1. URETHRAL CATHETERISATION

2. ANATOMY OF URETHRA & INDICATIONS FOR URETHRAL CATHETERISATION

3. ANATOMY OF MALE URETHRA Parts of the male urethra  Anterior  Fossa navicularis  Penile urethra  Bulbar urethra  Posterior  Membranous urethra  Prostatic urethra  Anterior urethra  Begins at perineal membrane/pelvic floor  Surrounded by corpus spongiosum  Bulbar and glanular segments dilated  Narrowest at external meatus

4. MALE URETHRAL ANATOMY Hinman, Frank Jr. Atlas of urologic surgery.2 nd ed. Philadelphia: WB Saunders Company,1998.

5. ANATOMY OF THE FEMALE URETHRA  4cm from bladder to vaginal vestibule  Layers of the urethra (inside to outside)  Urethral epithelium  Transitional epithelium changes gradually to non-keratinized squamous epithelium distally  Submucosa  Thick, vascular  Estrogen dependent  Muscle  Smooth muscle layers throughout length of urethra  Thick Inner longitudinal  Thin circular smooth muscle envelops longitudinal  Striated urethral sphincter  Invests distal 2/3 of urethra

6. FEMALE URETHRAL ANATOMY http://bluestarr.files.wordpress.com/ 2012/01/urethrafemale.jpg

7. INDICATIONS FOR URETHRAL CATHETERISATION  Urinary retention  Acute  Chronic  Output monitoring  Post bladder surgery/trauma  Keep the bladder empty  Divert urine  Post surgery  Fistula  Collect urine sample  Measure PVR  PVR=post void residual volume

8. INDICATIONS FOR URETHRAL CATHETERISATION  Instillation of contrast  radiological examinations  Urodynamic assessment  Instillations  BCG, chemotherapy  CISC  =clean intermittent self-catheterisation  Neurogenic bladder dysfunction  Other

9. CATHETER CHARACTERISTICS

10. CATHETER SIZE  French scale(Fr)  Circumference in millimetres  1mm diameter = 3Fr  Example:  18 Fr catheter = 6mm in diameter  Catheter sizes refer to the OUTSIDE diameter

11. TYPES STRAIGHT, NO BALLOON  Nelaton  “In-Out” catheterisation  Clean intermittent self-catheterisation FOLEYS/BALLOON  2 way  = 2 ports  for bulb inflation  small  for outflow of urine  3 way  = 3 ports  for bulb inflation  for outflow of urine  largest lumen  for instillation  irrigation fluid into bladder

12. CATHETER TYPE MATERIAL Latex 2 way FoleySilastic (Silicone) 2 way Foley

13. CATHETER TYPE Latex 3 way catheterIrrigation set

14. CATHETER MATERIAL  Rubber or latex  Short term  Less than one week  Silastic  More than one week  Polyvinylchloride/polyurothane  Nelaton

15. OTHER  Catheters with curved tip  Coude’  To traverse the prostatic urethra  prostate enlarged → urethral angle may be difficult to traverse

16. CHOOSE AN APPROPRIATE SIZE CATHETER  Pick the smallest catheter which will fulfil requirement  allows urethral secretions to drain out around the catheter  epididymitis may result from urethral catheterisation  necessitates conversion to supra-pubic catheter if continued catheterisation needed  Indications for larger catheters  Haematuria  Severe pyuria/sediment  Large catheters  20-24 Fr  Block less easily  Short-term only  3 way catheters which will allow irrigation  Re-enforced catheters allow aspiration of clots without “collapsing”  Larger holes at the tip allow small clots to drain  Rubber catheters tend to have smaller internal lumens than silastic catheters of similar external diameters

17. CHOOSE AN APPROPRIATE SIZE CATHETER  Indications for larger catheters  Haematuria  Severe pyuria/sediment  Large catheters  20-24 Fr  Block less easily  Short-term only  3 way allow irrigation  Re-enforced catheters allow aspiration of clots without “collapsing”  Larger holes at the tip allow small clots to drain  Rubber catheters have smaller internal lumens than silastic catheters of similar external diameters

18. CHOOSE AN APPROPRIATE TYPE OF CATHETER  Material  catheterisation >1 week  pick most biocompatible material  Silastic better than latex and polyurethane  3 way or 2 way  3 way required for irrigation  Useful to irrigate pus or blood from bladder  2 way routine use

19. TECHNIQUE & AFTERCARE

20. TECHNIQUE  Take a good history  Risk for stricture  Counsel the patient  Indication for catheter  Details of procedure  Get their consent  Ensure privacy  Place waterproof sheet under buttocks  “linensaver”  Position the patient supine

21. TECHNIQUE  Prep and drape the urethra and surrounding area as a sterile field  Use non-alcohol based cleansing agent to clean  [Note that clean intermittent self catheterisation is a clean and not a sterile procedure]

22. TECHNIQUE  Grasp the penis with the non-dominant hand  Use swab to cleanse the penis  Retract the foreskin and clean in circular motion from meatus to base of the penis  Drape the area

23. MALE CATHETERISATION  Place the penis on stretch perpendicular to the patient  Place the catheter tip into the urethral meatus  Gently advance  Bulbo-membranous urethra/ sphincter  Resistance may be encountered  Especially young men  Ask patient to cough or take deep breaths  Do not try to force the catheter  Lower the penis 90 degrees towards the feet  Apply gentle pressure  Reduce the foreskin after successful catheter placement

24. TROUBLESHOOTING  ONLY INFLATE THE BULB IF URINE DRAINS FROM THE CATHETER!  If urine doesn’t drain and unsure of position  Use 50 ml catheter tip (Toumy) syringe to flush 50 ml saline into the bladder.  If you can flush saline in and withdraw most of it catheter  probably in the bladder  If you can flush fluid in but cannot withdraw it  probably not in the bladder  If still doesn’t pass  Second tube of lubricant  Consider Coude’ tip if older male  If still fails consider supra-pubic catheter or urology consult  DON’T PLACE SUPRA-PUBIC IF PRESENTED WITH CLOT RETENTION, MAY HAVE BLADDER CANCER WHICH WILL SEED VIA SUPRA-PUBIC TRACT

25. NO URINE TROUBLESHOOT Urine drains Inflate bulb Urine doesn’t drain Flush with 50 ml syringe (50ml) Can’t aspirate fluid Catheter not in bladder Don’t inflate bulb Can aspirate fluid Catheter in bladder Inflate bulb Inflate bulb

26. CAN’T GET CATHETER IN Two tubes of lubricantCoude’-tip catheterAsk colleague with experienceSupra-pubic catheter

27. FEMALE CATHETERISATION  Position patient  Frog leg  Knees bent and apart with feet on the bed  Separate labia with non-dominant hand and wipe front to back  Discard swab after one front to back stroke  Start in midline and work outwards/laterally  Drape the area  Spread the labia  Usually easy to identify the urethra  Gently advance the lubricated catheter into the bladder

28. TROUBLESHOOTING THE FEMALE CATHETER  Get a good light  Get a second assistant to hold the labia apart  Use a speculum and pass under direct vision  Place finger in vagina and guide catheter on top of finger into urethra  Be aware that urethra can be quite posterior and seem to be on anterior vaginal wall

29. TROUBLESHOOT FEMALE CATHETER GOOD LIGHT Use speculum, do under vision Get assistant to spread labia Put finger in vagina, guide catheter on top of finger into urethra

30. DRAINAGE BAGS  Should be a closed drainage system  Should have a one way valve  to prevent reflux of urine back into the bladder  Should have a port to aspirate urine  for culture  Leg bags  smaller  used for ambulant patients  “belly bags”  Strapped to the belly instead of the leg  Useful for mobile patients

31. URINE DRAINAGE BAGS Leg bagStandard bag

32. BALLOON SIZE  5ml balloon suitable for most patients  Larger balloons on three way catheters  useful after TURP  CAUTION:  Don’t use larger balloons for bypassing urine  Especially in female patients with indwelling catheters  Bypassing due to bladder spasms  require anti-cholinergic medication  Progressively larger catheters with larger bulbs  dilate the urethra  over time patulous non-functional urethra develops  with total urinary incontinence

33. SECURING THE CATHETER  Never use adhesive tap directly onto the catheter to secure i  Glue adheres to the catheter  catheter retracts into the urethra  glue may cause urethritis

34. CATHETER CARE  Wash daily around the meatus with soap and water.  May apply some lubricant around the catheter if required  Silastic catheter  Change every 6 weeks to 3 months  AND after every urinary tract infection  Latex catheter  Change after 1 week