Managing the Foley catheter

Author: Leopoldo C. Cancio, Ian M. Thompson
Date: Oct, 1993

Urethral catheterization of the bladder with a Foley catheter is one of the most common invasive procedures performed in hospitalized patients. A seemingly innocuous procedure, catheterization is not without complications, some of which are serious.

Illustrative Cases

CASE 1

A 60-year-old man was admitted to the hospital for emergency esophageal surgery and spent four and one-half months in the intensive care unit. The same indwelling urethral catheter remained in place throughout this period, primarily to assist with fluid management. At some point it was noted that the catheter had eroded inferiorly, creating a groove in the glans penis. At the time of urologic consultation, anasacra prevented replacing the urethral catheter with a condom catheter, and a suprapubic catheter was placed instead. The laceration was treated conservatively.

CASE 2

A combative 37-year-old man who had been admitted to the hospital for poisoning pulled on his urethal catheter but failed to remove it entirely. Passage of gross blood clots, with cessation of urine output, was later noted. Attempts at irrigation through the catheter were unsuccessful, and it was therefore removed. Several subsequent attempts to pass a variety of catheters were unsuccessful because of an apparent false passage in the bulbar urethra; for this reason, a suprapubic catheter was placed.

Several weeks later a retrograde urethrogram showed a possible urethral stricture. A voiding cystourethrogram was equivocal. At cystoscopy, no stricture was found, but a false passage distal to the external urethral sphincter was discovered. The suprapubic catheter was subsequently removed, and the patient was able to void without difficulty.

Catheter Insertion

Techniques to aid in the insertion of the urethral catheter are presented in Table 1. Sterile procedure is often recommended to help prevent subsequent urinary tract infection, but little data support this practice. Still, it seems reasonable to limit the catheterization procedure to physicians, registered nurses or other staff appropriately trained in performing the procedure.

TABLE 1Tips for Urethal Catheterization of the BladderChoose sterile technique and insertion by trained personnel.Use a large-caliber catheter in patients with benign prostatichyperplasia, asmall-caliber catheter in patients with stricture.Remember, if a no. 14 French catheter won't pass, a smallercatheter willnot pass either.Use a coude catheter for difficult catheterization in males.Lubricate the urethra, not just the catheter.Apply perineal pressure during catheter insertion to direct thecatheter intothe prostatic urethra.Never force a catheter - try something else.Confirm location before balloon inflation by catheteraspiration (urine orirrigant fluid).Tape the catheter securely in the correct anatomic position (onthe abdomenfor men, on the thigh for women).

LUBRICATION

Copious lubrication, achieved by the injection of 10 t0 20 mL of sterile lubricant into the urethra, eases the procedure in male patients with difficult anatomy. In our experience, this technique is more effective than simply lubricating the tip of the catheter. Injection of the lubricant may be done before sterile preparation, although ideally it should be done after. Using 1 percent lidocaine jelly (10 mg per mL) as the lubricant rather than surgical lubricant makes the procedure more tolerable for the patient and may prevent sphincter spasm.

Because of a theoretic, although unreported, risk of injection of lubricant through the urethra into the venous system, excessive force must be avoided, and less than 3 mg per kg of lidocaine should be used. Tubes of lubricant for urethral instillation may be available. If not, a simple substitute is a 60-mL catheter-tip syringe. The plunger is removed, and the syringe is filled with lubricant. The plunger is then replaced and 10 to 20 mL of lubricant are gently injected into the meatus.

CATHETER SIZE

A small catheter (no. 16 or no. 18 French) is preferred because it is likely to be better tolerated and to cause less urethral reaction.[1] If obstruction is encountered, however, catheter size should be governed by the type of obstruction. The type of obstruction can sometimes be surmised by its location. Obviously, a blockage encountered soon after entering the meatus is due to a stricture, not benign prostatic hypertrophy. A past history of instrumentation (e.g., TURP) also suggests a stricture.

A frequent mistake is to use smaller and smaller catheters when confronted with an obstruction due to presumed benign prostatic hypertrophy. Instead, a larger catheter, such as no. 20 to no. 24 French, is often best, because the larger catheter is firmer and better able to push its way past the obstructing prostate. It is also less likely to kink at the bladder neck. On the other hand, a smaller-than-normal catheter (no. 14 to no. 16 French) is indicated for a patients with a presumed stricture.

CATHETER TYPES

A variety of catheter shapes is available. The coude catheter (Figure 1) is angled upward at the tip to assist in negotiating the upward bend in the male urethra as it passes through the prostate. This feature facilitates passage through a bladder neck that is elevated due to benign prostatic hypertrophy and avoid urethral injury in the membranous or bulbar urethra. Triple-lumen catheters, generally used only by urologists, allow continuous bladder irrigation with normal saline solution, which prevents clot formation and obstruction in patients with gross hematuria.

Foley-type catheter balloons are either 5 mL or 30 mL in capacity. The 30-mL balloon catheters are used primarily to facilitate traction on the prostate gland to stop bleeding. The larger balloons may be associated with a higher incidence of complications, especially if they are underinflated, and should not be left in place longer than two or three days.[2]

CATHETER PLACEMENT

As the catheter is passed into the urethra, perineal pressure applied by an assistant may help the catheter negotiate the anterior bend into the prostate and avoid a false passage.

Excessive force should never be used during catheter insertion. The necessity for force is a sure sign that the catheter is going in the wrong direction and the urethra is being damaged.

Before the balloon is inflated, catheter location must be confirmed, to prevent significant urethral trauma. Normally, once the catheter enters the bladder, a good flow of urine confirms its location, and the balloon can be inflated. At times, however, there will be no urine return, either because there is no urine in the bladder, the catheter is not in the bladder or the catheter port is occluded by lubricating jelly (the most common reason).

To determine the reason for a lack of urine flow, the catheter should first be aspirated; a good urine flow indicates proper position. If urine flow is still absent, the catheter can be gently irrigated with 30 to 60 mL of sterile water or saline. Return of all irrigant confirms proper catheter position, but pain or incomplete fluid return should prompt suspicion of false passage of the catheter. In addition, the catheter should be inserted far enough into the bladder that, after inflation of the balloon, the catheter can be easily pulled down until the balloon seats at the bladder neck. This avoids inflation in the prostatic fossa with the tip protruding into the bladder.

Sterile water should be used for inflation of the balloon. Normal saline or other electrolyte solutions carry the risk of crystallization over long periods, which may prevent subsequent balloon deflation. Air may diffuse out of the balloon over a period of time, resulting in balloon deflation.

The catheter should be taped to the patient in a neutral position without tension. Failure to tape the catheter allows traction to cause dislodgment of the catheter or urethral pressure necrosis. The catheter should follow the natural curve of the urethra. In men, this means that the catheter should be taped to the anterior abdominal wall, not to the thigh. In women, the thigh is appropriate. Four-inch tape is recommended.

Routine Management

The physician should routinely inspect the catheter and the meatus. Examination should ensure that the catheter is properly taped and that there is no meatal damage. If the patient is disoriented and combative, restraints may be necessary to prevent significant urethral trauma; the catheter should be removed if possible. Nursing care of the urethral catheter involves cleaning the meatus daily with soap and water only. The seals between the catheter, the collection tube and the drainage bag must not be broken.

Complications

Complications, listed in Table 2, include bacteriuria and infection, as well as urethral, bladder and catheter complications.

Indwelling catheters are prone to develop encrustations, because of the relative saturation of urine with substances such as struvite, calcium oxalate, calcium phosphate and organic material.[21] The catheter may eventually be obstructed by the encrustation, leading to urine leakage around the tube or to acute urinary retention. Encrustation may reflect metabolic differences among patients; an occasional patient may require a catheter change as often as every seven to 10 days.[28]

Catheters can also become obstructed by blood clots. Clots create a one-way valve effect, allowing irrigant to be pushed into the catheter but not withdrawn; this situation mimics the effect of a catheter placed extravesically (e.g., in a false passage or in the urethra). The bladder is irrigated through the catheter, using a 60-mL syringe and 1 L of normal saline solution, to evacuate gross clots and determine the rate of continued bleeding. If the irrigant clears, no immediate further treatment may be necessary. If it fails to clear, hospital admission for continuous bladder irrigation with a triple-lumen catheter and cystoscopy may be required.

Retained prostate "chips" are a possible cause of obstruction in a patient who has had a recent TURP.

Alternatives to the Urethral Catheter

Urethral catheters are commonly left in place to assist with fluid management of a seriously ill patient or the daily care of an incontinent patient. In view of the problems, however, it is clear that alternatives to an indwelling catheter should be aggressively pursue on a daily basis. These possibilities include spontaneous voiding, clean intermittent catheterization, external condom catheterization and suprapubic catheterizatio.[29] Each of these options has advantages and disadvantages. The best choices are spontaneous voiding if the patient is able to void with less than 60 to 100 mL residual urine, and clean intermittent catheterization if the patients is not.

Spontaneous voiding in the incontinent, bedridden patient may hasten the development of decubitus ulcers, but with attentive nursing care, anticholinergic medications and fluid restriction, this option is often an excellent choice for many patients.

Clean intermittent bladder catheterization remains the optimal approach for the patient who is unable to void. Although this technique requires extra effort by the patient and/or the caregiver, the reduced risk of infection, stones or urethral complications merits a full-fledged attempt.

External condom catheterization is a viable alternative but can cause maceration of the glans penis and is often associated with ascending infection.

Long-term suprapubic catheterization has not been adequately studied, but this method may, in our opinion, reduce the incidence of urethral or prostatic infection when compared with the use of an indwelling urethral catheter. However, a study[30] of patients with spinal cord injuries showed an increased risk of renal damage. Long-term suprapubic catheterization is also not protective against squamous cell carcinoma.[20] Further study is required before suprapubic catheterization can be routinely recommended.

REFERENCES

[1.] Getliffe KA, Mulhall AB. The encrustation of indwelling catheters. Br J Urol 1991;67:337-41. [2.] Kelly TW, Griffiths GL. Balloon problems with Foley catheters [Letter]. Lancet 1983;2(8362):1310. [3.] Haley RW, Culver DH, White JW, Morgan WM, Emori TG. The nationwide nosocomial infection rate. A new need for vital statistics. Am J Epidemiol 1985;121:159-67. [4.] Moody ML, Burke JP. Infections an antibiotic use in a large private hospital. January 1971. Comparisons among hospitals serving different populations. Arch Intern Med 1972;130:261-6. [5.] Martin CM, Bookrajian EN. Bacteriuria prevention after indwelling urinary catheterization. Arch Intern Med 1962;110:703-10. [6.] Warren JW, Muncie HL Jr, Hall-Craggs M. Acute pyelonephritis associated with bacteriuria during long-term catheterization: a prospective clinico-pathological study. J Infect Dis 1988;158:1341-6. [7.] Platt R, Polk BF, Murdock B, Rosner B. Mortality associated with nosocomial urinary-tract infection. N Engl J Med 1982;307:637-42. [8.] Warren JW. The catheter and urinary tract infection. Med Clin North Am 1991;75:481-93. [9.] Kass EH. Chemotherapeutic and antibiotic drugs in the management of infections of the urinary tract. Am J Med 1955;18:764-81. [10.] Roberts JB, Linton KB, Pollard BR, Mitchell JP, Gillespie WA. Long-term catheter drainage in the male. Br J Urol 1965;37:63-72. [11.] Kunin CM, McCormack RC. Prevention of catheter-induced urinary-tract infections by sterile closed drainage. N Engl J Med 1966;274:1155-61. [12.] Garibaldi RA, Burke JP, Dickman ML, Smith CB. Factors predisposing to bacteriuria during indwelling urethral catheterization. N Engl J Med 1974;291:215-9. [13.] Sotolongo JR Jr, Gribetz ME. Large caliber urethral false passage after catheterization: a case report. J Urol 1982;128:819-20. [14.] Hockberger RS, Schwartz B, Connor J. Hematuria induced by urethral catheterization. Ann Emerg Med 1987;16:550-2. [15.] Sklar DP, Diven B, Jones J. Incidence and magnitude of catheter-induced hematuria. Am J Emerg Med 1986;4:14-6. [16.] Barnes-Snow E, Luchi RJ, Doig R. Penile laceration from a Foley catheter. J Am Geriatr Soc 1985;33:712-4. [17.] Steidle CP, Mulcahy JJ. Erosion of penile prostheses: a complication of urethral catherization. J Urol 1989;142:736-9. [18.] Zimmern PE, Hadley HR, Leach GE, Raz S. Transvaginal closure of the bladder neck and placement of a suprapubic catheter for destroyed urethra after long-term indwelling catheterization. J Urol 1985;134:554-7. [19.] Ekelund P, Anderstrom C, Johansson SL, Larsson P. The reversibility of catheter-associated polypoid cystitis. J Urol 1983;130:456-9. [20.] Locke JR, Hill DE, Walzer Y. Incidence of squamous cell carcinoma in patients with long-term catheter drainage. J Urol 1985;133:1034-5. [21.] Merguerian PA, Erturk E, Hulbert WC Jr, Davis RS, May A, Cockett AT. Peritonitis and abdominal free air due to intraperitoneal bladder perforation associated with indwelling urethral catheter drainage. J Urol 1985;134:747-50. [22.] O'Gorman S, O'Brien A, Leahy A, Butler MR, Keane FB. Rectovesical fistula due to indwelling catheter. Br J Urol 1990;65:424. [23.] Bisset R. A technique for the removal of retained balloon bladder catheters [Letter]. Br J Radiol 1988;61:977-8. [24.] Naunton Morgan TC, Barrett NK, Boultbee JE. Simple procedure for the removal of a non-deflating balloon bladder catheter: two case. Br J Radiol 1986;59:1043-4. [25.] Lewandowski B, Hooper E, Gerridzen RG. Percutaneous deflation of a retained Foley catheter balloon with ultrasound guidance. Can Med Assoc J 1986;134:915-6. [26.] MacDermott JP. Removal of retained Foley catheter. Br J Surg 1987;74:25. [27.] Gaisie G, Bender TM. Knotting of urethral catheter within bladder: an unusual complication in cystourethrography. Urol Radiol 1983;5:271-2. [28.] Kunin CM, Chin QF, Chambers S. Indwelling urinary catheters in the elderly. Relation of "catheter life" to formation of encrustations in patients with and without blocked catheters. Am J Med 1987;82:405-11. [29.] Warren JW. Catheter-associated urinary tract infections. Infect Dis Clin North Am 1987;1:823-54. [30.] Hackler RH. Long-term suprapubic cystostomy drainage in spinal cord injury patients. Br J Urol 1982;54;120-1.

Leopoldo C. Cancio, MAJ, MC, USA is a resident in general surgery at Brooke Army Medical Center, Fort Sam Houston, Tex. Dr. Cancio is a graduate of Georgetown University School of Medicine, Washington, D.C., completed an internship at Brooke Army Medical Center, and served as surgeon, 1st Brigade, 82nd Airborne Division, Fort Bragg, N.C.

Edmund S. Sabanegh, Jr., MAJ, SAF, MC is an attending urologist at Wilford Hall Medical Center, San Antonio, Tex. Dr. Sabanegh graduated from the University of Virginia School of Medicine, Charlottesville, and completed a residuary in urology at Wilford Hall Medical Center.

Ian M. Thompson, LTC, MC, USA is chief of the Urology Service at Brooke Army Medical Center. After graduating from Tulane University School of Medicine, New Orleans, Dr. Thompson completed a residency in urology at Brooke Army Medical Center and a fellowship in urology at the Memorial Sloan Kettering Cancer Center, New York.

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