Bladder Catheterization (and Urethral Dilation)

CHAPTER 110 Bladder Catheterization (and Urethral Dilation)



Robert E. James, Grant C. Fowler


Bladder catheterization may be performed for diagnostic or therapeutic indications (or both). This procedure is the most common retrograde manipulation performed in the urinary tract. Familiarity with the anatomy of the urethra and the available catheters will increase the ease and success of this procedure. Like all procedures in urology, this should be performed in a gentle fashion; instruments need not be forced. This is considered by patients to be among the five most painful emergency procedures, so, when possible, anesthetic jelly should be used. Indications and contraindications for infants and children are basically the same as for adults.


In the adult male patient, there are two points where obstruction is commonly encountered when passing a catheter. The first is at the point of acute upward angulation located between the bulbous and the membranous urethra. The second is at the bladder neck, where a bladder neck stenosis or an enlarged median lobe of the prostate gland may be present (Fig. 110-1). In younger male patients, urethral folds or valves may resist the insertion of a catheter.


image

Figure 110-1 Male urethral anatomy.


In the female patient, the urethra is much shorter, averaging only 2 inches in an adult. The angle between the urethra and the bladder neck increases with age. Consequently, in the older patient, the urethra is normally directed toward the sacrum, whereas in the younger patient it is angled toward the umbilicus. Keeping these urethral angles in mind will improve the clinician’s technique, thereby increasing patient comfort and facilitating passage of the catheter. Catheter size is measured in French units. As the number increases, the size increases (i.e., a 16-Fr catheter is larger than a 12-Fr catheter). One “French unit” is approximately 0.33 mm.



Indications



Short-Term Catheterization



• Acute urinary retention

• Collection of uncontaminated urine specimen for analysis, culture, and sensitivity (especially for female patients)

• Diagnostic studies of the lower urinary tract (e.g., cystogram, voiding cystourethrogram, urodynamics)

• Monitoring of urinary output

• Measurement of postvoid residual urine volume

• Irrigation of the bladder or instillation of medication

• Surgery on the urinary tract or adjacent structures

• Bladder drainage during and after surgical procedures requiring anesthetics

• Intermittent (in and out) catheterization for neurogenic bladder


Long-Term Catheterization



• Chronic urinary retention

• Neurogenic bladder in patient with inability to intermittently self-catheterize

• Incontinence with complicating skin breakdown

• As a comfort measure for terminally ill or severely disabled patient with incontinence

NOTE: A Cochrane review found that patients requiring catheterization for up to 14 days had less discomfort, bacteriuria, and need for recatheterization when suprapubic catheters were used compared with urethral catheters. Similarly, in a recent meta-analysis of patients having abdominal surgery, suprapubic catheters were found to cause less bacteriuria and discomfort and were preferred by patients (see Chapter 113, Suprapubic Catheter Insertion and/or Change).



Contraindications



• Known or suspected urethral disruption resulting from pelvic trauma (be suspicious if there is blood at the urethral meatus, a perineal hematoma, or a high-riding prostate)

• Recent reconstructive surgery of the urethra or bladder neck (relative contraindication, but should consult urology)

• Known urinary tract obstruction, such as a urethral stricture (relative contraindication, may be able to dilate)

• A combative or uncooperative patient (relative contraindication; see Chapter 2, Procedural Sedation and Analgesia)

• An acute infection of the prostate and/or urethra (relative contraindication)


Equipment



• Urethral catheters
• Robinson catheter: A straight, rounded-tip catheter used for short-term catheterization; one version is the red rubber catheter. Low-friction, hydrophilic-coated catheters have been found to increase patient satisfaction and decrease urinary tract infection and hematuria in patients who practice clean, intermittent self-catheterization.

• Foley catheter: A straight, self-retaining catheter that may have two or three lumina. While urine flows through the main, large lumen, and the secondary, smaller lumen is connected to a port used to inflate the retaining balloon (Fig. 110-2A), a Foley with a third lumen may be selected if irrigation will be necessary, such as for ongoing hematuria. A 16- to 18-Fr Foley catheter may be used for adults or adolescents (smaller sizes are used for infants and children) who require either a temporary or a chronic indwelling catheter. Foley catheters have short- or long-nose tips. Silicone or silicone-coated versions tend to be preferred over rubber catheters for long-term use because they produce less tissue reaction, have less encrustation, and have a larger lumen. By design, the retaining balloons can be overinflated, if necessary, to twice their stated capacity.

• Coudé catheter: This catheter is similar to a Foley catheter with some slight variations: the terminal 2 inches are curved upward (coudé is the French word for “elbow”; Fig. 110-2B) and there is a small ball on the tip. This catheter is used in adult men for whom a Robinson or Foley catheter cannot be inserted because of an enlarged median lobe of the prostate or an elevated bladder neck. Some clinicians advocate using a coudé catheter in all men older than 50 years of age. Coudé catheters are available with or without a self-retaining balloon. A 16- to 18-Fr catheter is normally used.

• Filiforms and followers: Filiforms are very thin, very pliable solid catheters that range in size from 1 to 6 Fr and are used to dilate a male urethral stricture. They may be straight or pig-tailed, or have a coudé tip, but they all have a female screw tip on the opposite end for attachment of followers. Followers are larger in diameter (12 to 30 Fr), have a male screw tip to attach to the filiforms, and are usually hollow with an open end. (Avoid the solid or closed-end followers; it may be impossible to tell when the forward tip has reached the bladder, so significant damage can occur. With the hollow, open-ended followers, you can tell when you are in the bladder because urine starts to flow.) Both filiforms and followers have a smooth-coated surface and are made of plastic or have a woven fiber core.

image

image

Figure 110-2 A, Foley catheter with balloon inflated. B, Coudé catheter with balloon inflated.


NOTE: Silastic catheters are available for latex-sensitive patients. Although a Cochrane review found that silver alloy–impregnated catheters compared with standard catheters were associated with decreased rates of urinary tract infections, this is considered controversial and they are expensive.


• Lubricant: either a water-soluble lubricant (K-Y Jelly) or a lubricant with a local anesthetic (2% lidocaine jelly) may be used. When available, the latter is preferred; 10 mL is sufficient for adult and adolescent female patients and 10 to 20 mL for adult and adolescent male patients, with smaller amounts for infants and children.

• Sterile towels and gloves

• Sterile cotton-tipped applicators

• Antiseptic solution

• Closed urinary drainage system (bedside overnight drainage bag, leg bag, or abdominal drainage system [belly bag])


Preprocedure Patient Preparation


The specific indications for catheterization, as well as the risks, benefits, alternatives, and technique, should be reviewed with the patient, parent, or caregiver. Long-term catheter care should be discussed if the catheter is to remain in place. (See the sample patient education form available online at www.expertconsult.com.) Informed consent is not always necessary for catheterization; however, at least verbal consent should be obtained and documented in the chart. Self-catheterization should be taught to the patient (or parent or caregiver) with the neurogenic bladder. Adequate lubrication and sufficient frequency are more important than sterile conditions if the patient is going to intermittently self-catheterize. If dilation is necessary, the patient should also understand the risks, benefits, alternatives, and technique. Informed consent should be obtained. It may be comforting to reassure the patient that everything possible will be done to maintain his or her modesty.



Technique



Bladder Catheterization



1 The female patient is placed in the dorsal lithotomy or the supine position with the legs abducted (i.e., frog-legged position). The male patient is placed in the supine position; the legs may be either abducted slightly or straight. The clinician should observe universal blood and body fluid precautions.

2 Identify the urethral meatus. For men, the penis should be grasped by the clinician’s nondominant hand and positioned pointing toward the umbilicus. Although the meatus should be easily identified in the circumcised man, gentle retraction of the foreskin (prepuce) may be necessary to identify the meatus in the uncircumcised man. Lateral and outward traction on the labia by the clinician’s nondominant hand may help identify the meatus in women. Applying downward pressure with the posterior bill of a vaginal speculum may also be helpful in women. In female infants or girls, hymenal folds may obscure the meatus, but again, lateral traction by the nondominant hand will usually help identify the meatus. If not, downward pressure with a cotton-tipped applicator placed over the introitus will usually improve visualization. Women who will be self-catheterizing can be taught to identify the meatus with a mirror. For repeat catheterizations in women, a finger inserted into the vagina can help guide the catheter.

Related posts:

  1. Antibiotic Prophylaxis
  2. Removal of Perianal Skin Tags (External Hemorrhoidal Skin Tags)
  3. Knee Braces
  4. Compartment Syndrome Evaluation

Stay updated, free articles. Join our Telegram channel
Tags:
May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Bladder Catheterization (and Urethral Dilation)

Full access? Get Clinical Tree
Get Clinical Tree app for offline access