Situation: A 70-year-old man with benign prostatic hyperplasia (BPH) has had a weak stream and dribbling for several months. He comes to the emergency room because he has not been able to void for 12 hours. His lower abdomen is tender, a firm, rounded mass is felt above the pubis, and his creatinine is 2.1 mg/dL (186 µmol/L). The physician orders insertion of an indwelling urinary catheter. While advancing the catheter, the nurse meets resistance before any urine appears. What should the nurse do?

Resistance may come from sphincter spasm or the enlarged prostate. The nurse pulls back slightly, asks the client to take a deep breath and bear down gently to relax the sphincter, and advances slowly without force; if resistance continues, the nurse stops and notifies the physician, who may use a coudé-tip catheter. Forcing the catheter or inflating the balloon in the urethra can cause trauma, bleeding, and a false passage.

Understanding the clinical picture
A 70-year-old man with known benign prostatic hyperplasia (BPH) presents with 12 hours of inability to void, a palpable bladder above the pubis, and a creatinine of 2.1 mg/dL (186 µmol/L). These findings point to acute urinary retention (AUR), a urological emergency in which the bladder cannot empty despite being full. The elevated creatinine reflects post-renal acute kidney injury from back-pressure on the kidneys, which is why prompt bladder decompression with an indwelling catheter is ordered ^[1].

Why resistance occurs during catheter insertion
When the catheter tip meets resistance before any urine drains, the most likely causes are external urethral sphincter spasm or obstruction from the enlarged prostate. The external sphincter is under voluntary control, and anxiety or pain can make it contract involuntarily. In BPH, the prostatic urethra is narrowed and elongated, so the catheter must navigate a tighter, angled passage. Resistance is a signal to pause and reassess, not to push harder.

Step-by-step nursing action
The correct response is to pull back slightly, ask the patient to breathe deeply and bear down gently, then advance slowly without force. Deep breathing and gentle bearing down promote relaxation of the external sphincter. Pulling back a small amount repositions the catheter tip so it is not wedged against the sphincter or prostatic tissue. If resistance persists after these measures, the nurse must stop and notify the physician rather than continue advancing. The physician may then use a coudé-tip catheter, which has a curved tip designed to pass more easily through an enlarged prostate.

Why the other options are unsafe

Action	Why it is incorrect
Push firmly past resistance	Forcing the catheter can tear the urethral mucosa, cause bleeding, and create a false passage — a channel outside the true urethral lumen.
Withdraw fully and instill more lubricant	Withdrawing completely loses progress and does not address sphincter spasm. Additional lubricant is not the primary issue when the tip is already in the urethra.
Inflate the balloon partly	Inflating the balloon inside the urethra can rupture the urethra, cause severe pain, bleeding, and long-term stricture. The balloon must only be inflated after urine return confirms the tip is in the bladder.

Watch out! Balloon inflation in the urethra is a serious, preventable injury. Urine must be seen in the tubing before any balloon inflation.
Key point! Resistance during catheterization is managed with repositioning, relaxation, and slow advancement — never with force.

Clinical reasoning for the licensure exam
AUR is a common complication of BPH and a frequent scenario in nursing licensure examinations. The standard management sequence includes transurethral catheterization, initiation of an alpha-blocker, and later a trial without catheter (TWOC) to determine whether the patient can void spontaneously ^[1]. The nurse’s immediate responsibility during catheter insertion is to protect the urethra from trauma while achieving bladder decompression. Recognizing resistance as a physiologic or anatomic obstacle — not something to overcome with force — is the central safety principle in this question. The creatinine elevation also reinforces the urgency of decompression, but it does not change the technique: gentle, patient, and atraumatic insertion remains the priority.