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URETHRAL CATHETERISATION
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ANATOMY OF URETHRA & INDICATIONS FOR URETHRAL CATHETERISATION
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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
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MALE URETHRAL ANATOMY
Hinman, Frank Jr. Atlas of urologic surgery.2nd ed. Philadelphia: WB Saunders Company,1998.
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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
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FEMALE URETHRAL ANATOMY
http://bluestarr.files.wordpress.com/2012/01/urethrafemale.jpg
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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
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INDICATIONS FOR URETHRAL CATHETERISATION
Instillation of contrast radiological examinations
Urodynamic assessment
Instillations BCG, chemotherapy
CISC =clean intermittent self-catheterisation Neurogenic bladder dysfunction
Other
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CATHETER CHARACTERISTICS
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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
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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
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CATHETER TYPE MATERIAL
Latex 2 way Foley Silastic (Silicone) 2 way Foley
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CATHETER TYPE
Latex 3 way catheter Irrigation set
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CATHETER MATERIAL
Rubber or latex Short term Less than one week
Silastic More than one week
Polyvinylchloride/polyurothane Nelaton
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OTHER
Catheters with curved tip Coude’
To traverse the prostatic urethra prostate enlarged → urethral angle may be difficult to traverse
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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
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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
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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
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TECHNIQUE & AFTERCARE
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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
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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]
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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
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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
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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
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NO URINE TROUBLESHOOT
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CAN’T GET CATHETER IN
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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
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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
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TROUBLESHOOT FEMALE CATHETER
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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
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URINE DRAINAGE BAGS
Leg bag Standard bag
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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
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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
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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