Assistant Program Director, John H. Stroger, Jr. Hospital; Assistant Professor

(+)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
johnbailitz@gmail.com
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.
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