Anesthetic jellies (gels), such as lidocaine 2%, reduce the discomfort of male catheterization, although this is not true in women.1,2 Lidocaine jelly may not be available, so it helps to know about the alternatives.
Diphenhydramine (e.g., Benadryl) and promethazine (e.g., Phenergan) may be used effectively as urethral anesthetics. The dose is the same, or less, than would be used orally. Inject the drug into the urethra using a bulb syringe and keep it in place for about 5 minutes using a penile clamp or equivalent. Some patients experience an initial burning sensation. The anesthesia lasts about 1 hour. To obtain more extensive anesthesia, coat a small urethral sound with an ointment of these medications and leave in it place about 5 minutes before passing larger sounds.3
Use mineral oil to lubricate urethral catheters if standard lubricating jellies are unavailable.4 In women, apply 10% cocaine jelly with a cotton-tipped applicator for an effective urethral anesthetic. Leave this in place for 5 minutes.5
Difficult Urethral Catheter Placement
Passing a urethral catheter is almost routine from the clinician's perspective. Some catheters are difficult to pass, especially in older men. When calling the urologist is not an option, the following technique may make catheter insertions more successful.
In males >50 years old, use a syringe to inject 25 to 50 mL lidocaine jelly 2% into the urethra before attempting to pass any catheter. If lidocaine jelly is not available, use any sterile gel (e.g., K-Y). If you anticipate that passing a urethral catheter will be difficult, use at least an 18- to 20-Fr Foley rather than a smaller-sized catheter. Smaller catheters simply bend if they hit an obstruction, rather than passing into the bladder. Use slow, steady pressure to insert it all the way to the Foley's hub. Do not inflate the balloon until the catheter is fully inserted and urine returns. Inflate balloons with water only; do not use normal (0.9%) saline. (See "Retained Urethral Catheters" later in this chapter.)
Use a coudé catheter if you suspect that the patient may have an enlarged prostate. A coudé catheter has a gentle upward curve at its distal 3 cm that allows easier passage through an enlarged prostate. When inserting a coudé catheter, point the tip anteriorly. This means that the balloon inflation side port should be facing up (on the same side as the curve). If the patient has a red catheter in place, it generally means that it is either a coudé or a Councill (used by urologists to pass over a guidewire). In either case, beware of removing it for replacement.
If multiple attempts at catheter placement have failed, a suprapubic aspiration using a needle and large syringe can easily buy time until a suprapubic tube can be placed or an experienced clinician can use alternative methods (e.g., filiforms and followers) to drain the bladder.
Bladder clots are reasonably common, and often cause painful obstructive symptoms. Assuming that you know why these are occurring (chronic infection, tumor, anticoagulant), treat the acute problem and ensure bladder drainage. To do this, put in a ≥4-Fr catheter. Do not place a 3-way catheter, which is normally used for continuous bladder irrigation, until the clot is removed—the opening is too small, since two smaller catheters and an inflation port must fit into the one catheter. Advance the catheter all the way. It may pass beyond the clot and allow the urine to drain. Then use an irrigation syringe to instill 60 to 120 mL aliquots of sterile water, which is more lytic than saline. Give up to 200 to 300 mL total. Then withdraw the fluid and repeat the process. If the clot cannot be removed in this fashion, a surgical approach may be necessary. If surgery is not an option, some clinicians have instilled thrombolytics.6,7
Securing Non-Balloon Catheters/Tubing
If only a straight (non-balloon) catheter or a makeshift catheter (e.g., a nasogastric tube) must be placed, the trick is securing it to the penis. After inserting the tube, secure it to the penis using three long strips of adhesive tape. First, attach about 1 inch of a tape strip to the catheter just as it exits the urethra. Lay the rest of the tape along the penis. Do the same for the two other pieces of tape. Use benzoin, if necessary, to keep the pieces in place. Then wrap one or two non-constricting circular pieces of tape around the penis to secure the long strips further (Fig. 30-1).
Securing a straight, non-balloon catheter, method #1.
Another method of securing a non-balloon catheter is to tie a suture around the catheter just beyond the external meatus and carry the ends along the body of the penis (Fig. 30-2). Secure the ends with a piece of tape, wrapping it in a spiral beginning at the catheter and then around the penis.8
Securing a straight, non-balloon catheter, method #2.
In infants, using a pediatric feeding tube as a catheter is common. Matt Steinway, MD, an urologist in Phoenix, AZ, suggests securing these with a clear adhesive dressing (e.g., OpSite) or with a suture placed through the glans and tied to the tube at the meatus. (Personal written communication, received February 2008.)
In women, securing a straight catheter may be less successful. It can be taped to the labia, after shaving.9 Alternatively, as Keyes wrote in 1917, "In the female, the (non-balloon) catheter is held in place by tying a number of silk strings to it as it issues from the vulva and fixing these to the pubic hairs in front, and by means of adhesive strapping to the lateral gluteal creases behind."10
A condom (external) catheter can easily be improvised using a normal condom and any tube that connects to the collecting bottle or bag. Slip the end of the tube completely into the condom. Make a small hole at the end of condom, but don't pass the tube through it or it will rub against the penis. Tie the end of the condom tightly around the end of the tube and invert the condom so it dangles free of the tube (Fig. 30-3). Put the condom over the penis and secure it with tape around the penis, extending the tape onto the anterior abdomen.
Condom catheter. Putting it on (left) and in place (right).
Cleaning Reusable Catheters
For intermittent catheterization of the same patient, clean catheters as follows:
Wash the catheter using plain liquid soap (without deodorant or fragrance); rinse well until the soap residue is gone. Shake out any excess fluid, air dry the catheter, and then place it on a clean paper towel or in a clean basin. Alternatively, soak the catheter for 30 minutes in a homemade vinegar solution (one part white vinegar to three parts room-temperature water). Rinse, thoroughly shake out excess water, and air dry.
Store the washed catheters in a clean zip-top bag, tampon case, toothbrush holder, small camera case, or other clean container. Discard reusable catheters when they become hard, brittle, or cracked, or when they change color.11
Retained Urethral Catheters
Retained urethral catheters (those that cannot easily be removed by simply deflating the balloon) are a common problem. The longer the catheter is left in place, the more chance this will occur. Most often, the inability to deflate the balloon is due to either a complete or a partial obstruction of the catheter's inflation canal.
The first step should be to cut off the balloon valve. If that is the problem, as it often is, the balloon deflates and can be removed. If not, pass a thin wire, such as a wire from a catheter introducer, through the balloon port to either burst the balloon or alter its shape so that it can be removed.
A number of methods may be used to deflate the balloon and remove the catheter. These include injecting ether,12 liquid paraffin (kerosene), chloroform,13 or toluene14 to dissolve the balloon, although these may cause chemical cystitis to varying degrees.15,16 A common practice in some developing countries has been to deflate the balloons in malfunctioning urethral catheters by injecting 2 to 3 mL of mineral oil through the balloon port.4 The balloon deflates (ruptures?) within about 2 hours.17 Even though mineral oil is inert and generally considered innocuous and causes no discomfort to the patient, reports have suggested that the presence of mineral oil in the urinary tract may cause oil granulomas in a small number of patients.18
The balloon can also be punctured by using a suprapubic, transvaginal, or perineal approach.19-21 Use these methods, with or without ultrasound guidance, only after other methods have failed. For the suprapubic approach, use the stylet from an 18-gauge spinal needle. With the catheter balloon pulled against the floor of the bladder, direct the stylet vertically downward until the balloon is punctured or the entire stylet has been introduced. If this is unsuccessful, withdraw the stylet and reinsert it progressively caudally or cranially, 10 to 15 degrees from vertical. In men, the mean angle for puncture is 2 degrees cephalad of vertical; in women, it is 17 degrees caudal of vertical.20
One concern is that pieces of the punctured balloon may be retained in the bladder, causing irritation and infection. While this seems to occur frequently with in vitro tests,16 in practice, it is rarely seen.22 The chances of this seem to be lessened if catheter balloons with a 30-mL capacity have ≤40 mL of fluid injected before puncture; balloons with a 10-mL capacity should have ≤15 mL before puncture.16
A relatively simple method of deflating these balloons is to inject the balloon with normal saline until it bursts, which may take up to 500 mL! If the inflation canal is blocked at its proximal port so no fluid can be injected, pull the catheter so that its original light brown color is visible. At that point, clamp the catheter so it does not retract and cut it. Then carefully insert a 21-gauge needle with an attached syringe into this part of the exposed inflation canal and either deflate the balloon or, more commonly, inflate it until the balloon ruptures; then remove the catheter. This reportedly works ≥90% of the time.22 Use this technique cautiously, since if the Foley is misplaced (such as in the urethra), overinflating the balloon could cause significant pain and, possibly, damage to the patient.
Rarely, an encrustation on the end of the catheter blocks removal. This may require surgical removal of the catheter.
Alternative Urine Collection Bags/Systems
Use old IV or irrigation bottles, rather than disposable urine collection bags, to collect urine from urethral catheters. Make tubing for the bottle from an old intravenous set (Fig. 30-4). Put a tape on the side of the bottle and mark it as you add water in 100-mL increments (Fig. 30-5). Empty the bottle, put a hole in the lid for the tube, and it is ready to collect and measure urine output.
Empty IV bottle used for urinary drainage.
Improvised collecting jar with volume measurements. (Adapted from Olson.23)
Pediatric urine collection bags (a technique not useful for urinalysis or culture) can be made inexpensively from disposable plastic bags, adhesive tape, old IV tubing, and waxed paper (or something similar).24 (For details, see Fig. 5-10 in Chapter 5, Basic Equipment, and "Urine Collection" in Chapter 34, Pediatrics and Neonatal.)