URETHRAL CATHETERISATION ANATOMY OF URETHRA INDICATIONS FOR URETHRAL

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. 2 nd ed. Philadelphia: WB Saunders Company, 1998.

ANATOMY OF THE FEMALE URETHRA 4 cm 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=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 1 mm diameter = 3 Fr Example: 18 Fr catheter = 6 mm in diameter Catheter sizes refer to the OUTSIDE diameter

TYPES STRAIGHT, NO BALLOON FOLEYS/BALLOON Nelaton 2 way = 2 ports “In-Out” catheterisation Clean intermittent self-catheterisation 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 Urine drains Urine doesn’t drain Inflate bulb Flush with 50 ml syringe (50 ml) Can’t aspirate fluid Catheter not in bladder Don’t inflate bulb Can aspirate fluid Catheter in bladder Inflate bulb

CAN’T GET CATHETER IN Two tubes of lubricant Coude’-tip catheter Ask colleague with experience Supra-pubic catheter

FEMALE CATHETERISATION Position patient Frog leg Knees bent and apart with feet on the bed Separate labia with non-dominant hand 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 GOOD LIGHT Use speculum , do under vision Get assistant to spread labia Put finger in vagina, guide catheter on top of finger into urethra

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 5 ml 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 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