JOURNAL OF ENDOUROLOGY

Volume 25, Number 5, May 2011

Mary Ann Liebert, Inc.
Pp. 841844
DOI: 10.1089/end.2010.0591

Silicone Catheters May Be Superior to Latex Catheters

in Difficult Urethral Catheterization After Urethral Dilation
Carlos Villanueva, M.D.,1 S.G.M. Hossain, M.S.,2 and Carl A. Nelson, Ph.D. 2

Abstract

Background and Purpose: Urethral dilation in the setting of difficult urethral catheterization is sometimes
necessary to avoid suprapubic catheterization. Anecdotally, we have observed that less dilation is needed when
advancing a silicone catheter over a Glidewire compared with a latex catheter of the same size. Our aim was to
quantify the difference in the resistance to buckling between silicone and latex catheters.
Materials and Methods: A BOSE Electroforce load testing device was used to test 12F and 16F silicone and latex
catheters under tensile and compressive forces. This information was used to characterize the buckling (kinking)
behavior of the catheters.
Results: Silicone catheters showed more than 50% greater resistance to kinking when compared with regular
latex or coude latex catheters.
Conclusions: In the setting of the difficult urethral catheterization, silicone catheters should be used after urethral
dilation, advanced through a Glidewire, because they offer more resistance to buckling and might necessitate
less dilation than conventional latex catheters.

Introduction

he difficult urethral catheterization (DUC) is one

of the most common consultations for the general urologist. There are many causes of DUC, among which urethral
strictures and bladder neck contractures are probably the
most commonly reported in the literature (Fig. 1).13
The fact that strictures and bladder neck contractures
are common in cases of DUC suggests that many of these
patients end up needing urethral dilation to achieve a successful catheterization.
Urethral dilation in an awake patient is a very painful
procedure. Urethral dilation using Heyman dilators or filiforms and followers can result in serious trauma. Dilation
performed in the setting of infection or anticoagulation can
result in sepsis or severe bleeding.
More and more evidence has recently been accumulating
regarding the low success rates of endoscopic approaches to
urethral stricture disease (direct vision internal urethrotomy
and dilation).4 Some have now claimed that urethral stricture
is an open surgical disease. The purpose of dilating a urethral
stricture in the setting of DUC is to be able to drain the bladder
as a temporizing measure before definitive surgical repair of
the stricture.
For these reasons, it is of utmost importance to dilate up to
where a reasonable size catheter can be placed in the patient to

avoid unnecessary pain, trauma, bleeding, and the possibility

of infection. Most patients without hematuria will do fine
with a 12F Foley catheter, whereas in cases of gross hematuria
with clots, larger catheters are needed.
In theory, dilation to a certain size (ie, 16F) should allow the
placement of a same size catheter. In practice, that is not
the case, and usually one has to dilate at least 2F sizes above
the catheter needed to pass a urethral catheter over a Glidewire after dilation. The explanation is that urethral dilators
offer more resistance to kinking compared with a urethral
catheter that tends to kink more easily.
In our experience with 65 DUC, three patients underwent
urethral dilation to achieve urethral catheterization. These patients were dilated with a 12F ureteral access sheath after which
a 12F silicone catheter was advanced over a Glidewire successfully. Anecdotally, we have tried doing the same with latex
catheters unsuccessfully. Our clinical experience has shown
that latex catheters kink more easily than silicone catheters
and thus need dilation to a larger F size when compared with
silicone catheters. This could mean that when using latex
catheters, patients are subjected to unnecessary pain and
complications in the setting of urethral dilation during DUC.
In this study, our aim was to quantify the difference in the
susceptibility to kinking of silicone catheters compared with
latex catheters to translate our clinical experience into something more objective.

Department of Urology, University of Nebraska Medical Center, Omaha, Nebraska.

Department of Mechanical Engineering, University of Nebraska-Lincoln, Lincoln, Nebraska.

841

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VILLANUEVA ET AL.

FIG. 1. Most common causes of difficult urethral catheterization. Pooled data from Beaghler,1 Freid,2 and Mistry3 series. Included are the 54 patients from the Beaghler series, all
of whom underwent flexible cystoscopy, and the 13 patients
in the Mistry series who underwent flexible cystoscopy.
Twenty patients from the Freid series were included, too, but
it was not mentioned in the article how the cause of difficult
urethral catheterization was found in these patients.
Materials and Methods
For the experiment, 12F and 16F catheters of three different
types (regular latex, latex coude, and silicone) were used. The
initial objective was to test these catheters under tensile and
compressive loading. A BOSE ElectroForce load testing
device was used to perform these tests (Figs. 2 and 3). From
these load tests, it would be possible to find the Young
modulus of the materials, which would be used later to
characterize the buckling (kinking) behavior of the catheters.
Young modulus, or material stiffness, is a measure of how
much a material will deform when subjected to either compressive or tensile load.5
For both tests, samples were cut out of the catheters
longer samples for tensile tests and shorter samples for compressive tests. The geometry of the samples was measured
and recorded. For tensile tests, the samples were clamped
using the clamping grips of the BOSE ElectroForce load testing device, and for compressive tests, samples were held between flat platens of that device. Three samples were tested
for each type of catheter without repeating from the same

FIG. 3. Close-up of catheter sample in tensile grips of Bose

instrument.

catheter. The principle of the load testing device was to apply

displacement on the sample using its electromagnetic actuators and record the corresponding load on the load cell. The
values for the maximum displacements were kept in the linear
region (small amounts of stretch, consistent with the kinking
phenomenon being studied) so that the materials could be
assumed as linear elastic.
Results
Tables 1 and 2 show the results obtained from the load tests
on the 16F and 12F catheters. In Tables 1 and 2, one can clearly
observe (despite sample-to-sample variations in stiffness) that
the silicone catheter material is significantly stiffer than either
the regular latex or latex coude material. A stiffer material,
simply put, is more resistant to kinking. This trend is illustrated in Figure 4, using the average stiffness values from
Tables 1 and 2.
Combining measurements of the tested catheter crosssections with the compressive material stiffness data from
Figure 4, the overall flexural rigidity, or resistance to kinking,
is shown in Figure 5 for the different catheters tested. It is
clearly observed that despite a larger cross-section contribution from the latex catheters, the stiffness of the silicone material causes it to dominate in overall flexural rigidity.
Discussion

FIG. 2.

Bose ElectroForce instrument setup.

Two factors play a role in the susceptibility to kinking of a

urethral catheter. The first one is the stiffness of the catheter,
which was addressed in Tables 1 and 2. The other factor that

SILICONE CATHETERS AFTER URETHRAL DILATION

843

Table 1. Tensile and Compressive Test Results on 16 Fr Catheters

Sample 1t
Sample 2t
Sample 3t
Average

Tensile tests

Compressive tests

Youngs modulus (Pa)

Youngs modulus (Pa)

Silicone

Latex Coude

Regular Latex

6.86E + 06
9.14E + 06
8.55E + 06
8.18E + 06

3.84E + 06
4.22E + 06
3.38E + 06
3.81E + 06

2.13E + 06
2.17E + 06
2.01E + 06
2.10E + 06

Sample 1c
Sample 2c
Sample 3c
Average

Silicone

Latex Coude

Regular Latex

6.22E + 06
7.21E + 06
7.59E + 06
7.01E + 06

3.16E + 06
4.51E + 06
4.50E + 06
4.06E + 06

3.17E + 06
2.41E + 06
2.74E + 06
2.77E + 06

Table 2. Tensile and Compressive Test Results on 12 Fr Catheters

Sample 1t
Sample 2t
Sample 3t
Average

Tensile tests

Compressive tests

Youngs modulus (Pa)

Youngs modulus (Pa)

Silicone

Latex Coude

Regular Latex

4.86E + 06
7.29E + 06
6.72E + 06
6.29E + 06

3.30E + 06
3.34E + 06
3.64E + 06
3.43E + 06

2.04E + 06
3.03E + 06
3.24E + 06
2.77E + 06

Sample 1c
Sample 2c
Sample 3c
Average

Silicone

Latex Coude

Regular Latex

4.72E + 06
4.49E + 06
6.14E + 06
5.12E + 06

3.82E + 06
4.00E + 06
3.87E + 06
3.90E + 06

2.74E + 06
3.38E + 06
3.60E + 06
3.24E + 06

plays a role in susceptibility to kinking is the geometry of the

specimen (primarily the cross-section shape of the catheter).
When a catheter pushes against a stricture, it is analogous to a
structural column holding up the weight of a building. The
shape and size of the column determine how much load it can
carry before it buckles. Likewise, the cross-section geometry
of the catheter helps determine how much resistance it can
overcome in the stricture without kinking. Thus, the resistance to kinking is related to the product of Young modulus
and a geometric property called second moment of area or
area moment of inertia.5,6 Simply put, a catheter cross-section with material distributed away from its center (like a
hollow tube) has a higher second moment of area than a
catheter cross-section with material distributed at or near its
center (like a solid cylinder), and will thus be more resistant to
kinking. The combination of both factors is illustrated in
Figure 5.
These experiments provide an explanation of why less
urethral dilation is needed when using silicone catheters

passed over Glidewires in clinical practice, because these

catheters showed more than 50% greater resistance to kinking
when compared with latex or coude catheters. We believe that
when urethral dilation is needed in the setting of the DUC, it
should be minimized to prevent complications and the
smaller catheter passed over a Glidewire that could appropriately drain the bladder should be used. To achieve these
goals, this study provides a basic science basis to recommend
the use of silicone catheters in this setting.
There are other advantages to the use of silicone catheters.
Silicone catheters are safe in cases of latex allergy. According
to the Centers for Disease Control and Prevention catheterassociated urinary tract infections guideline,7 silicone might
be preferable to other catheter materials to reduce the risk of

FIG. 4. Stiffness values for three different catheter materials

taken from two different size catheters.

FIG. 5. Model prediction of resistance to kinking for 16F

catheters.

844
encrustation in long-term catheterized patients who have
frequent obstruction. Silicone catheters are just slightly more
costly than latex catheters, so cost should not be a consideration when using them.
Nevertheless, for the same reason that silicone catheters
may be superior when passed over a wire (because of their
increased stiffness as demonstrated in our experiment), they
probably should not be used in all urethral catheterizations.
Because of their stiffness, when advanced blindly without a
Glidewire to guide them into the bladder, they can potentially cause more trauma than the regular softer latex
catheters. In the case of a urethral stricture, for example, a
silicone catheter can potentially cause a larger deeper false
passage compared with a latex catheter if advanced forcefully.
Conclusion
Urethral dilation in the setting of the DUC carries many
risks and can be very unpleasant to the awake patient.
Urethral dilation is a suboptimal treatment for strictures or
bladder neck contractures. Despite these drawbacks, dilation is occasionally needed to place a urethral catheter if
suprapubic catheterization is to be avoided (patient receiving anticoagulants, etc.). When dilation of the urethra
needs to be performed, dilating to the smallest size that
would allow the passage of the smallest catheter that could
drain the bladder appropriately can minimize trauma, pain,
and other complications and potentially make a future urethroplasty easier. To achieve this goal, silicone catheters
passed over a Glidewire should be the first choice, because
they offer more resistance to kinking and thus may necessitate less dilation for the same size catheter compared with
regular or coude latex catheters.

VILLANUEVA ET AL.
Disclosure Statement
No competing financial interests exist.
References
1. Beaghler M, Grasso M III, Loisides P. Inability to pass a
urethral catheter: The bedside role of the flexible cystoscope.
Urology 1994;44:268270.
2. Freid RM, Smith AD. The Glidewire technique for overcoming urethral obstruction. J Urol 1996;156:164165.
3. Mistry S, Goldfarb D, Roth DR. Use of hydrophilic-coated
urethral catheters in management of acute urinary retention.
Urology 2007;70:2527.
4. Morey A. Urethral stricture is now an open surgical disease. J
Urol 2009;181:953954.
5. Shigley JE. Mechanical Engineering Design. 3rd ed. New
York, McGraw-Hill, 1977, p 695.
6. Gere JM, Timoshenko S. Mechanics of Materials. 3rd ed.
Boston: PWA-Kent Publishing Co, 1990, p 807.
7. Gould CV, Umscheid CA, Agarwal RK, et al. Guideline for
Prevention of Catheter-Associated Urinary Tract Infections
2009. Infect Control Hosp Epidemiol 2010;31:319326.

Address correspondence to:

Carlos Villanueva, M.D.
Department of Urology
University of Nebraska Medical Center
Omaha, NE 68198-2360
E-mail: cvillanueva.uro@gmail.com

Abbreviation Used
DUC difficult urethral catheterization