RW, Watts MR & Reeves DS. Perineal cleansing before midstream urine: a necessary ritual. Lancet 1979;2:158-159
7) Immergut MA, Gilbert EC, Frensilli FJ & Goble M. The myth of the clean catch urine specimen. Urology 1981; 17:339-340.
8) Rao, S. et al (2004). An improved urine collection pad method: a randomised clinical trial. Archives of Disease in Childhood. 89: 8, 773–775.
9) Rao, S. et al (2003). A new urine collection method; pad and moisture sensitive alarm. Archives of Diseases of Childhood. 88: 9, 836.
10) Welch, Thomas R. Bagging the Bag. Journal of Pediatrics 2009; 154(6):A1.
Occasionally, medical staff will suggest they need to collect an uncontaminated sample, or verify the results of a sample previously obtained through non-invasive means, with catheterization.
Adult intact male with Foley catheter in place to demonstrate how the catheter would appear inside your son. Infants and children have a shorter urethra (and shorter penis) which is one reason they have a tendency to get more UTIs. Therefore, the catheter itself will be smaller and shorter, without as far to go to reach the bladder. The balloon you see here (for the Foley) would be present if your son is catheterized for a surgery, but not present for a brief urine sample. The catheter goes directly from the urethra to the bladder - above the prostate gland that you see pictured here between the penis and bladder.
There are two types of catheters that are most commonly used with infant or young boys: the Foley catheter and the intermittent or Robinson catheter. The Foley catheter is used most often during surgery when the instrument needs to stay in place. This is done with a small balloon at the tip of the catheter that is inflated with sterile water once inside the bladder. The intermittent/Robinson catheter is a flexible catheter that is used most often when medical staff are checking for urinary tract infection. It is designed for the brief drainage of urine - to obtain a quick sample - and cannot stay in place without being held.
When an intact male baby or child is catheterized, retraction of the prepuce (foreskin) is not necessary or indicated.
In the United States there is quite a well founded concern that forced retraction will come into play when an intact male child is catheterized. However, it is the female patient for whom catheterization is actually more diverse and confounding. Age, weight, childbirth, past surgeries, female genital cutting, and many natural variations in the female body make catheterization of a girl or woman much more complex than catheterization of a boy or man, intact or otherwise. In general (unless hypospadias is a factor) the meatus (urinary opening) is going to be somewhat centrally located directly behind the opening to the prepuce, and fairly easy to 'hit on feel.'
The prepuce will typically be tightly adhered to the glans (penis head) of a baby or young toddler with little slack or room for movement, as seen in the photograph below. Even in boys as old as 10 years, many will still not have a retractible prepuce. In Pediatrics, Rudolph and Hoffman note, "The prepuce, foreskin, is normally not retractile at birth. The ventral surface of the foreskin is naturally fused to the glans of the penis. At age 6 years, 80 percent of boys still do not have a fully retractile foreskin. By age 17 years, however, 97 to 99 percent of uncircumcised males have a fully retractile foreskin." The average age of retraction is 10 1/2 years -- some will retract naturally, on their own, sooner, and some later. Each is within the range of normal, but no one should retract a baby or child except for the boy himself when he chooses to do so.
In their bulletin, Care of the Uncircumcised Penis, the American Academy of Pediatrics stresses, "...foreskin retraction should never be forced. Until natural separation occurs, do not try to pull the foreskin back - especially an infant's. Forcing the foreskin to retract before it is ready may severely harm the penis and cause pain, bleeding and tears in the skin."
Simply put, there is never a reason to forcibly retract the prepuce. Writes Doctors Opposing Circumcision in their article, Forced Retraction of Intact Boys: An Epidemic:
Only in the instance of significant hypospadias or epispadias (congenital malposition of the urethral opening) might retraction be necessary, and even then only if it is unavoidable collateral damage for which there should be specific follow-up care.If your son has already been the victim of forced retraction, see Forced Retraction: Now What? for more information on how to handle things from here on out.
Intact baby boy and where the catheter will go.
If retraction of intact boys is not going to take place for catheterization, how then should it be done? By feel alone.
Nurse K. at Johns Hopkins Hospital in Baltimore, Maryland (top ranked urology hospital in the nation), writes,
I know for certain as a result of working with many intact boys that the catheter can be inserted without retracting the foreskin. There is no reason whatsoever that the foreskin would need to be retracted for a simple catheter insertion procedure. The catheter used on an infant will be tiny and should be easily slipped into the small opening at the tip of the foreskin, right into the meatus. Parents: be firm and tell others that retracting the foreskin is not acceptable! Not even 'just a little.' If you must, you be the one to hold your son's penis and slide the catheter into place. They can take it from there. Or, specifically ask for someone who has catheterized an intact baby without retraction.Just as the skilled hand of a midwife can determine a baby's position by feel alone, without need for seeing or intervention, so can a nurse or practitioner catheterizing an intact boy without laying eyes on the meatus itself. There is simply no need to see the meatus in order to 'hit' it with a catheter. With one hand on the penis for steadying, the small tube can gently be moved into the prepuce, and pressed against the glans, so it will either hit the spongy tissue of the glans, indicating the need for ever-so-slight readjustment, or it will glide smoothly into the urethra. With a small amount of patience and practice, nurses can become skilled in catheterizing an intact boy so that it rarely takes more than the first try to get it.
Because the prepuce on an infant boy is typically quite stationary and non-mobile, there is not much prepuce slack, and there are not many places to 'go' with the catheter. If the first try does not work, a mere glance to the right or left, up or down, will. In an older, retracting child, after separation from the glans has started to occur naturally, he may wish to retract his foreskin enough on his own for a catheter to be inserted directly into the meatus (if he is awake during the procedure). But even for older children, simply holding the penis steady with one hand, while gliding the catheter into the prepuce opening, until it touches the glans where it can be pressed into the urethra, works quite well and uneventfully. If your practitioner is not willing to take the extra moment to catheterize without forced retraction, ask to see another staff member, or request a set of sterile gloves, while you take your son's penis, and his health, into your own hands.
For additional resources on raising intact boys see: How to Care for Your Intact Son
Medical Professionals for Genital Autonomy
Catheterization Without Retraction in Canadian Family Physician. 2017 Mar; 63(3): 218–220. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5349724/ • FULL TEXT
Image from Catheterization Without Retraction, 2017, sited above
REFERENCES
1) Hardy JD, Furnell PM & Brumfitt W. Comparison of sterile bag, clean catch and suprapubic aspiration in the diagnosis of urinary tract infection in early childhood. British Journal of Urology1976;48(4):279-83.
2) Alam MT, Coulter JB, Pacheco J, Correia JB, Ribeiro MG, Coelho MF & Bunn JE. Comparison of urine contamination rates using three different methods of collection: clean-catch, cotton wool pad and urine bag. Annals of Tropical Paediatrics. 25(1):29-34, 2005 Mar.
3) Lohr JA, Donowitz LG & Dudley SM. Bacterial contamination rates for non-clean-catch and clean-catch midstream urine collections in boys. Journal of Pediatrics 1986; 109:659-660.
4) Lohr JA, Donowitz LG & Dudley SM. Bacterial contamination rates in voided urine collections in girls. Journal of Pediatrics 1989;114:91-93
5) Bradbury SM. Collection of urine specimens in general practice: to clean or not to clean? J R Coll Gen Pract [Occas Pap] 1988;38:363-365.
6) Morris RW, Watts MR & Reeves DS. Perineal cleansing before midstream urine: a necessary ritual. Lancet 1979;2:158-159
7) Immergut MA, Gilbert EC, Frensilli FJ & Goble M. The myth of the clean catch urine specimen. Urology 1981; 17:339-340.
8) Rao, S. et al (2004). An improved urine collection pad method: a randomised clinical trial. Archives of Disease in Childhood. 89: 8, 773–775.
9) Rao, S. et al (2003). A new urine collection method; pad and moisture sensitive alarm. Archives of Diseases of Childhood. 88: 9, 836.
10) Welch, Thomas R. Bagging the Bag. Journal of Pediatrics 2009; 154(6):A1.
Australian urine collection instructions.
Note that (1) a clean catch sample by bag is perfectly acceptable and
(2) NO retraction should take place for an intact male.
United Kingdom urine collection kit. Includes:
• collection sheet • collection pad • plastic bottle • 5ml syringe
Danielle, who shared this photo (above) writes:
I hear so many stories of doctors wanting to cath babies for a urine sample, so I thought I'd show you the UK way! The sterile pad goes inside the diaper (nappy) and we use a syringe to draw out the urine, and put it into the specimen bottle. No cath needed! Ever!
Note that (1) a clean catch sample by bag is perfectly acceptable and
(2) NO retraction should take place for an intact male.
• collection sheet • collection pad • plastic bottle • 5ml syringe
Danielle, who shared this photo (above) writes:
I hear so many stories of doctors wanting to cath babies for a urine sample, so I thought I'd show you the UK way! The sterile pad goes inside the diaper (nappy) and we use a syringe to draw out the urine, and put it into the specimen bottle. No cath needed! Ever!
As a nurse I have done my share of male catheterizations. In adult intact males retraction is not necessarry, so I do not see why it would be necessarry on an infant. It does not make any sense to me why anyone would feel the need to have to retract an intact penis to simply insert a urinary catheter. That's just my two cents
ReplyDeleteI am a nurse and I don't work with children, but I don't see why there would be a need to retract. Males are very easy to catheterize, there's only one hole down there, pretty easy to find!
ReplyDeleteI understand why someone would WANT to retract the foreskin - it's always going to be easier to hit your mark if you have a viisual. BUT, unless there's a hypo/hyperspadius, it is pretty simple to accomplish a catheter insertion without retracting a foreskin.
ReplyDeleteI'm not a nurse, but our second boy had to stay in Cincinnati Childrens for 3 months and when he needed catheterizations, they did not make his intact penis seem like a big deal at all and did not retract the foreskin. One nurse mentioned the same as above (easier with a visual) but she did not mean it in disrespect and had no trouble at all.
ReplyDeleteawesome, this is like #2 for circumcision issues that I get in messages...
ReplyDeleteWhenever I had to be in the hospital I'd ask for either an older or a foreign nurse bc they're more likely to know how to properly (ahem) handle an intact penis. It also helped to have an extremely vigilant wife standing guard. She's even been known to use a Sharpie to write instructions on my leg for when I wasn't conscious and she wasn't there.
ReplyDeleteMy intact son has had to be catheterized twice! The first time it happened was in an emergency room and the nurse had no problem doing it blindly, and she did it so fast. I was so relived!
ReplyDeleteThe second time was awful. He had a procedure called a ECUG. We made it a point to tell the nurse that she would not be retracting the foreskin because we had previously had experiences with two other nurses who said we had to pull it down a little to clean him. One even told me that my son had a uti because he wasn't circumcised! Anyways, during the procedure she started to pull his foreskin down, and my sons father had to literally jump between them to make her stop! I was so upset! And she proceeded to go on and on about how she had been a nurse for so many years and that was how they always did it, but that if we wanted her to do it blindly she could, but that it was possible that he could get another uti. She was very rude!
Our pediatrician though is awesome. When I thought that my boy had another uti he sent us home with a bunch of little cups so that i could catch his urine with on my own and all we had to do was drop it by to the office in the morning! The easiest way was to hold it in front of him right after I put him in the bath as he always seems to go like clockwork. Thankfully he was fine.
I've learned that there really isn't much that you have to do to care for an intact penis, I just make sure to change him often and I always bathe him after he has very messy diapers...just to be safe!
Thanks again for all the info. Makes me feel good about my decision to keep my son whole! :)
I am a nurse in peds and we are told NOT TO retract as it can cause damage and unnecessary discomfort. I have never had a problem cathing a intact babe.
ReplyDeleteMy son had a UTI due to kidney reflux and I had to be a huge advocate for proper care of his penis. The first time the ped cathed him she ripped the tip of his foreskin. I was so mad I screamed at her. He healed but I was forever mistrusting of the medical community after that. 8 years later he is healed and has no more UTIs. Great article!
ReplyDeleteWouldn't it be easier of doctors and nurses were trained in this short of thing...?
ReplyDeleteMy son is intact and was hit by a car in 2002, they had to catherize (sp?) him and I am so thankful that the hospitals that cared for him in trauma and ICU knew how to deal with an intact penis. They also used those little bags that went over his penis when he was in the hospital due to flu complications. There are drs and nurses that know how to deal with intact penii, you just have to ask for them and make sure they know what they are doing.
ReplyDeleteI don't get it?? Maybe in Australia there isn't such a large proportion of circumcised men, but I am a nurse and I have catheterised way more intact men than circumcised...
ReplyDelete@Medhbh In the U.S. the medical community is not taught how to care for an intact penis, believe that retraction is required for normal development, and routinely treat uti, inflamation of the foreskin, and "tight foreskin" (in children as young as 2) with circumcision. The thought among many docters and nurses is that it a worthless flap of skin that is worth more trouble than it is worth keeping.
ReplyDeleteThats why we are fighting so hard here in the US.
Here in American nursing schools, the intact penis isn't even mentioned. Nor is how to cath one.
ReplyDeleteI'm a NICU nurse, so we don't have any clipped penises (thank god, because the ONE time I saw a freshly circumcised penis I nearly *died*). We don't retract foreskin. However, inserting catheters into baby boys is not as easy as you've made it out to be. Even my veteran co-workers have struggled with catheterizing a baby. But thanks for this! :) We only catheterize when we absolutely have to (usually if a birth has gone horrible horrible wrong and we need to monitor urine output, or if the kid has some kind of congenital urinary tract obstruction, etc).
ReplyDeleteI am a lawyer in my last semester of nursing school. I have done several catheters on intact men (never a baby or child), and it has simply not been an issue at all. For a young boy or infant, I can see how easy it would be to simply align the foreskin opening with the meatus and insert a catheter without retracting. I have seen people forget to REPLACE the adult foreskin to its natural position after insertion, and I always mention the importance of doing so when I see this error.
ReplyDeleteHi im Jenny ,
DeleteMy Daughter is 9 years old at 10 months she had a catheror put in For a uti and till this day she pees every single day anywhere anytime it's so frustrating cause I brought her to the doc . At 8 years old and they said she's fine after examination but how is that if she pees everyday her clothes all smell like pee and more vaginal bad smell too . I feel like after the Catheror was put on it must have affected her .because there's not one day that passes by and she pees everyday , What should I do ?
At age 9 years, frequent urination (if there is no other physical issue) can be a sign of anxiety. Is your daughter dealing with anything else traumatic, scary, or anxiety-causing at home? What is the rest of her day like? Also, is she able to feel the sensation of a full bladder (i.e. does she know when she needs to go before it is too late?) This can be missed in physical exams, as can the emotional side of things. In addition, double rinsing clothes in cold water is a good idea to ensure the scent is out between washes. My heart goes out to your daughter - I'm sure it is frustrating for her too.
DeleteI had one nurse in the ER at the children's hospital insert a catch on my intact son with no issues whatsoever. I had to stop a nurse on his floor because she obviously didn't have a clue. I will not allow my son to be catheterized again unless it's a lifeor death emergency. A UTI was later successfully diagnosed through a clean catch. Thanks for posting this. I will be bookmarking it for the next time we are at the ER.
ReplyDeleteI was once asked for a urine sample from my infant daughter. Those bags looked awful and my sister later warned me to NEVER stick one on my child. I just set my daughter naked on the counter in the exam room and offered her lots of water until she peed on the counter. The doctor didn't care - since he wasn't the one that would have to clean it. Pfft.
ReplyDeleteThank you for the info here. I have a newborn son - intact! There is a lot to remember in order to protect our little boys from misinformed medical staff!
I almost heaved my guts out when one of my friends told me about her experience with this. Dingbat nurse "has worked for THREE pediatricians" in the area so she definitely knows what to do -RETRACT, then insert. I wonder where she got her license. So unfortunate. :(
ReplyDeleteThis is a must. I learned the hard way (or my 18 month old son did). Nurses had no clue how to cath an intact penis. He is fine, but I worried so much at the time that I didn't know how to protect him better!
ReplyDeleteRecently we had an ER run that resulted in a doctor trying to forcibly retract my 6 month old. I was furious! I had to explain proper anatomy of a penis, function, etc., to a doctor who did not know what intact meant. Needless I say I have compiled a letter to the hospital and put together a pamphlet about Intact care thanks to your site!
ReplyDeleteI wish someone would have had this for me months ago when my son had to go to the ER. The nurse was an idiot and I know she hurt my son, but I didn't know what to do about it. The damage was done before I even realized what she was doing. I think people that work in healthcare need to be better educated. Now at 14 months that doctor said he is fine now, but he wasn't then.
ReplyDeleteSo glad I live in the UK. Circumcision isn't the norm over here, so little boys don't get their foreskins pulled about. I've done several adult male catheters and one was on a man with such bad hernias, you couldn't see his penis. But we just aimed at the hole, slide it in and got urine back. So much easier with an intact little boy than it was with that guy!
ReplyDeleteI agree with Emma. I live in the UK and I am utterly bemused at your campaign. Not because I dont agree with it - because I am amazed it is so necessary. Apart from religious groups it is just not routine in this country. I have four boys and it has NEVER been mentioned to me by any health professional. Why is it such an issue in the US? Surely there is enough data from countries that do not routinely carry out this practice to work out that it is not medically indicated?
ReplyDeleteThis is a very good thing to have! We had issues with one nurse at Children's Hospital in Denver having absolutely no clue how to care for an intact penis. We got a new nurse, then mailed the hospital lots of documents "to share with your nursing staff" after we got home... It was ridiculous (but she was one nurse among 20 or 30 we had while hospitalized and she was the only one who had no clue).
ReplyDeleteOur son just had to be catheterized at Children's Hospital Boston. The nurse doing it said she had to see the meatus. I countered with the information in this article. She made no commitment not to retract him so I was worried (they were attentive to our concerns, but must have been trained incorrectly).
ReplyDeleteAfter the surgery they proudly told us they were able to do a blind insertion like I explained. There is no sign that he was retracted in any way! We are going to send her flowers and an info pack. Being pleasant but firm worked for us, but we were at an amazing hospital. Address the issue before anyone gets near your son's penis.
I just read this a few weeks ago, just a few days before needing to take my intact two year old with special needs to the ER. I checked with the nurse before she touched him that she knew how to do a cath on an intact boy, then verbally reviewed with her what that meant. She said she had done it hundreds of times before and knew there would be no medical reason to retract him. She then proceeded to RETRACT him! I was beside myself. She kept saying it wasn't retraction because his foreskin was only halfway back instead of all the way back. I told her it absolutely was retraction and I had never in my son's life seen that much of his glans, even when he had baby erections or played with it in the tub. He's been rubbing, itching at his penis ever since and screams while shaking any time I get near his penis to try to see what's bothering him (he won't let me touch it...that reaction is just from him thinking I *might* touch it). I feel so sad for him. :-(
ReplyDeleteThank God I live in the UK where we leave our boys as they come into this world and don't mess with them once they're here. Come on USA! Follow us brits, keep your boys intact, and stop this silly business! x x x
ReplyDeleteAudreyBC - so sorry that this happened to your son. If there is still irritation, you may want to pick up some Calmoseptine from a local pharmacist and put this all around the outside of the penis. This will soothe and heal and is perfect for using on intact little boys (does not interfere with normal pH and healthy microflora of the developing genitals). You can also find more about 'what to do now' in this article, "Forced Retraction: Now What?" http://www.drmomma.org/2009/12/forced-retraction-what-now.html Hug your little guy for us.
ReplyDeleteMy son was cathed at six months at Children's Hospital because of an unknown fever. They told me they "had" to retract because they couldn't get a clen sample if they didn't. Guess what - my pediatrician told me a few days later that the sample grew 3 bacteria (none of which caused the fever) which was a sure sign that the sample was... CONTAMINATED. More than year later it still makes me made when I think about it. They all try to tell me hat it won't cause any lasting harm ,but my hert fears thy are wron, even if it was only once. I will also be checking with my church's childcare coordinator to make sure that the caretakers ALL know not to retract during diaper changes. I feel like an idiot for not asking when he was born.
ReplyDeletemy daughter is 4 months old she had a catherization today to check for a uti the doctor said the they had a lot of trouble getting her catheter in they said her anatomy was different and that it was also off to the side of her but they didnt explain does anyone know what that means
ReplyDeleteExcellent info on the common-sense method this nurse recommended of inserting a catheter into an intact boy. I want to point out the critical info that the most important way to prevent a UTI in older boys is to encourage regular urination and hydration. Homeschooled boys have the best chance of being able to meet their basic human need for elimination, because they are allowed to use the toilet when their bodies have the need. However, boys in school, especially in the middle and high school years, are often forced to painfully retain their urine, putting them at risk for UTIs and more serious urinary health problems such as reflux to the kidneys, back pressure on the kidneys, over-stretching of the bladder, incomplete voiding, voiding against a tight sphincter, weakening of the brain-bladder signal, kidney infections, epididymitis and even kidney failure. I spoke with a pediatric urologist at Boston Children's Hospital for research on this issue. He said that one of the greatest obstacles to urinary health in children ages 5 to 18 is the inhumane toileting rules in schools. He told me that well-hydrated adolescent boys should be urinating about every two hours and children should not go more than three hours without urinating at any age. If your sons are not urinating often, they may be dehydrated or their bladders may be over-stretched. Prevent problems in your sons before they start!
ReplyDeleteI just don't understand. I have a son who is intact (and two who are circ'ed, so this is new to me), and I hate to reveal my ignorance, but I do not understand what constitutes "retraction." I do nothing with my son's foreskin. I wash what I can see, and that is all. When my son's pediatrician examines him, she does handle his foreskin. I have stopped her multiple times, saying, "Please do not retract his foreskin." She reassures me she is NOT retracting the foreskin. She has a son who is intact, and she reassures me, what she is doing is fine.
ReplyDeleteDuring a recent ER visit, my baby boy refused to give up a urine sample in the handy plastic bag taped to him, and after waiting for quite a long time, the ER doc advised they really needed to use a catheter to get the urine sample. I stood guard, explained to the nurse that his penis was intact, and asked her to use care. She reassured me that she was familiar with doing this procedure on an intact male, and went to work. I watched, and to me, what I saw was retraction, but again, I really don't think I know what it is! (Incidentally, the catheter was unsuccessful as they were unable to obtain a sample. So frustrating.)
I really wish I understood this, because it's hard to protect my son when medical professionals are telling me what they are doing is not retraction. Okay, so when IS it retraction?
I'm an RN living/working in Brooklyn and this is something we were never taught in nursing school. I was always told to retract to insert a catheter. In fact, I had never even had a parent question the way we did things (and yes, sometimes baby boys cried hysterically when we had to cath), until someone came in and had this article pulled up on his phone (a father). I'd like to think of myself as open-minded, but honestly, I didn't even know what he was talking about at first (demanding we not retract, etc.). So he read us some quotes here and told us where to look it up ourselves. I did (and I think a few other staff did too). We did change the way we handle things (or at least those on my shift did) and surprised myself with how easy it is to *not* retract during a cath. So thanks - to the dad who brought this in, and for those writing. Just figured I'd share my response as well. To other RNs - it's easy. Just try it...
ReplyDeleteWhen my son was born they found fluid in his kidney.2Months after his urologist said he no longer had fluid ,but he needed to get a vcug.He has been fine. He is only four months I dont wanto go through with it.What should I do?
ReplyDeleteJennifer - I am not understanding your question fully, but you can email SavingSons@gmail.com or visit the SOS UTI/Kidney page: http://www.savingsons.org/2014/11/uti-resource-page.html
DeleteI'm lucky to work in a prominent NY hospital where the majority of our physicians are actually those who were trained overseas - retracting to cath is unheard of, and every new RN who comes on with our team is quickly schooled on how we do things - in a way that doesn't hurt our youngest patients.
ReplyDeleteHere is a video on catheterizing a male infant from Switzerland, where almost all boys are intact. They say not to forcibly retract the foreskin, only clean off the outside of the penis, and slip the catheter in through the foreskin outlet sight-unseen - no big deal! https://www.youtube.com/watch?v=gTRc1vJM324
ReplyDelete