CATHETERIZATION DR AFZAL JUNEJO ASSOCIATE PROFESSOR SURGERY , LUMHS .

Urethral Catheterization - A Simple Plan

Catheterisation

Drainage…

Indications Management of acute urinary retention or bladder outlet obstruction. Urine output measurement in critically ill patients. During surgery to assess fluid status. During and following specific surgeries of the genitourinary tract or adjacent structures (ie, urologic, gynecologic, colorectal surgery). Reference: Schaeffer AJ. Placement and management of urinary bladder catheters. UpToDate ® (2010)  

Indications – Copied from UTD Management of hematuria associated with clots. Management of immobilized patients (eg, stroke, pelvic fracture). Management of patients with neurogenic bladder. Management of open wounds located in the sacral or perineal regions in patients who are incontinent. . Reference: Schaeffer AJ. Placement and management of urinary bladder catheters. UpToDate ® (2010)  

Indications – Copied from UTD Intravesical pharmacologic therapy (eg, bladder cancer). Improved patient comfort for end of life care. Management of patients with urinary incontinence following failure of conservative, behavioral, pharmacologic and surgical therapy. Reference: Schaeffer AJ. Placement and management of urinary bladder catheters. UpToDate ® (2010)  

Urethral Catheterization - Indications Collection of uncontaminated specimen Intermittent bladder decompression Urologic study of anatomy of urinary tract

Indications simplified

Indications for catheterisation Retention of urine Monitor urine output / acutely ill patient Pre/peri/post-operatively Assessment and investigations Treatment (e.g. to instil chemotherapy) Irrigation of bladder Bypass an obstruction Management of incontinence (as a last resort)

Urethral Catheterization – Absolute contraindications Known urethral trauma - blood at meatus, fractured penis, etc.

Relative contraindications urethral stricture, recent urinary tract surgery (ie, urethra, bladder), presence of an artificial sphincter.. Reference: Schaeffer AJ. Placement and management of urinary bladder catheters. UpToDate ® (2010)  

Catheter Selection Drainage system (closed / link system) Points to consider; Size Balloon size Length Material (consider latex allergy) Drainage system (closed / link system)

Catheter size Ranges: Infant: 8F Child/adolescent: 10-12 Urinary catheters are sized using French (F) units. The French number divided by 3 is the outer diameter of the catheter in millimeters. Ranges: Infant: 8F Child/adolescent: 10-12 Adult and large adolescent: 14-18F (female/male) Most common: 14F to 16F used in large, older adolescents and adults

Balloon size 5 – 10 ml balloon usually with fluid to inflate (15-30cc balloons may be used in patients with prostate surgery)

Catheter Materials Short-term materials Long-term materials May stay in up to 3/52 Latex PTFE coated latex Siliconised latex PVC Long-term materials May stay in up to 3/12 Silicone elastomer (silastic) Hydrogel coated latex Silver coated latex 100% silicone 100% silicone + hydrogel coating

Types of Catheters

Many styles and colors from which to choose

Straight Catheter The rounded tip of this intermittent catheter reduces urethral trauma as the catheter is passed. Urine enters the lumen of the catheter through two "eye" holes. Courtesy of http://www.vetmed.wsu.edu/courses_samDX/urinary.htm

intermittent or straight

intermittent or straight catheter

Foley catheter or retention or indwelling catheter

Foley Catheter (indwelling)

Silicone Catheter

Other Catheters Coude Mushroom (Pezzer) is a intermittent catheter with a tapered curved tip that is designed to be easier to insert when enlargement of the prostate is suspected. Mushroom (Pezzer) The mushroom-shaped tip this continuous catheter secures it in the patient's bladder after percutaneous placement. It may be sutured to your patient's abdomen or flank, or you may need to tape it in place.

Other Urinary Equipment Three-way Foley for Continuous Bladder Irrigation Continuous Bladder Irrigation Catheter Clamp

External Urinary Device Condom or Texas Catheter Female external Urinary Collection system (In infants/young children; referred to as urine collection bag)

Drainage System: closed system Overnight drainage bag / 2 litre bed bag The bag attaches directly to the catheter and stays there for 7 days Don’t break/open the system!

Link drainage system

Urethral Catheterization - procedure

Procedure Aseptic technique - consent Patient preparation - information - consent Aseptic technique - to prevent the transmission of micro- organisms , thus reducing risk of infection

Gather supplies Insertion procedure Catheter kit Uro-Jet ® 14-16 Fr latex catheter Drainage bag, sterilization solution & sterile gloves.

Equipment Catheter pack Two pairs sterile gloves Sachet of normasol (to clean round urethral meatus) 10ml syringe Ampoule of sterile water for injections (if not in pack with catheter) Lubricant e.g. instillagel 6ml for females and 11ml for males An appropriate catheter Drainage system

Catheter kit

Unpack supplies Insertion procedure Unpack kit Place catheter and Uro-Jet® on sterile field Pour sterilization solution in cup

Prep & Drape Insertion procedure Don sterile gloves. Place syringe onto Foley. Sterilize the external urethral orifice. Drape the field and transfer equipment

Insertion procedure Insert Foley With non-dominant hand stretch penis or open labia. With dominant hand, insert Foley. Insert to hilt and ensure that there is urine flow prior to balloon inflation. Replace forekin, attach drainage bag.

Urethral Catheterization - procedure Normal male urethra - 20 cm from tip of external meatus to internal meatus Best to “insert full hilt” before inflating balloon Sometimes helped by straightening urethra and pulling up

Urethral Catheterization - procedure Female urethra short, straight, and usually wide caliber BUT meatus is not always obvious Urethra = 4 cm + tip & balloon = 4 cm  about 1/2 the catheter inserted before inflating balloon

Documentation Date inserted & date due to be changed Rationale for catheterisation Any problems encountered Size inserted Batch / lot number Expiry date Fluid used in balloon Type & volume Volume of urine drained Drainage system used

Acute Urinary Retention - difficulties

Acute Urinary Retention - difficulties Coude catheters

Complications of long-term catheterization : UTI, septicemia, urethral injury, hematuria Bacteriuria Chronic renal inflammation Pyelonephritis Nephrolithiasis Cystolithiasis Bladder cancer

Indwelling foley catheters are a major source of UTI’S. Direct relationship between duration a f/c is in the patient and incidence of infection. Risk factors: Female Advanced age Duration Diabetes Renal insufficiency

Bacteria is a function of time with a f/c: Single event – risk < 1% 4 days – risk increases to 30% 30 days – risk 95-100%

Monitor for Complications Foul smelling urine Thick, cloudy urine with or without sediment Painful urination (dysuria) Fever, chills Urethral swelling around the catheter Bleeding into or around the catheter Catheter draining little or no urine despite adequate fluid intake Leakage of large amounts of urine around the catheter

Care Meatal hygiene Minimise handling Maintain asepsis Do not allow bag to become too full Keep drainage bag below level of bladder

Suprapubic Catheterization Suprapubic catheterization allows bladder drainage by inserting a catheter or tube into the bladder through a suprapubic (above the pubis) incision or puncture.

4/14/2017 Miss Iman Shaweesh

Suprapubic Catheterization It may be a temporary measure to divert the flow of urine from the urethra when the urethral route is impassable (because of injuries, strictures, prostatic obstruction, after gynecologic or other abdominal surgery after pelvic fractures.

Suprapubic Catheterization may also be used on a long-term basis for women with urethral destruction secondary to long-term indwelling urethral catheters