URETHRAL CATHETERISATION

ANATOMY OF URETHRA & INDICATIONS FOR URETHRAL CATHETERISATION

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

MALE URETHRAL ANATOMY

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

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

FEMALE URETHRAL ANATOMY

http://bluestarr.files.wordpress.com/2012/01/urethrafemale.jpg

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

INDICATIONS FOR URETHRAL CATHETERISATION

Instillation of contrast radiological examinations

Urodynamic assessment

Instillations BCG, chemotherapy

CISC =clean intermittent self-catheterisation Neurogenic bladder dysfunction

Other

CATHETER CHARACTERISTICS

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

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

CATHETER TYPE MATERIAL

Latex 2 way Foley Silastic (Silicone) 2 way Foley

CATHETER TYPE

Latex 3 way catheter Irrigation set

CATHETER MATERIAL

Rubber or latex Short term Less than one week

Silastic More than one week

Polyvinylchloride/polyurothane Nelaton

OTHER

Catheters with curved tip Coude’

To traverse the prostatic urethra prostate enlarged → urethral angle may be difficult to traverse

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

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

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

TECHNIQUE & AFTERCARE

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

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]

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

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

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

NO URINE TROUBLESHOOT

CAN’T GET CATHETER IN

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

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

TROUBLESHOOT FEMALE CATHETER

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

URINE DRAINAGE BAGS

Leg bag Standard bag

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

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

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