Urethral Catheterization (your opportunity to be a hero) Darren Desantis Eric Saltel Outline catheterization – contra/indications, complications, catheters, procedures difficult catheterization suprapubic cystotomy Indications for Catheterization Drain bladder – Unconsious - OR/Intubated – Retention - Neurogenic bladder, Obstruction, Clots Monitor output – Trauma – Medical (CHF, RF, sepsis) Urine specimen Diagnostic studies – Residual – Radiographic contrast studies – Renal function (24 h) – Urodynamics Contraindications Traumatic urethral injury – Mechanism (90% will have pelvic #) – Blood at meatus – High riding prostate Retrograde Urethrogram Duration Intermittent / In & Out – CIC- usually colonized Indwelling – 4% colonization / day Complications of Catheterization Short Term Trauma False passage Hematuria UTI Long Term colonization urethral sloughing malignancy stones hematuria obstruction stricture Catheters Size – French size = circumference in millimeters – French: 10 Fr circumference = 3.14 mm diameter Material – Latex – Silicone (silastic) – Teflon Types Way – 1 vs 2 vs 3 way Design – – – – Foley Coude (Tieman) Malecot Council - Couvaliere Holes: – hematuria – 6 eyed Catheters Equipment Foley trays – Gloves, drapes, bottle, gauze, lubricant – prep, syringe w/ water Collection bag 2% xylocaine (Urojet) Catheter + extra set of hands Procedure (male) Sterile technique Lubricant in urethra and on catheter “Penis up to the sky” = Procedure “Penis to the sky” No force needed – not an orthopedic procedure DO NOT INFLATE UNTIL URINE SEEN Inflate with hub at meatus in males Procedure Procedure How do you know when you are in the bladder? 1. Urine 2. Hub of catheter at tip of penis 3. Balloon inflates easily 4. Patient should not have pain when inflating balloon 5. When catheter pulled back (after balloon inflated) an end-point is felt. 6. Catheter can slide in and out 7. Catheter can irrigate easily (in = out) Important Misc. Lubricant is your friend Pull the penis up Antibiotics – Infected: short course – SBE prophylaxis (not indicated unless infected) – traumatic Latex allergy Water (not saline) Reduce foreskin (paraphimosis) Difficult catheterization Difficult catheterization History – attempts, PMHx, surgery, LUTS P/E- abdomen, genitals Instrumentation 1. Why? 2. Where? 3. Options? WHY Difficult catheterization? Females Exposure – lots of hands Female hypospadius – Tieman run along finger Urethral stenosis – Introital mass WHERE Difficult catheterization Males meatus urethral stricture sphincter prostate (BPH/Cancer) bladder neck Difficult Catheterization Lubricant and proper technique Catheter – Size (go larger not smaller) – Type eg. Coude (Tieman) Filiforms and Followers Stylet Flexible Cystoscope and Guide Wire Suprapubic Tube WHERE is Difficulty ? Males Meatus- dilatation ( sounds, snap), lubricant urethral stricture - f + f, scope, SP Sphincter- lubricant, relaxation prostate (BPH/Cancer)- f+f, scope, SP bladder neck- stylet, f+f, scope, SP Suprapubic Cystostomy Should be familiar to all surgeons Percutaneous approach Different from OR formal procedure – 24-32 Fr malecot cut down Suprapubic Tube Indications – unable to catheterize per urethra – Traumatic urethral disruption – Full bladder Contraindications – empty bladder – known Bladder cancer – Fem-fem bypass – extensive scarring (relative) – clot hematuria (relative) Suprapubic Tubes U/S guided “MacGyver” – Cystocentesis: 22 G spinal needle – Seldinger- Central line, femoral art line SP Kits ( 10 – 16 Fr) – Balloon – Malecot – Pigtail SP Equipment sterile procedure tray SP kit 22 G spinal needle, local anesthetic, scapel blade, 3 x 10cc Syringes, nonabsorb. suture drainage bag SP Procedure Landmarks – Check groins and abdo for scars (Bypass) – Midline, 2 fingerbreaths above symphasis – Percuss bladder Local anesthetic – Infiltrate skin, then perpendicular to skin, aspirate as you go beyond fascia (point posterior - not inferior) 22 G spinal with syringe- to sacrum (perp) and aspirate – Mark depth of bladder with a hemostat on the needle …SP Procedure if no urine, try superior approach set up SP with trocar and syringe aspirate until same distance plus 1 cm remove trocar malecot / inflate balloon/ tie pigtail secure with nonabsorbable suture SP Tube Complications Bleeding – urinary (bladder/prostate) or extraurinary Catheter Obstruction – irrigate routine + prn – ensure not displaced Adjacent organs i.e. bowel – use 22 G spinal needle SP DEMONSTRATION Summary Find the Foley Love the Lube Pull the Penis up Think of where obstruction is SP tube – Contraindications – 22 Gauge needle To bring to session