When urethral catheterization proves difficult, generally in a patient of previous history of urological intervention/catheterisation or stricture or glans is showing obvious whitish patches suggestive of Balanitis Xerotica Obliterans then Retrograde Urethrogram should be performed.
Progressively smaller lumen tubes can be tried. If that does not succeed then rather than using force, which may lead to the formation of a false passage, one should place a glidewire into the bladder through the area of resistance, followed by the placement of a Foley catheter over the glidewire. This is a very easy procedure and can be taught to nurses and nurse practitioners to avoid an unnecessary call for a urologist in the emergency department. A 10 Fr or 12 Fr Silastic Foleys has adequate stiffness to slide past the stricture so should be used preferentially.
If there is urethral bleeding then catheterization should be abandoned (don’t persist in catheterization if urethral bleeding is there) for supra-pubic placement of catheter and then the case should be referred to a urologist.
If there is no past history of urethral instrumentation and the patient is over 60 years then probably prostatic enlargement is the cause. To bypass prostate swelling due to benign prostatic hyperplasia, prostate tumor, or external mass by using a 10-cc syringe to inject normal saline into the catheter lumen while pushing the Foley catheter at the same time. The Foleys Catheter should be wide bored preferably 18 Fr otherwise smaller bore catheters have a tendency to get coiled in curvaceus urethra (this is in contrast to stricture disease where smaller catheters –infant feeding tubes/Nelatons is preferred).
Sometimes a simultaneous digital rectal manipulation of the catheter helps to prevent coiling of the catheter in the urethra.
The underlying main thing in both prostatic and stricture disease is to lubricate the urethra with upto 20 cc of viscous 1% lidocaine. (This provides not only lubrication for the entire length of the urethra but also some anesthesia to prevent external sphincter spasm.)