Download Urethral Catheterization

Urethral Catheterization
(your opportunity to be a hero)
Robert Payne
Jim Watterson MD, FRCS
November 18, 2008
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


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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 (scilastic)
– 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 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 on the penis
 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 Pecker
 Think of where obstruction is
 SP tube

– Contraindications
– 22 Gauge needle
To bring to session
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