A Mechanical Aid to Control Bladder Infection and Function Using Indwelling Catheters*

JAMES BARRON, M . D .

From the Division o) General Swrge~y, Henry Ford .Hospital; Detroit, Michigan

URETHRAL CATHETER drainage has been the subject of much criticism in recent }'ears. According to most published re- ports, at least 10% of patients in general hospitals must undergo urinary catheteriza- tion. Th e usual incidence of urinary catheterization in patients undergoing rectal and colon surgery ranges from 30 to 40%. An indwelling catheter, left in place for 24 hours, wilt cause significant bac- teriuria in about 50%. of patients and, if left in place for 4 days or longer, it will cause bacteriuria in more than 90%. Obviously, the problem of bacteriuria in connection with urinary catheterization is not simple, and its prevention is important.

At the present time, many patients who undergo major surgery on the anal canal and terminal port ion of the colon require urinary catheterization. Therefore, meas- ures that can prevent or reduce the inci- dence of bacteriuria are well in order. Conservative measures to avoid catheteriza- tion, such as those advocated by Hopping s and Bemstein, 2 can help a great deal in many patients undergoing anorectal surgery. Systemic medication, such as administra- tion of antibiotic agents and other drugs, have been proved to have little practical value, and they do appear to be more effec- tive when used in conjunction with a closed urinary drainage system. 6 Tida t drainage has been used a great deal in the past, and this provides intermit tent filling, but it is fairly complicated and time-consuming and is not widely used at the present time. T h e

* Read at the meeting of the .American Procto- logic Society, Cleveland, Ohio, June 20 to 22, 1966.

l:m, 1. Relative cross sections of large triple- lumen catheter as contrasted with smaller double- lumen catheters used with mechanical irrigator. Large triple-lumen catheter is necessary for usual constant bladder rinse method.

use of a triple-lumen catheter with a neomycin-polym?'xin dr ip has been advo- cated by many authorities. However, this method has the disadvantage of requir ing the at tention of floor personnel to regulate the drip. T h e catheter is quite large and causes irri tation frequently. Furthermore, there is no intermit tent filling of the blad- der, the bladder volume may decrease fairly rapidly, there is no mixing of urine with the irrigating fluid and, despite the drip, a fa i r ly significant percentage of pa- tients have bacteriuria.

Since 1957, I1 have worked on a device for bladder irrigation, which is the subject of this presentation.

There is nothing radically new about this device and this has been true of electro- mechanical devices advocated by others in the past. Wi th this part icular apparatus (Fig. 1) I am able to use a small No. 12 or 14 double-Iumen catheter rather than

7O

MECHANICAL AID TO CONTROL BLADDER INFECTION 71

FIG. 2. Etectromechanical bladder irrigator. Bottle contains saline with neomycin-polymyxin solution. Pump will deliver 42 cc. per hour. Switch provides for selective bladder-emptying time of half an hour, one hour, or every two hours. Amb, u~ladon is per- missible. In case of electrical fatlure, apparatus opens to allow free bladder drainage. Delivery rate is constant, regardless of patient's position.

the large No. 20 triple-lumen catheter (Fig. 2). I t requires vet- / l i t t le at tention and can be taken care of easily by the floor per- sonnel. It provides selective i n t e rmi t t en t filling of the bladder, which allows int imate contact between the rinsing fluid and urine. It is quite difficult to improve upon nature, and intermit tent filling is obviously na- ture's way of handl ing the function of the urinary bladder. T h e closer we are able to approach the natural way, the "better will be the results. Ambula t ion is permissible and presents no problem. The device is so arranged that any interruption of the elec- trical supply automatically allows the tube to open and drain (Figl 3). A constant flow of the antibiotic rinsing agent is easily provided, regardless of the position of the

ANTIBIOTIC SOLUTION

UMP

# l UTOMATIC SHUT OFF VALVE

3LLECTING BOTTLE

or BAG

Fro. 3. Diagram of electromechanical bladder irrigator. Heavy-duty plastic bag may be used in place of bottle to keep system completely closed.

patient. Current opinion supports the view that per iurethral contaminat ion is important , bu t it is not as impor tan t as ascending infection caused by contaminated collecting tubes. Th is mechanical b ladder irrigator can be converted readily into a closed system by attaching a closed plastic collection bag to the outlet tube in place of the collecting bottle. My experience proves that a combinat ion of constant b ladder ir- rigation, combined with closed bladder drainage, will provide greater protection than either one utilized alone. One of the problems connected with this i r r i ga to r is the fact that drainage is accomplished by gravity and the drainage tubes cannot be raised above high bedside rails.

Th is apparatus has been used extensively at the Henry Ford Hospi tal by the Depart- ment of Gynecology, as well as the Surgical Division. Hodar i and Hodgkinson,~ in a detailed review, pointed out that in their experience at the Henry Ford Hospital , prophylactic systemic antibiosis in gyne- cologic patients requir ing urinary catheteri- zation proved ineffectual in over 90%. In

72 BARRON

their experience, local b ladder antibiosis proved more effective in prevent ing and t reat ing bacter iur ia than prophylac t ic sys- temic therapy. Seventy ¢'/o of their patients treated with tile mechanica l b ladder irri- ga tor had a negative ur ine cul ture at the end of tile fifth postoperat ive day, and in 88% the cul ture was negative at the t ime of discharge f rom the hospital .

In my series of cases, which has consisted main ly of pat ients undergo ing ma jo r sur- gery of the rec tum and colon, cultures of the ur ine have been negative in 85% at the end of 5 to 20 days. I n general, with the use of neomycin and po lymyxin mix- tures for irr igation, I have f o u n d that the Proteus species was the ma in c o n t a m i n a n t after p ro longed b ladder irrigation. In their recent studies, T h o r n t o n and associates 7 have also found this to be true.

In pat ients requ i r ing bladder drainage, suprapubic cystostomy appears to show a good deal of promise. Hodgk inson and Hodari ,4 in a recent series of female pa- tients at the H e n r y Ford Hospital , have re- por ted an instance of 7% of significant bacteriuria at the end of 5 days. T h e ma in p rob lem in regard to suprapubic cystostomy appears to be that of insert ing the tube in to the bIadder,

I do no t presume to present the mechan- ical b ladder i r r igat ion system as a perfect method. However , d u r i n g the past years it has appeared that b l adde r func t ion has been improved by its use. T h e infect ion rate is low and opera t ion of the appara tus requires very little a t tent ion. Th i s is be- coming an i m p o r t a n t feature when the shortage of personnel avai lable for floor care today is taken in to Consideration. T h e combina t ion of constant b ladder i r r iga t ion with closed b ladder d ra inage appears to offer more pro tec t ion than e i ther one used alone.

R e f e r e n c e s

1. Barton, J.: Technique of and apparatus for bladder irrigation. Henry Ford Hosp. M. Bull. l h 443, 1963.

2. Bernstein, W. C.: Is urinary retention a neces- sary complication of anorectal surgery'? Minn. Med. 49: 463, 1966.

3. Hodari, A. A. and C. P. Hodgkinson: Iatro- genic bacteriuria and gynecology surge~': A basic study on incidence, prophylaxis and therapy. Am. J. Obst. & Gynec. 95: 153, 1966.

4. Hodgkinson, C. P- and A. A. Hodari: Trochar suprapubic cystostomy for postoperative blad- der drainage in the female. (In press.)

5. I-lopping: Quoted by Bernstein, W. C.2 6. Kunin, C. M. and R. C. McCormack: Preven-

tion of catheter-induced urinary-t~cacr infec- tions by sterile closed drainage. New Eng. J. Med. 274: 1155, 1966.

7. Thornton, G. F., B. Lytton and V. T. Andriole: Bacteriuria during indwelling catheter drain- age. J.A.M.A. 195: 179, 1966.