Urethral Trauma After Foley Catheter Placement: A Teachable Moment

Iatrogenic bladder neck rupture due to traumatic urethral catheterization: A case report

BACKGROUND

In this article, we present a case of iatrogenic bladder neck rupture due to catheter insertion in a 94-year-old comorbid male patient.

CASE SUMMARY

The patient, who had a urethral catheter inserted in the palliative service 3 d ago, was consulted because the catheter did not work. Because the fluid given to the bladder could not be recovered, computed tomography was performed, which revealed that the catheter had passed the bladder neck first into the retrovesical area then into the intraabdominal area. The appearance of the anterior urethra and verumontanum was normal at cystoscopy. However, extremely severe stenosis of the bladder neck, and perforated posterior wall of the urethral segment between the prostatic urethra and the bladder neck were observed. Internal urethrotomy was applied to the bladder neck with a urethrotome. An urethral catheter was sent over the guide wire into the bladder. The patient was followed in the palliative care service and the catheter was removed 7 d later. No extravasation was observed in the control urethrography.

CONCLUSION

Although catheter insertion is a simple and frequently performed procedure in hospitalized patients, it is necessary to avoid unnecessary extra-indication catheter insertion.

Perceptions of a Nurse-Driven Urinary Catheter Removal Protocol in a Hospital Setting

PURPOSE/AIMS

The purpose of this study was to examine the feasibility and acceptability of a nurse-driven catheter removal protocol among nurses in a hospital setting.

DESIGN

A mixed-methods design was used. A modified version of the Abbreviated Acceptability Rating Profile was used in this study, along with 3 open-ended questions.

METHODS

Staff nurses assigned to care for nonpregnant, cognitively intact adults with a short-term Foley catheter were asked to apply a nurse-driven catheter removal protocol on the enrolled patient every 12 hours. They were asked to complete a modified version of the Abbreviated Acceptability Rating Profile and open-ended questionnaire each time they used the protocol.

RESULTS

A total of 13 questionnaires were completed (52% completion rate). Nurses reported that the nurse-driven catheter removal protocol was highly acceptable in intensive care units and intermediate care units, but not in medical-surgical units. Nurses felt that the protocol should be effective in preventing catheter-associated urinary tract infection, that they would be willing to use the protocol with their loved ones, and that overall, the protocol was helpful for their patient. However, they did not feel that their patient's risk for catheter-associated urinary tract infection was high enough to warrant using the protocol. Barriers to using the protocol as planned included encrustation, inconvenient times of day, unawareness, and a desire to follow orders and current institutional policies.

CONCLUSION

Findings from this study generally support the acceptability of the nurse-driven catheter removal protocol, particularly in higher-acuity units. Recommendations are provided to help clinical nurse specialists support adherence to these protocols.

A Novel Risk Prediction Model to Triage Difficult Urethral Catheterizations

OBJECTIVE

To construct a risk prediction model to identify cases of difficult urethral catheterizations (DUC) in order to prevent complications from improper placement.

MATERIALS AND METHODS

Using a single-institution database of urologic consults for Foley catheterizations from June 2016 to January 2020, a model to predict DUC in male patients was constructed. DUC was defined as requiring the use of a guidewire, cystoscopy, urethral dilation, and/or suprapubic tube (SPT) placement, while a simple Foley was defined as an uncomplicated placement of a regular or coudé catheter. A final model to predict DUC was constructed using multivariable logistic regression and internally validated using bootstrap statistics.

RESULTS

A total of 841 consults were identified, with 181 (21.5%) classified as a DUC. On multivariable regression, patient-specific factors as overweight BMI (OR: 1.71; P = .014), urethral stricture disease (OR: 7.38; P < .001), BPH surgery (OR: 2.47; P < .001), radical prostatectomy (OR: 4.32; P = .001), and genitourinary (GU) prosthetic implants (OR: 3.44; P = .046) were associated with DUC. Situational factors such as blood at the meatus (OR: 2.40; P < .001), and consulting team (eg, surgery OR: 4.82; P < .001) were also significant. Bootstrap analysis of the final model demonstrated good overall accuracy (predictive accuracy: 75%).

CONCLUSION

This model is a promising tool to help providers identify patients who likely require catheterization by a urologist and potentially reduce catheterization-related complications. The high rate of uncomplicated catheterizations also highlights the need for continuing education amongst healthcare professionals. External validation and application to the initial Foley encounter will shed light on its overall utility.

Catheter Balloon-trauma: Design, Development, and Ex-vivo Studies Using Intact Human Penis Specimens

OBJECTIVE

To present a novel urethral catheter design with a pilot balloon to reduce intraurethral retention balloon inflation pressures and to provide a visual alert during catheter placement.

METHODS

We manufactured our pilot balloon prototype from both molded and extruded silicone components. Various pilot balloon thicknesses were tested in order to determine the ideal compliance. We studied the filling pressures of the retention balloon of our prototype in a mechanical urethral model. The prototype catheter was then tested in ex-vivo human penis specimens obtained from gender affirming surgery and changes in the size of the retention balloon were measured under fluoroscopy.

RESULTS

The thickness of the pilot balloon was directly related to the inflation pressure of the retention balloon in the mechanical urethral model. The thickness chosen for the pilot balloon in our prototype was based on a retention balloon pressure of 70 kPa. In the ex-vivo human penis model, the presence of the pilot balloon resulted in a 40% reduction in the cross-sectional area of the retention balloon compared to a standard urinary catheter.

CONCLUSION

The prototype urinary catheter appears to decrease the filling pressure and size of an improperly positioned retention balloon inside a urethra. This can potentially reduce the risk of iatrogenic urethral catheter injuries. In addition, the prototype urinary catheter may act as a visual warning sign for the healthcare practitioner.