(+)John M. Bailitz, MD, FACEP Assistant Program Director, John H. Stroger, Jr. Hospital; Assistant Professor of Emergency Medicine, Rush University Medical College, Chicago, Illinois “Urine” Trouble: How to Deal With a Problem Foley Foley catheters are frequently used in the emergency setting. What happens when that “simple” Foley placement suddenly isn’t so simple? This presentation will describe methods of bladder decompression, complications that can occur during placement attempts, and ways to restore flow to an obstructed Foley. In addition, the management of hematuria after a failed or successful Foley attempt will be discussed. Various critical management decisions, including when to consult a urologist and which patient to admit, will also be discussed. • Describe the proper method of Foley placement. • Describe indications for and methods of Kudet catheter placement. • List the various bladder decompression options, including surgical options. • Describe the management of hematuria after a failed Foley attempt. • Describe the management of hematuria in patient with an indwelling Foley. WE-199 Wednesday, October 7, 2009 10:00 AM - 10:50 AM Boston Convention & Exhibition Center (+)No significant financial relationships to disclose Urine Trouble: How to Deal with a Problem Foley John Bailitz, MD Assistant Program Director Cook County Emergency Medicine Residency Assistant Professor of EM, Rush University Medical School [email protected] Lecture Description: Foley catheters are frequently used in the emergency setting. What happens when that “simple” Foley placement suddenly isn’t so simple? This presentation will describe methods of bladder decompression, complications that can occur during placement attempts, and ways to restore flow to an obstructed foley. In addition, the management of hematuria after a failed or successful foley attempt will be discussed. Various critical management decisions, including when to consult an urologist and which patient to admit, will also be discussed. Objectives: • Describe the proper method of Foley placement. • Describe indications for and methods of Coude catheter placement. • List the various bladder decompression options, including surgical options. • Describe the management of hematuria after a failed Foley attempt. • Describe the management of hematuria in patient with an indwelling Foley. Code Yellow: Ambulance call: Code Yellow coming in. 67 year old with a history of BPH with inability to urinate x 24 hours. Took extra water pills and drank extra coffee to help it come out. BP: 210/110 HR: 105 RR: 20 Pox: 98% T: 100.2 PEX: Sweaty and grabbing bed. 18 week bladder. Key Questions: What do we try first to decompress his bladder? What do we try second to decompress his bladder? Foley Placement: The Basics Equipment: Size matters. • Insert the smallest catheter possible to prevent urethral trauma, obstruction of the peri-urethral glands and subsequent infection. • Remember a 12 French (Fr / 3 = mm of outer diameter) red rubber catheter (1 lumen) will have a bigger internal lumen than an 16 french irrigation catheter with balloon port (3 lumens) Patient Choosing the Right Size (Fr) Neonates 2-5 Feeding tube. and Infants Children 5-12 Red Rubber or Foley Adult 14 Failed 14 or BPH 14-18 Coude or Larger 18-22 Foley Procedure: Sterility essential since sloppy technique significantly increases the risk of UTI.1. 1. Before procedure: a. Retract foreskin and warp in gauze prior to start of procedure. Be sure to remove the gauze and restore the foreskin after the procedure. b. Apply betadyne to meatus. With sterile technique inject 5-10 ml of viscous lidocaine and clamp urethra for 5-10 minutes urethra for initial distention and anesthesia in men 2. Smaller amounts may be helpful in female patients especially those with vaginal inflammation. c. Test balloon. 2. Nondominant Hand: Expose Meatus a. Males: Nondominant ring and middle finger secure the penile shaft and foreskin leaving index and thumb free to manipulate the catheter. b. Females: Nondominant thumb and index finger spread labia. c. Once meatus exposed then nondominant hand is not moved. 3. Dominant Hand: Insert Catheter a. Cleanse again with Betadyne. b. Insert catheter with slow steady pressure. To the hub in males and at least ½ way in females. If resistance is met on insertion, have patient relax pelvis, and proceed with slow gentle pressure. c. Only when inserted to the appropriate depth, inflate balloon with air or water. If resistance or significant discomfort occurs, then deflate and reposition to hub. If still unsuccessful, remove catheter and reinsert. 4. With successful passage and balloon inflation, withdraw catheter slightly until balloon lodges at bladder neck. 5. Connect to a closed system drainage bag or leg bag. a. With drainage bag, secure catheter in males to lower abdomen to reduce traction and left thigh in females. b. Fasten leg bag to lower thigh and upper calf. Educate patient and family on catheter and leg bag care. What to try when the Foley won’t go in a male patient: Remember the urethra is 20 cm of discomfort. • Anesthesia with 5 ml of lidocaine jelly 5 minutes prior to procedure for initial distention and anesthesia. 3 Key Sections: • • • Penile Urethra: Irish 3 cm. Irish cold Male Urethra Anatomy: Membranous 1cm. All others variable. Most likely site Urethra is the most common stopping of urethral stricture. point. Membranous Urethra: About 16 cm from meatus and 4 cm from bladder neck at the urogenital diaphragm encompassed by external urethral sphincter. o Hold penis taut and upright to prevent kinking here. o Ask patient to breathe out slowly and relax the pelvic floor and hence external urethral sphincter. Plantar flexion of feet and toes will also help relax the sphincter. Maintain slow gentle pressure, striated muscle will eventually fatigue and allow passage. o Digital Assistance: Occasionally catheter will become lodge posteriorly just before urogenital diaphragm. With nondominant hand apply perineal pressure between anus and scrotum to dislodge dip anteriorly. o In patients with BPH, bladder displaced superiorly and anteriorly. Perineal pressure may not be adequate. Insert index finger into rectum and direct tip anteriorly. 3 o Urine may start to flow just past this point, but don’t’ inflate balloon yet! Prostatic Urethra: Another 3.5 cm long Perineal Push: Rectal push with BPH If 14 Fr foley won’t go then: • Go bigger: 18 Fr . • Go curved. Coude Cather = Catheter with curved tip and small ball on end to slide past narrow portions or urethra. Use first in patients with known BPH, urethral stricture, valves, or narrowing. Keep elbow anterior while inserting by noting mark on proximal connector. What to try when the Foley won’t go in a female patient: 4 cm urethra lying below clitoris atop vagina. Meatus may be hidden in neonates, anxious patients, cystourethrocele patients, and the elderly. • Neonates: First of three orifices • Nervous Female: Get rid of the nervous medical student. Lithotomy position. Ask the patient to breathe out slowly and relax the pelvic floor as above. • • Elderly Patients and Cystourethrocele: Meatus may recede superiorly into top of vaginal vault. Insert index and middle finger of nondominant hand into superior vagina and palpate, elevate and visualize. Obese patients: Use assistants and a vaginal speculum to open labia and expose meatus. When should I call the urologist? • Before the Foley: Post op patients. Especially those post radical prostatectomy or complex urethral reconstruction. 4 • After a failed foley: If the all the foley tricks above fail, call your urologist before attempting advanced procedures described below. Back to our code… Nothing is working. Patients: 220/120 HR: 110 RR: 20 and swearing. Pox: 98% T: 100.2 Sweating Profusely. Bladder at 20 weeks. Our Vitals: BP: 220/110 HR: 110 RR: 20 Pox: 98% T: 100.2 Key Questions: What do we do when the Foleys, coudes and tricks aren’t working? Filiform and Followers • Never use manual force with a foley catheter to dilate a urethral stricture. Simply worsens cycle of bleeding, false passage and scarring. • Purpose and Indications: Locate and negotiate a strictured urethral segment. Urethral stricture typically results from trauma, infection, instrumentation, or long term indwelling catheter damage or mechanical stricture from BPH or bladder neck contracture What is a Filiform? A Follower? Filiform: Very narrow, flexible, solid catheters used to locate and successfully navigate a strictured area in the urethra. • Distal End: Straight or Curved • Proximal End: Female threaded end to connect to male end of follower. Follower: Flexible hollow catheters that insert onto filiform to enter the bladder. • Distal end: Male connector wit hole to allow urine drainage • Proximal end: Open and accepts Christmas tree adapter for connection to drainages bag. • Come in a variety of sizes to allow progressive dilation of a stricture. Multiple Filiforms to Fill Areas of Stricture Attach follower to filiform. How to: Learn from a Urologist First3, 5 . 1. Lidocaine and IV Sedation 2. Slowly pass filiform by feel with gentle pressure and twisting motion. 3. Resistance often due to urethral stricture or fold. Do not force. Instead withdraw slightly, rotate 90-180 degrees and gently reinsert. 4. If resistance is again encountered, leave in this filiform in to fill passage (A). 5. Insert a second filiform alongside the first. Three to four in may be needed to successfully pass an area of stricture (B and C). 6. Success = Effortless passage of filiform into bladder without spontaneous extrusion upon release. Extrusion means filiform has not negotiated stricture and requires replacement or additional filiform. 7. Advance until thread coupling near meatus and attach the smallest size (8 Fr) dilating follower (A). Lubricate the follower and insert. 8. Side drainage holes of follower allow urine drainage when properly placed. Proper placement = Urine out (B). With easy and bloodless (no blood at thread when changing to next size) placement of follower without urine out, then drainage hole likely occluded by gel. Gently irrigate or apply negative aspiration to follower to dislodge gel and get urine return (C). 9. Repeat the dilating process until a follower once size larger than catheter has been inserted. Then remove the follower and filiform. 10. Apply additional lidocaine. Insert appropriate size Coude catheter. 11. If unable to dilate a dense and irregular urethral stricture, leave filiform and follower in place for 24 hours pending follow up with urologist. Tape to penile shaft with longitudinal not circumferential strips of paper tape. Now we’re in trouble! Filiforms and Followers leave a bloody mess but no urine out. Now he is really really mad! Patients BP Now 250/140 HR: 115 RR: 20 and swearing in multiple languages. Pox: 98% T: 100.8 Sweating Profusely. Our Vitals: BP: 250/140 HR: 115 RR: 20 and swearing Pox: 98% T: 101.0 Key Questions: What do we do next after Foleys, coudes and filiforms have failed? Suprapubic Catheter Placement 2, 3, 5: • Indications: Emergent bladder decompression in a patient who urethral catheterization is not possible. o Trauma patients: Complete urethral transection is the absolute indication. o Urethral stricture o Complex prostatic disease • Contraindications o Unable to define bladder due to body habitus or lack of an US machine. Never a blind procedure! Just wait for bladder to fill. o Bowel adhesions to lower anterior abdominal wall due to prior lower abdominal surgery or irradiation. o Bleeding diathesis o Bladder Cancer Common Options • Cook Peel Away Catheter recommended by experts for ED use 5. Uses familiar Seldinger technique to gain bladder access and results in placement of traditional foley into bladder. • Trocar Type: Multiple varieties. Cystocath one of the best. Contains all needed materials in one kit, in 8-12Fr sizes, and can be used for long periods of time. • MacGyver: Temporary decompression with spinal needle buys your 4-8 hours. . Procedure for Cook Peel Away Sheath Suprapubic Catheter 1. Remove hair and prep the skin. Anesthetize with lidocaine first with a wheal 4 cm above pubic symphysis in the midline. Using a 22 gauge spinal needle infiltrate along tract at 60 degree angle to the skin towards the feet (finder needle for trocar technique) while aspirating for urine. Once urine aspirated, advance an Cook Peel Away Catheter Placement 2. 3. 4. 5. 6. additional 2 cm. Hold the needle against the anterior abdominal wall (A). Remove syringe and insert guidewire (B). Make small incision into skin to accommodate sheath and dilator. Pass sheath and dilator together over the wire into the bladder (C). Remove guidewire and dilator leaving sheath in the bladder (D-E). Insert foley catheter 2 Fr smaller than sheath through sheath into bladder. Inflate foley balloon with 10ml of air (F). Withdraw sheath from abdominal wall. Peel away sheath leaving foley in place (H). Withdraw foley to lodge balloon against cystostomy site (J). Procedure for Trocar type kits3: 1. Carefully note depth and angle of insertion at which urine is aspirated with spinal needle as above. 2. Make a 4 mm stab incision through the skin wheal and place tip of (needle tip) obturator catheter unit in incision. 3. Grasp the tip of the obturator catheter unit with the nondominant thumb and index finger on the abdominal wall to stabilize and thereby control angle and depth during insertion (A). Trocar Placement 4. Advance the obturator catheter unit with the dominant hand. Expect resistance at the linea alba. Puncture but do not Plunge! Resistance is felt again when the tip is against the anterior bladder wall. With short stabbing motion, advance into bladder. Urine flow confirms correct placement of the obturator catheter unit. If no flow, then attempt aspiration to dislodge clotts or tissue. Advance an additional 2 cm. 5. Inflate balloon of catheter (B). Unscrew the obturator from the catheter. Hold the catheter now with nondominant hand at the abdominal wall. Remove the obturator from the catheter (C). Attach stopcock at the distal end of the connector tube to the catheter (D). Gently withdraw to lodge catheter against the bladder. Correct placement confirmed when urine returns and catheter easily flushed. • If easily flushed, but no return, then likely in perivesicular space. • If cannot flush and no return then catheter likely kinked. • Tract matures at 7-14 days. For patients whose chronic suprapubic catheter came out, Go ahead and just stick in a new catheter through the stoma. Complications: Prevention and Treatment • Bowel perforation: Be sure bladder if filled and defined. • Intraperitoneal extravasation: Be sure last hole in cystocath is in bladder not peritoneal cavity. • Extraperitoneal extravasation • Infection: Apply antibiotic ointment and gauze dressing. Deeper infections may still develop. • Obstruction: Irrigate as below. • Tube dislodgment: Careful positioning and securing of non-balloon catheters essential, inflate Foley balloons to 10ml, careful patient transfers. Code Yellow Returns! Suprapubic catheter in position. But he’s peeing around the catheter. Patient: BP 160/90 HR: 105 RR: 20. T 99.8. Suprapubic catheter in position. Urine leaking around catheter. Key Questions: How do you restore flow to an obstructed foley? Is the catheter really obstructed or is it just bladder spasms? Flush Test: • Flushes Easily = Bladder Spasms. Treat with antispasmodics such as oxybutynin, flavoxate and dicyclomine. • Will not flush = Obstructed. Replace. Encrustations: Long term catheters commonly obstruct from encrustations. Typically result from infection with urease splitting bacteria such as Protease that cause alkaline urine and precipitation of compounds such as magnesium sulfate (struvite) and calcium phosphate (apatite)6 . • Increases risk of obstruction from infected stones and blood clotts from rolling stones. • Management: o Irrigation o Methenamine (prophylactic antibiotic therapy) with urinary acidification. o Replacement – Sometimes easier said than done. Code Yellow turns Red! Wife grabs you from the hall and says – Now he is bleeding! Patients BP Now 140/90 HR: 90 RR: 20. T 99.8 Still swearing. Key Questions: How do we manage hematuria after an unsuccessful foley attempt? How do we manage hematuria after a successful foley attempt? Management of hematuria after an unsuccessful foley attempt: Iatrogenic urethral trauma typically anterior (distal to urogenital membrane). 7. • One more gentle attempt: Anesthesia, positioning, equipment, relaxation. • Filiforms and followers: Definitely talk to the urologist first. • Guide Wire Guided Catheter placement. Best left to the urologist due to possible creation of a false passage and subsequent passage of a foley nicely into. • Suprapubic Catheter Placement • Flexible cystourethroscopy. Water instillation clears bleeding and allows visualization of injury, foley placement and stenting of injured segment. Retrograde urethrogram: To diagnose site of stricture and or injury. • Partial Injury (Small amt of contrast extravasation with contrast in the bladder): Consider one more gentle try after calling the urologist. 8. • Complete Injury (Extravasation with no contrast in bladder): Requires suprapubic catheter. Management of hematuria after a successful foley attempt: Multiple Clinical Scenarios. • Post-obstructive diuresis and hemorrhage: Formerly believed that rapid decompression of a distended bladder resulted in hematuria, hypotension and post-obstructive diuresis requiring gradual decompression to prevent. No longer the case. 4, 9, 10 o Your BP would drop too. o If urine output > 200ml/hour for > 4 hours then recheck Na and admit for observation. • Microscopic Hematuria Detected on UA Post Foley Placement: Microscopic hematuria (not visible to the eye) = > 5 RBC’s/HPF on a single sample. o 1-3 RBCs/per High powered field in normal since actually about 1 million RBC’s normally pass into the urine each day. o Small increase not unusual but any increase > 4 RBC per high powered field should be investigated for likely upper tract (kidney) disease 5. • Hematuria as a reason for foley placement to begin with or the patient who returns after a foley placement who now has gross hematuria. Gross Hematuria = Visible with the eye. Requires only 1ml of blood per liter of urine. o Most commonly results from lower tract disease including cancer, stones, or infection, as well as iatrogenic causes including TURP and intravesical delivery of chemotherapy or antifungal agents o Normal saline irrigation to prevent obstruction • o High powered (Manual Toomey Syringe) bladder irrigation: Necessary if large clotts are obstructing foley. Better to use larger lumen of foley rather than smaller lumen of triple lumen irrigation catheter.11 o Continuous bladder irrigation with NS using gravity only until urine almost clear. 12 Urethral injury suspected after a Foley placed: With high clinical suspicion of urethral injury with Foley in place, a pericatheter urethrogram must be performed with foley in place. If positive, foley remains in for 4-6 weeks. References: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Sedor J, Mulholland SG. 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