Reducing Iatrogenic
Urethral Injury and Urinary
Tract Infections
Colleen Kasa RN BScN CMSN©
CNE Urology
May 2015
UTI’S
► 600,000
patients developed hospital acquired UTI
per year
► 80% of these are urinary catheter associated
(CAUTI)
► Common pathogens: E. Coli, Klebsiella, Proteus,
enterococcus, Psuedomonas, Candida.
► Every day that catheter remains, risk of CAUTI
increases by 5%; 100% in 30 days
► PROMPTLY REMOVE UNNECESSARY URINARY
CATHETERS
Indications for a urinary catheter
► Urinary
tract obstruction
► Gross hematuria with clots
► Neurogenic bladder dysfunction or urinary
retention
► Urologic or other surgery or studies
► Stage 3 or 4 sacral area decubitus ulcer with
incontinence
► Accurate outputs in critically ill patients
► Hospice or palliative (if patient requests)
Migrating Bacteria
► Immunocompromised
patients
► Patients on antibiotics – fungus/yeast
► Introduction of the bacteria with the
insertion, especially if mucosal disrupted
► Migrate up the catheter in the periurethral
sheath
► Migrate up the internal lumen of the
catheter if break in the closed drainage
system – reduce UTI’s to 25%
Catheters are NOT for:
► Incontinence
► Immobility
► Obtaining
specimens
► Monitoring of outputs
► Patient request/convenience
Strongly Recommended-CDC
1.
2.
3.
4.
5.
6.
7.
8.
9.
Educate personnel in correct techniques of catheter
insertion and care
Catheterize only when necessary
Emphasize handwashing
Insert catheter using aseptic technique and sterile
equipment
Secure catheter properly
Maintain closed sterile drainage
Obtain Urine samples asepticlly
Maintain unobstructed urine flow
Empty drainage system at least every 8 hours, using
aseptic technique, pt. specific container
Moderately Recommended
1.
2.
3.
4.
5.
Periodically re-educate personnel in
catheter care
Use smallest suitable bore catheter and
balloon possible
Avoid irrigation unless needed to prevent
obstruction
Refrain from daily meatal care
Do not change catheters at regular
intervals
Weakly Recommended
1.
2.
3.
4.
Consider alternative techniques of urinary
drainage
Replace the collection system when sterile
closed system has been violated
Spatially separating infected and
uninfected patients with indwelling
catheters
Avoid routine bacteriologic monitoring
Other Complications
1.
2.
3.
Non bacterial urethral inflammation
Urethral strictures
Mechanical Trauma (catheter not
stabilized, confused patients, etc)
Any traumatic/difficult catheterization
predisposes the male urethra to future
difficulties…scarring, false passages,
fistulas.
Catheters
► Clean
Intermittent Catheters
► Foley Catheters Size 14-16 French
► Materials: latex, silicone, lubricious
► Balloon Sizes: 5cc to 30cc
► 3-Way catheters: balloons 30cc – often 45-50cc in
balloon – may actually be tethered into the
prostatic fossa (applies pressure to the operative
site)
► Used for continuous bladder irrigation (TURP`s)
Notice the functional diameter of the holes
Female Catheterization
Male Anatomy
Benign Prostatic Hypertrophy
Pressure Points in the Male Urethra
Support the troops!
Urethral Tear
Inspect carefully for meatal damage
Paraphimosis with constriction
Edema and Discoloration
Manual reduction of Paraphimosis
Catheter in Male Bladder
Difficult Catheterizations (Male)
► Resistance
- not the nurses fault
► (strictures, false passages, scarring, BPH)
► Pain During Insertion
► (explanations, pointing toes, Xylocaine gel)
► (consider specially shaped catheters-coude)
► PAIN DURING INFLATION OF BALLOON
Problem with Female
Catheterizations
► Difficulty
Visualizing Urethra
► (good lighting, know anatomy, review history for
bladder repair, female circumcision, have patient
bear down as if to void..urethra opens)
► How many of you have put the catheter into the
vagina? (leave it there so you know where not to
go!)
► Difficulty with insertion- abuse
► (use smaller catheter, explanations, consider
Xylocaine gel for lubrication of catheter)
Xylocaine Gel
Physician’s Order (some programs may have standing
order)
► Xylocaine must be sterile
► Insert into the urethra for 5 - 15 minutes.
1. Opens the posterior urethra (hold penis at 90 degrees to
straighten the path)(TUG)
2. Lubricates the path for the catheter
3. Desensitizes the urethra during and after the procedure
4. Psychological benefit – you are acknowledging that this
is unpleasant and you are doing your best to alleviate
discomfort
►
Xylocaine Syringe
Checklist for Proper Placement of
Catheter
► 1.
► 2.
► 3.
► 4.
► 5.
►
► 6.
►
Insert Catheter to the hub
Wait for Urine return (? flush)
Catheter does not recoil when released
Balloon fills without resistance
Patient does not have pain during
inflation
Balloon can be brought to the wall of
the bladder
Moving Along
Question 1
► 1.
How often does a catheter need to be
changed?
Answer 1
► Catheters
should not be routinely changed.
► Always follow manufacturers’ recommendations
► Change catheter if encrusted, plugged or not
functioning well
► In general short term catheters are intended for 510 days (latex foley)
► Long term catheters can remain as long as
functioning well (silicone, silastic)
► NB: catheters should be last resort for urine
drainage.
Question 2
► Should
you ever irrigate a catheter?
Answer 2
► Generally
catheters should not be irrigated, as
bacteria and/or debris can be forced back into he
bladder and potentially cause infection.
► However, when a catheter is initially inserted, the
catheter may need to be irrigated to flush out any
lubrication that may be obstructing the drainage
eye.
► Three way catheters are intended to be irrigated
to flush out clots and keep the catheter patent.
Question 3
► Doesn’t
a bigger catheter do a better job?
Answer 3
► No,
the smallest catheter that allows free
flow of the urine is best. The periurethral
mucosa is less compressed and is able to do
a better job of lubricating the urethra and
deterring bacterial migration up the outside
of the catheter
Question 4
► Isn’t
a bigger balloon better to hold the
catheter in place?
Answer 4
A bigger balloon actually causes stress at the
bladder sphincter (1cc of H2O weighs 1 gm)
May cause spasms, significant injury if
catheter is removed with the balloon intact
► A larger balloon holds the drainage higher
in the urine at the base of the bladderleaves residual of urine at the base
Large Balloon Problems
Question 5
► How
forceful should a nurse be to get a
catheter inserted?
Answer 5
Steady even pressure should be all that is required to
insert a urinary catheter
► Knowledge about the anatomy is essential so the nurse is
aware of the locality of spincters, which might spasm
during insertion and require a hesitation
► Explanations, xylocaine gel, breathing techniques all assist
the patient to relax the
► Sphincters
► If catheter is not inserting easily…STOP and get help!
Consider coude catheter, experienced nurse or urologist.
►
Question 6
► What
kind of catheter is best for the
patient?
Answer 6
► Often
best solution is no catheter
► Consider the purpose for the catheter (ie. Draining
large clots will require a much larger catheter)
► Generally the smallest catheter to drain the
bladder is the best
► Consider latex allergies…most catheters are made
of a latex combination
► Latex is generally used for short term (5-10 days)
and silicone for long term (>10 days)
Question 7
► Why
should a catheter be tethered?
Answer 7
Both make and female catheters should be
tethered to maintain the integrity of the
urethral mucosa (reduces pistoning effect)
and reduces the pressure on the urinary
tract spincters and stress points
Question 8
► What
if no urine comes out of the catheter?
Answer 8
► Possible
considerations:
► patient may have just voided
► Catheter isn’t in the bladder
► Catheter is plugged – drainage eye,
catheter may be bent, catheter may be
above the bladder…need gravity to flow
► Patient may be hypovolemic….may need
bolus to have urine
Question 9
► What
causes a catheter to bypass?
Answer 9
► Bypassing
is caused by detrusor instability
► Common Causes:
► Obstruction: clots, encrustation, kinking
►
constipation
►
infection
►
large balloon…5gms vs. 30gms
Question 10
► Why
cc.?
can’t you just fill a 10cc balloon with 5
Answer 10
►A
balloon should always be spherical and
symmetrical in the bladder. This prevents
potential erosion of the bladder mucosa and
sphincter.
It also keeps the drainage eye lower in the
urine, allowing for better drainage.
We’re Finished!
References
1) Amukele Samuel A, Lee Gene W., et al 20-Year Experience with Iatrogenic Penile Injury The Journal
of Urology Copyright © 2003 by American Urological Association Vol. 170, 1691-1694 October 2003
2) APIC Centers for Disease Control and Prevention Infectious Diseases Society of America Society for
Healthcare Epidemiology of America et al Getting Started Kit: Prevent Catheter-Associated Urinary
Tract Infections How-to Guide pages 1-32
3) Canes, David MD Male Urethral Catheterization The New England Journal of Medicine Volume
344:1178-1179 September 14, 2006 Number 11
4) Chung c, Chu M, et al. Comparison of lignocaine and water-based lubricating gels for female urethral
catheterization, Emergency Medicine Australas.2007 Aug;19(4):315-9
5) Conterno LO, Mayhew A, Pereira CR The Cochrane Collaboration Intervention aimed at improving
professional adherence to guidelines for prevention of device-related infections (Protocol) Copyright
© 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
6) Cummings James M. MD, Boullier John MD, Urethral Trauma emedicine.medscape.com, Updated Jul
13, 2006
7) Dandan Imad S, MD, Farhat Walid, MD Trauma, Lower Genitourinary emedicine.medscape.com
Updated April 16, 2009
8) DohertyW. Instillagel: an anesthetic antiseptic gel for use in catheterization. Br J Nurs. 1999 Ja28-Feb
10;8(2):109-12. Review.
9) Gray Mikel L Securing the Indwelling Catheter AJN December 2008 Vol 108, No 12 pages 4451
References (continued)
10) Greene Linda, Marx James, et al Guide to the Elimination of Catheter-Associated Urinary
Tract Infections (CAUTIs) Developing and Applying Facility-Based prevention
Interventions in Acute and Long-Term Care Settings Association for Professionals in
Infection Control and epidemiology pages 1-41
11) Kashefi Carol, Messer Karen, et al Incidence and Prevention of Iatrogenic Urethral
Injuries The Journal of Urology Copyright © 2008 by American Urological Association
Vol. 179, 2254-2258, June 2008
12) Kelly Janis ADHD Medications Narrow But Do Not Close the Academic Achievement Gap
www.medscape.com
13) Leone Marc, Perrin Anne-Sohpie et al A randomized trial of catheter change and short
course of antibiotics for asymptomatic bacteriuria in catheterized ICU patients Intensive
Care Med (2007) 33:726-729
14) Lo, Evelyn MD; Nicolle, Lindsay MD; et al Strategies to Prevent Catheter-associated
Urinary Tract Infections in Acute Care Hospitals S41 Infection Control and Hospital
Epidemiology October 2008, Vol. 29, Supplement 1
15) Moore Katherine, Rayome R. Problem solving and Troaubleshooting: The Indwelling
Catheter. JWOCN. 1995. Volume 22 (5)
16) Moore Katherine N, Hunter Kathleen F, et al Do Catheter Washouts Extend Patency Time
in Long-term Indwelling Urethral Catheters? JWOCN January/February 2009 Copyright ©
2009 by the Wound, Ostomy and Continence Nurses Society pages 82-90
References (continued)
17) Nazarko, Linda Effective evidence based catheter management British Journal of
Community Nursing Vol 13, No 3 110-114
18) Newman, Diane K The Indwelling Urinary Catheter Principles for Best Practice Journal of
Wound, Ostomy and Continence Nursing November/December 2007 volume 34 Number
6 pages 655-661
19) Parker Diana, Callan Laurie et al Catheter-Associated Urinary Tract Infections JWOCN
March/April 2009 Copyright © 2009 by the Wound, Ostomy and Continence Nurses
Society pages 156-159
20) Parker Diana, Callan Laurie et al Nursing Interventions to Reduce the Risk of CatheterAssociated Urinary Tract Infection Part 1: Catheter Selection JWOCN January/February
2009 Copyright © 2009 by the Wound, Ostomy and Continence Nurses Society pages
23-34
21) Parker Diana, Callan Laurie et al Nursing Interventions to Reduce the Risk of CatheterAssociated Urinary Tract Infection Part 2: Staff Education, Monitoring, and Care
Techniques JWOCN March/April 2009 Copyright © 2009 by the Wound, Ostomy and
Continence Nurses Society pages 137-154
22) Potter, Patricia A., Perry Anne Griffin, et al Canadian Fundamentals of Nursing Fourth
Edition pages 1096-1113
23) Reilly Laura, Sullivan Patty et al Reducing Foley Catheter Device Days in an Intensive
Care Unit AACN Advanced Critical Care Volume 17, Number 3, pp. 272-283 © 2006,
AACN
References (continued)
24) Roberts James A., MD Kaack M. Bernice, PH.D., Fussell E.N., MS Adherence to Urethral Catheters by
Bacteria Causing Nosocomial Infections Urology Volume 41 Number 4 April 1993 pages 338-342
25) Robinson John Clinical skills: how to remove and change a suprapubic catheter British Journal of
Nursing 2005 Vol 14, No 1 pages 30-35
26) Siderias J, Guadio F, Singer AJ. Comparison of topical anesthetics and lubricants prior to urethral
catheterization in males. Acad Emerg Med. 2004 June;11(6):703-6.
27) Senese Victor, Hendricks Mary Beth, et al Clinical Practice Guidelines. Care of the Patient With an
Indwelling Catheter Published: 04/11/2006 http://www.medscape.com/viewarticle/525695_print
28) Smith JoAnn Mercer Indwelling Catheter Management: From Habit-Based to Evidence-Based Practice
OstomyWound Management 2003;49(12)34-45
29) Tanabe P, Steinman R, Anderson J, Johnson D, et al. Factors Affecting Pain Scores during Female
Urethral Catheterization. Acad Emerg Med. June 2004. Vol11(6)
30) Tanagho Emil A, MD, McAninch Jack W., MD,FACS Smith’s General Urology Seventeenth Edition
McGraw Hill Medical, page 293-296
31) Trautner Barbara W Darouiche Rabih O Role of biofilm in catheter-associated urinary tract infection
AIIC state of the science report Vol. 32 No 3 pages 177-183
32) Tzortis V, Stavros G, Melekos M. Intraurethral Lubricants: Acritical Literature Review and
Recommendations. Journal of Endourology. Vol23;
33) Wein Alan J. Campbell-Walsh Urology Ninth Edition Volume 3 pages 1923-1924
34) Wong, Edward S. M.D. in consultation with Thomas M. Hooton, M.D. Guideline for Prevention of
Catheter-associated Urinary Tract Infections CDC Department of Health and Human Services Centers
for Disease Control and Prevention Published: February 1981