Troubleshooting Foley Caths and Suprapubic Caths

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Key History and Physical Exam

After determining your patient has a clear indication for foley placement, it’s important for the clinician to determine if the patient has any history or conditions that increase the difficulty of foley insertion (See Table 1 below). Knowing before attempts whether you anticipate the catheterization will be challenging allows the clinician to appropriately plan methods, gather supplies, and call for help if needed. Generally, patients with penises are associated with significantly higher incidence of DUC due to the long and tortuous urethra.(6-8) A recent observational study proposes a novel risk prediction model that may be used to identify patients at risk for difficult urinary catheterization according to presence or absence of certain risk factors.(9) This tool identifies overweight BMI, presence of urethral stricture, history of BPH surgery, radical prostatectomy, and presence of prosthetic implants as the most predictive factors for difficult caths. Although this particular clinical decision making tool is not yet validated, models like it are a promising future in detecting highly difficult urinary catheterizations that will likely require specialist intervention and may prevent unnecessary complications from inexpert attempts.

Table 1. Factors predictive of difficult urinary catheterization (6,7, 9-11)

As with any other procedure, a thorough physical examination of the area should be performed prior to any attempt at instrumentation. Special attention should be paid to detect any external signs of trauma including blood at the urethral meatus - confirmed or suspected urethral trauma is an absolute contraindication to foley placement. (6) Conditions that affect local anatomy such as prolapse, atrophy, or lichen sclerosis in women and epispadias/hypospadias, phimosis, or buried/hidden penis can also be detected on exam in a patient with unknown history or who is an incapable/unreliable historian. 

Approach to Placement

The first step in placement is the selection of an appropriate catheter. There are several options including the Foley (straight catheter with a balloon), Coude (curved tip catheter with or without a balloon), Robinson (straight catheter without a balloon), and irrigation catheter (straight catheter with a balloon and 3 ports for continuous bladder irrigation). In most male patients, starting with a 16 to 18-Fr Foley catheter is an ideal choice.(7) 

While standard technique for either male or female foley placement is well-known and straightforward, there are several measures that can be taken to ensure the highest likelihood of first-pass success. Many sources recommend injection of 10-15cc of a water-soluble lubricant combined with topical anesthetic into the urethral meatus several minutes prior to attempt. (6,7) This serves not only to lubricate and anesthetize the urethral passage but also to provide some modest distention of the lumen to facilitate tube passage. During insertion, elongating the penis along the anatomical curve at approximately 60 degrees can help prevent the creation of obstructing turns and compressions. (7) Always make sure to insert the catheter all the way to the Y-shaped hub even if you see urine return as this does not always indicate you have reached the bladder. (6,7) By inserting the catheter all the way to the hub, you decrease the chance of inadvertently inflating the balloon in the urethra which can cause significant trauma. 

Minimizing the number of attempts at urinary catheterization is crucial for success in the procedure and minimizing subsequent complications. With each failed attempt at tube passage, the performing clinician risks superficial damage to the thin urothelium of the urethra resulting in bleeding and edema that will make subsequent attempts both more difficult and dangerous. As such, knowing the patient’s risk factors for DUC allows the provider to select materials and techniques that will maximize the success of the procedure and minimize risk of iatrogenic injury.

Table 2. Troubleshooting tips based on confirmed or suspected issue (6,7,12,13)

As a note, the performance of percutaneous cystostomy is entirely within the EM physician’s scope of practice under several key indications. In the setting of a patient with acute urinary retention and inability to pass a transurethral catheter at an institution without urology or IR, the EM physician can perform this procedure, preferably under ultrasound guidance. (14) This is also appropriate in patients with acute urinary retention in whom a transurethral approach is contraindicated such as in urethral trauma 

Indications for Consult/Transfer 

  • Presence of any suspected or confirmed urethral injury as this is the only absolute contraindication to blind urinary catheter placement. (6,7) 

  • Consider in presence of one or more relative contraindications such as known urethral stricture or recent bladder/urethral surgery. (7,13) 

  • Any signs of urethral injury after attempts at catheterization. It’s important to call urology or transfer the patient early and perform no further blind attempts. 

  • Inability to pass catheter despite multiple attempts and appropriate adjustments for patient condition as above

Complications of Bedside Placement

Iatrogenic injury and catheter-associated urinary tract infections (CAUTIs) are the most common complications of urinary catheterizations. The most extreme form of injury is the creation of a false urethral passage or perforation which can occur if the clinician forces the tube upon encountering resistance. (6) This most commonly occurs at the bulbous and posterior urethra in males. Early inflation of the balloon prior to entry into the bladder is also a common cause of iatrogenic urethral injury, usually resulting in injury to mucosa and submucosa. (6) Any bleeding or significant pain during the insertion should prompt the clinician to stop the procedure and re-evaluate as it may indicate potential injury. If the clinician has any suspicion that an instrumentation injury has occurred, prompt urological consultation is needed to evaluate and address the injury as well as to navigate draining the bladder in a patient with this new possible urethral injury.

References

  1. Quallich SA, Thompson T, Jameson J, et al. Management of patients after suprapubic catheter insertion. Urologic nursing. 2023;43(2):61-73. https://search-proquest-com.uc.idm.oclc.org/docview/2805226031. doi: 10.7257/2168-4626.2023.43.2.61.

  2. Huang JG, Brough SJ, Jensen RS, Monsour MJ. Suprapubic catheter displacement: A forgotten phenomenon. Emergency medicine Australasia. 2010;22(3):249-251. https://onlinelibrary-wiley-com.uc.idm.oclc.org/doi/abs/10.1111/j.1742-6723.2010.01293.x. doi: 10.1111/j.1742-6723.2010.01293.x.

  3. Hobbs C, Howles S, Derry F, Reynard J. Suprapubic catheterisation: A study of 1000 elective procedures. BJU international. 2022;129(6):760-767. https://onlinelibrary-wiley-com.uc.idm.oclc.org/doi/abs/10.1111/bju.15727. doi: 10.1111/bju.15727.

  4. Sweeney A. Suprapubic catheter change methods: A crossover comparison cohort trial. Journal of wound, ostomy, and continence nursing. 2017;44(4):368-373. https://www-ncbi-nlm-nih-gov.uc.idm.oclc.org/pubmed/28489676. doi: 10.1097/WON.0000000000000335.

  5. Ejikeme C. Suprapubic catheter change, what could go wrong? BMJ case reports. 2019;12(7):e229855. http://dx.doi.org.uc.idm.oclc.org/10.1136/bcr-2019-229855. doi: 10.1136/bcr-2019-229855.

  6. Bianchi A, Leslie S, Chesnut G. Difficult foley catheterization. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2023. https://www.ncbi.nlm.nih.gov/books/NBK564404/.

  7. Willette PA, Coffield S. Current trends in the management of difficult urinary catheterizations. The western journal of emergency medicine. 2012;13(6):472-478. https://www-ncbi-nlm-nih-gov.uc.idm.oclc.org/pubmed/23359117. doi: 10.5811/westjem.2011.11.6810.

  8. Willette PA, Banks K, Shaffer L. Visually guided male urinary catheterization: A feasibility study. Journal of emergency nursing. 2013;39(1):27-32. https://dx-doi-org.uc.idm.oclc.org/10.1016/j.jen.2011.07.009. doi: 10.1016/j.jen.2011.07.009.

  9. Ha AS, Pak J, Haas CR, et al. A novel risk prediction model to triage difficult urethral catheterizations. Urology (Ridgewood, N.J.). 2021;157:35-40. https://dx-doi-org.uc.idm.oclc.org/10.1016/j.urology.2021.05.059. doi: 10.1016/j.urology.2021.05.059.

  10. Villanueva C, Hemstreet 3, George P. Difficult male urethral catheterization: A review of different approaches. International Brazilian journal of urology. 2008;34(4):401-412. https://www-ncbi-nlm-nih-gov.uc.idm.oclc.org/pubmed/18778491. doi: 10.1590/S1677-55382008000400002.

  11. Mikkilineni N, Lipsky M, Li G, Weiner D, Rutman MP. Difficult foley: Factors predicting appropriate urologic consultation. Journal of the American College of Surgeons. 2018;227(4):S280. https://dx-doi-org.uc.idm.oclc.org/10.1016/j.jamcollsurg.2018.07.576. doi: 10.1016/j.jamcollsurg.2018.07.576.

  12. Gardi M, Balta GM, Repele M, et al. The challenge of difficult catheterization in men: A novel technique and review of the literature. Urotoday international journal. 2013;6(4). doi: 10.3834/uij.1944-5784.2013.08.12.

  13. Haider MZ, Annamaraju P. Bladder catheterization . In: StatPearls. Treasure Island, FL: StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560748/.

  14. Ramos-Fernandez MR, MD, Medero-Colon R, MD, Mendez-Carreno L, MD. Critical urologic skills and procedures in the emergency department. Emergency medicine clinics of North America. 2013;31(1):237-260. https://www.clinicalkey.es/playcontent/1-s2.0-S0733862712000636. doi: 10.1016/j.emc.2012.09.007.

Authorship

Written by Sophia Newton, PGY-1, University of Cincinnati Department of Emergency Medicine

Editing and Posting by Jeffery Hill, MD MEd, Associate Professor, University of Cincinnati Department of Emergency Medicine

Cite as Newton, S, Hill, J. Troubleshooting Foley Caths and Suprapubic Caths. TamingtheSRU. www.tamingthesru.com/blog/3/12/14/troubleshooting-foley-caths-and-suprapubic-caths. 12/18/23