1. Urethral Catheterization (your opportunity to be a hero)
Robert Payne
Jim Watterson MD, FRCS
November 18, 2008

2. Outline catheterization difficult catheterization suprapubic cystotomy
contra/indications, complications, catheters, procedures
difficult catheterization
suprapubic cystotomy

3. 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

4. Contraindications Traumatic urethral injury
Mechanism (90% will have pelvic #)
Blood at meatus
High riding prostate

5. Retrograde Urethrogram

6. Duration Intermittent / In & Out Indwelling CIC- usually colonized
4% colonization / day

7. Complications of Catheterization
Short Term
Trauma
False passage
Hematuria
UTI
Long Term
colonization
urethral sloughing
malignancy
stones
hematuria
obstruction
stricture

8. Catheters Size Material French size = circumference in millimeters
French: 10 Fr circumference = 3.14 mm diameter
Material
Latex
Silicone (scilastic)
Teflon

9. Catheters Types Way Design Holes: 1 vs 2 vs 3 way Foley Coude (Tieman)
Malecot
Council
- Couvaliere
Holes:
hematuria
6 eyed

10. Equipment Foley trays Collection bag 2% xylocaine (Urojet) Catheter
Gloves, drapes, bottle, gauze, lubricant
prep, syringe w/ water
Collection bag
2% xylocaine (Urojet)
Catheter
+ extra set of hands

11. Procedure (male) Sterile technique
Lubricant in urethra and on catheter
“Penis to the sky” =

12. 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

13. Procedure

14. Procedure How do you know when you are in the bladder? Urine
Hub of catheter at tip of penis
Balloon inflates easily
Patient should not have pain when inflating balloon
When catheter pulled back (after balloon inflated) an end-point is felt.
Catheter can slide in and out
Catheter can irrigate easily (in = out)

15. 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)

16. Difficult catheterization

17. Difficult catheterization
History – attempts, PMHx, surgery, LUTS
P/E- abdomen, genitals
Instrumentation
Why?
Where?
Options?

18. WHY Difficult catheterization?
Females
Exposure
lots of hands
Female hypospadius
Tieman run along finger
Urethral stenosis
Introital mass

19. WHERE Difficult catheterization
Males
meatus
urethral stricture
sphincter
prostate (BPH/Cancer)
bladder neck

20. 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

21. 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

22. Suprapubic Cystostomy
Should be familiar to all surgeons
Percutaneous approach
Different from OR formal procedure
24-32 Fr malecot cut down

23. Suprapubic Tube Indications Contraindications
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)

24. Suprapubic Tubes U/S guided “MacGyver” SP Kits ( 10 – 16 Fr)
Cystocentesis: 22 G spinal needle
Seldinger- Central line, femoral art line
SP Kits ( 10 – 16 Fr)
Balloon
Malecot
Pigtail

25. SP Equipment sterile procedure tray SP kit
22 G spinal needle, local anesthetic, scapel blade, 3 x 10cc Syringes, nonabsorb. suture
drainage bag

26. SP Procedure Landmarks Midline, 2 fingerbreaths above symphasis
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

27. …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

28. SP Tube Complications Bleeding Catheter Obstruction
urinary (bladder/prostate) or extraurinary
Catheter Obstruction
irrigate routine + prn
ensure not displaced
Adjacent organs i.e. bowel
use 22 G spinal needle

29. SP DEMONSTRATION

30. Summary Find the Foley Love the Lube Pull the Pecker
Think of where obstruction is
SP tube
Contraindications
22 Gauge needle

31. To bring to session