A practical approach to difficult urinary catheterizations

Improving outcomes in foley catheterization: A retrospective review with a proposed protocol

BACKGROUND

Urologists are commonly consulted regarding difficult and traumatic urethral catheterizations. Complications surrounding Foley catheterizations represent a significant burden to the healthcare system.

AIM

To assess the demographic and patient characteristics surrounding urological consultation for difficult and traumatic Foley catheterizations at our institution across multiple hospitals.

METHODS

This is a single-institution, multi-hospital, 263 patient, retrospective chart review from Jan 2020–December 2023.

RESULTS

The majority of consultations (80.2%) did not require heroic measures by the urology service. A Foley catheter placement was determined not difficult in the majority 191 (72.6%) of patients. Sub-group analysis of “difficult by urology” vs “not difficult by urology”, showed a significant difference between those with zero attempts, one attempt, and greater than one attempts (P = 0.004). Those patients specifically with greater than one attempts were more likely to be seen as a difficult insertion by urology assessment (60.6%) compared to not difficult (38.6%). Likewise, those patients with a history of difficult urethral catheter (DUC)/traumatic urethral catheterization (TUC) (25.8%) were more likely to be difficult compared to those without a history of DUC/TUC (14.2%) (P = 0.038).

CONCLUSION

The study found that majority of consultations received did not require heroic measures by the urology service to place a catheter. Patients who had a history of DUC/TUC and those who had greater than one catheter attempts were statistically more likely to be a DUC based on urology assessment. At our institution we hope to propose a protocol in which nursing staff and non-urologic clinicians will utilize a troubleshooting checklist and an algorithm when difficult or traumatic urethral catheters are encountered in order to improve patient care and decrease healthcare costs. For example, this protocol would ideally address complications of multiple catheter attempts such as urethral trauma, development of urethral strictures, and infection risk. Additionally, future trainings and availability of additional resources will be provided and assessed with a goal of reducing healthcare cost surrounding these complications.

A practical approach to the difficult urethral catheterization for urology trainees

Urethral catheterization is an important skill to develop as consultations for "difficult catheterization" are common in practice. Developing a broad approach to difficult urethral catheterization is crucial to improve trainee success rates. Strategies and techniques to improve catheterization success are often passed down and shared between trainees without formal documentation or dissemination of techniques. Herein, we present a framework for difficult urethral catheterization based on clinical history and patient examination, while also providing additional techniques and troubleshooting to overcome common challenges with urethral catheterization in adult and pediatric patients.

Urethral strictures - General aspects: Definition, anatomy of the urethra and its clinical application in stenosis, epidemiology, etiology, and principles of urethral reconstruction

BACKGROUND

Urethral strictures are a common and persistent pathology in urology with significant clinical repercussions. Our aim is to provide an overview of the general aspects of this condition.

METHODS

A comprehensive review of the literature from PubMed was conducted covering the period from 2020 to 2023. This was complemented by a synthesis of the latest guidelines from the American, European, and French Urological Associations (AUA, EAU, AFU), as well as references from textbooks.

RESULTS

Urethral stricture is defined by a narrowing of less than 16 French. The urethra is divided into posterior and anterior parts. The prevalence of urethral stricture is approximately 0.9%. The most common location for strictures is the anterior urethra, particularly its bulbar portion in males. The main causes are idiopathic, iatrogenic, traumatic, inflammatory, and infectious. A better understanding of urethral anatomy and histopathology provides a key element. Urethral reconstruction is based on prior urethral rest, detailed analysis of the stricture characteristics, and the use of grafts and flaps.

CONCLUSION

Urethral strictures remain a broad pathology. Their definition and epidemiology have been clarified. They require a thorough understanding of the anatomy, etiologies, and principles of urethral reconstruction to optimize management.

Expanding access to difficult urinary catheter insertion services through a novel nurse practitioner-led team

BACKGROUND

Within the United States health care system, one of the most common procedures performed daily is urinary catheterization. Oftentimes, the urinary catheter is placed by nursing personnel without any difficulty. Although the procedure is usually simple and routine, there are instances in which placement can be problematic.

LOCAL PROBLEM

Urology is one of the smallest surgical subspecialties, with intermittent availability given active commitments in the operating room and clinic. This opened an opportunity for nurse practitioners (NPs) at an urban quaternary care hospital to further enhance their skill set in the care of these patients.

METHODS

Fifteen Rapid Response Team NPs were selected based on specific criteria. Their roles expanded to include consults for difficult urinary catheter insertions.

INTERVENTION

A 2-step training program was implemented for NPs to develop proficiency in inserting urinary catheters in patients with new or known urologic conditions.

RESULTS

Of the 391 catheter consults made to the NP group, 73 (18.7%) of them required urology follow-up.

CONCLUSION

This program can benefit patients by potentially reducing catheter-related complications and associated length of stay.

A Rare Cause of Gross Hematuria Due to Placing a Patient with Distended Bladder in Prone Position

How to cite this article: Seema S, Trivedi S, Padala SRAN, Kiran M. A Rare Cause of Gross Hematuria Due to Placing a Patient with Distended Bladder in Prone Position. Indian J Crit Care Med 2023;27(1):73-74.

A PEDOT nano-composite for hyperthermia and elimination of urological bacteria

Novel modalities for overcoming recurrent urinary tract infections associated with indwelling urinary catheters are needed, and rapidly induced hyperthermia is one potential solution. PEDOT nanotubes are a class of photothermal particles that can easily be incorporated into silicone to produce thin, uniform coating on medical grade silicone catheters; subsequent laser stimulation therein imparts temperature elevations that can eliminate bacteria and biofilms. PEDOT silicone coatings are stable following thermal sterilization and repeated heating and cooling cycles. Laser stimulation can induce temperature increases of up to 55 °C in 300 s, but only 45 s was needed for ablation of UTI inducing E. coli biofilms in vitro. This work also demonstrates that mild hyperthermia of 50 °C, applied for only 31 s in the presence of antibiotics could eliminate E. coli biofilm as effectively as high temperatures. This work culminates in the evaluation of the PEDOT NTs for photothermal elimination of E. coli in an in vivo model to demonstrate the safety and effectiveness of a photothermal nanocomposite (16 s treatment time) for rapid clearance of E. coli.

A new urethral catheterisation device (UCD) to manage difficult urethral catheterisation

The cost of urethral catheterisation injury (UCI) is significant, but the true incidence of patient care error is difficult to establish in the absence of specific hospital codes recording difficult urethral catheterisation (DUC) and UCI. For many years urologists are familiar passing a non-traumatic hydrophilic guidewire blindly into the bladder to aid urethral catheter insertion in difficult circumstances. However, so far, no purpose-built regulated medical device was available on the market and clinicians had to improvise. Urethrotech filled that gap and developed the Urethral Catheterisation Device (UCD^®), which integrates a standard hydrophilic Nitinol guidewire into a 3-way 16F Silicone urethral catheter design to enable safe second-line urethral catheterisation when first-line catheterisation with a standard urethral catheter is unsuccessful. The safety and efficacy of UCD^® catheterisation were evaluated in consecutive cohorts of men undergoing cardiac surgery and compared to the incidence of DUC and UCI with standard Foley catheterisation. A simple new Male Catheterisation Algorithm is proposed that can deliver a safe male urethral catheterisation treatment protocol for all clinical settings of healthcare services, which is easy to implement and integrate into standard catheterisation training programs to manage DUC and avoid UCI, empowering a frontline workforce to deliver better patient care.

Urethral Catheterization of Buried Penis in Obese Patients: a Novel Technique and Literature Review

BACKGROUND

Urethral catheterization is a common procedure in daily medical practice and most medical staff are trained for the procedure. Buried penis in morbid obese patients with scrotal edema makes urethral catheterization challenging and sometimes fails. Different methods have been published to overcome the urethral catheterization difficulties in buried penis of obese patients.

METHODS

A 51-year-old morbidly obese male patient presented with urine retention. On inspection of his external genitalia, there was no penile shaft seen and the penis was buried within the cavity between pubic fat and severely edematous scrotum. To overcome the urethral catheterization difficulties, we used a laryngoscope which helps in visualization of the glans and external urethral meatus. The figures demonstrate the technique used.

RESULTS

Successful urethral catheterization under direct visualization was achieved.

CONCLUSIONS

The technique is well tolerated by patients and increases the overall likelihood of successful urethral catheterization.

Ultrasound-guided Placement of a Foley Catheter Using a Hydrophilic Guide Wire

Acute urinary retention is a common problem in the emergency department. Patients can present in significant distress, necessitating the placement of a urinary catheter. Foley catheter placement can be difficult to accomplish depending on the etiology of the retention and the degree of the obstruction. In the case presented here, we used ultrasound guidance, a guidewire, and a Foley catheter to successfully relieve a patient’s urinary retention after multiple failed attempts.

A Simulation-based, cognitive assessment of resident decision making during complex urinary catheterization scenarios

BACKGROUND

This study explores general surgery residents' decision making skills in uncommon, complex urinary catheter scenarios.

METHODS

40 residents were presented with two scenarios. Scenario A was a male with traumatic urethral injury and scenario B was a male with complete urinary blockage. Residents verbalized whether they would catheterize the patient and described the workup and management of suspected pathologies. Residents' decision paths were documented and analyzed.

RESULTS

In scenario A, 45% of participants chose to immediately consult Urology. 47.5% named five diagnostic tests to decide if catheterization was safe. In scenario B, 27% chose to catheterize with a 16 French Coude. When faced with catheterization failure, participants randomly upsized or downsized catheters. Chi-square analysis revealed no measurable consensus amongst participants.

CONCLUSIONS

Residents need more training in complex decision making for urinary catheterization. The decision trees generated in this study provide a useful blueprint of residents' learning needs.

SUMMARY

Exploration of general surgery residents' decision making skills in uncommon, complex urinary catheter scenarios revealed major deficiencies. The resulting decision trees reveal residents' learning needs.

Resident performance in complex simulated urinary catheter scenarios

BACKGROUND

Urinary catheter insertion is a common procedure performed in hospitals. Improper catheterization can lead to unnecessary catheter-associated urinary tract infections and urethral trauma, increasing patient morbidity. To prevent such complications, guidelines were created on how to insert and troubleshoot urinary catheters. As nurses have an increasing responsibility for catheter placement, resident responsibility has shifted to more complex scenarios. This study examines the clinical decision-making skills of surgical residents during simulated urinary catheter scenarios. We hypothesize that during urinary catheterization, residents will make inconsistent decisions relating to catheter choices and clinical presentations.

METHODS

Forty-five general surgery residents (postgraduate year 2-4) in Midwest training programs were presented with three of four urinary catheter scenarios of varying difficulty. Residents were allowed 15 min to complete the scenarios with five different urinary catheter choices. A chi-square test was performed to examine the relation between initial and subsequent catheter choices and to evaluate for consistency of decision-making for each scenario.

RESULTS

Eighty-two percent of residents performed scenario A; 49% performed scenario B; 64% performed scenario C, and 82% performed scenario D. For initial attempt for scenario A-C, the 16 French Foley catheter was the most common choice (38%, 54%, 50%, P's < 0.001), whereas for scenario D, the 16 French Coude was the most common choice (37%, P < 0.01). Residents were most likely to be successful in achieving urine output in the initial catheterization attempt (P < 0.001). Chi-square analyses showed no relationship between residents' first and subsequent catheter choices for each scenario (P's > 0.05).

CONCLUSIONS

Evaluation of clinical decision-making shows that initial catheter choice may have been deliberate based on patient background, as evidenced by the most popular choice in scenario D. Analyses of subsequent choices in each of the catheterization models reveal inconsistency. These findings suggest a possible lack of competence or training in clinical decision-making with regard to urinary catheter choices in residents.

Intermittent urethral catheterisation: the reality of the lubricants and catheters in the clinical practice of a Brazilian service

AIMS AND OBJECTIVES

To identify how catheters and lubricants have been used among patients using intermittent urinary catheterisation in rehabilitation.

BACKGROUND

The clean intermittent urinary catheterisation technique is an invasive procedure can cause discomfort, pain and urethral traumas. The use of lubricants and lubricated urinary catheters reduces the friction between the catheter and the urethral mucosa, minimising the risks.

DESIGN

A descriptive exploratory design was used.

METHODS

Quantitative and descriptive study developed at a rehabilitation centre of a University Hospital in the interior of the state of São Paulo, Brazil, at the Intermittent Urinary Catheterisation Outpatient Clinic, between June 2012-December 2014. After ethical approval, the data were collected through an interview with the support of a semistructured questionnaire, held during the nursing consultation. Among the users, patients using intermittent urinary catheterisation were interviewed, over 18 years of age and minors younger than eight years accompanied. Descriptive statistical analysis was applied.

RESULTS

Most of 214 (100·0%) patients were interviewed were male, single, young adults and with a primary medical diagnosis of bone marrow injury and myelomeningocele. Most patients perform the urinary catheterisation between four and six times per day. For the procedure, the majority uses polyethylene (polyvinyl chloride) catheter and, as a lubricant, 2·0% lidocaine hydrochloride on the catheter itself. Many mention lack of sensitivity when passing the catheter.

CONCLUSION

In the study sample, a risk of urethral traumas was evidenced, related to the inappropriate use of catheters and lubricants. For the patients' safety, the professionals need to acknowledge the importance of the appropriate use of lubricants and lubricated catheters to implement evidence-based practices that mobilise public policies.

RELEVANCE TO CLINICAL PRACTICE

The use of evidences demonstrates that the appropriate use of lubricants for intermittent urinary catheterisation is fundamental for patient safety and the performance of the best practices.

[Urethral meatus deformities and urethra hypospadias in women: prevalence, problems and definitions. Study of 12,739 patients]

The difficulty to access to the urethral meatus is found in women in relation to morphological abnormalities of urogenital or ectopic locations meatus, whether acquired (urethral meatus buried [UMB]) or congenital reality (urethra hypospadias [UH]). The pathophysiology is not unequivocal with lack of clear and specific studies.

PURPOSE

Verify the existence of specific functional problems, assess the prevalence and identify the anatomical features of UMB and UH.

MATERIALS

UMB and UH were sought in a computerized database listing the patients attending a neurourology department between 2000 and 2014 for a pelvic-perineal disease. Each case was analysed for specific reached leaks, urinary tract infections and difficulties catheterization.

RESULTS

Of the 12,739, 131 patients (1%) met the inclusion criteria, including 18 UH and 113 UMB. Ninety-one patients consulted for urinary disorders of neurological origin. The circumstances of UMB and UH discovery were: perineal systematic review in 63 cases (48%); difficulties of urethral catheterization in 65 cases (49%); urinary incontinence for 3 patients (3%). Urinary tract infections have not led to the discovery of UMB or UH. Difficulties locating the urethral meatus were congenital (UH) in 18 cases (13%). In 113 cases (87%), it was an acquired abnormality (UMB) overweight for 16 patients (12%), troublesome spasticity of the adductor muscles in 18 cases (14%), vulvovaginal atrophy in 5 cases (4%) and a patient (1%) with a pelvic organ prolapse. No details were given for the remaining 72 patients (54%).

CONCLUSION

The urethral meatus difficult access due to MUE or UH can be met in a specialized service but the exact concept of MUE be defined. It can be considered as urethral meatus difficult to access and the cause is acquired. Functional impairment may be particularly important in patients requiring catheterization for bladder emptying.

LEVEL OF EVIDENCE

4.