1. DR. SWAPNIL S. TOPLEDNB UROLOGY9/29/2014 1

2. Dr. Frederick Foley Developed in the 1920sby Dr. Frederick Foley The urinary catheter wasoriginally an opensystem with the urethraltube draining into anopen container. In the 1950s, a closedsystem was developed inwhich the urine flowedthrough a catheter into aclosed bag.9/29/2014 2 3. What is a urinary catheterUrinarycatheter is anytube placed inthe body todrain andcollect urinefrom the9/29/2b014ladder 3 4. INDICATIONS FORCATHETERISATION broadly divided into two main categories:1. to obtain drainage or2. to allow the instillation of diagnostic or therapeuticagents The relief of acute or chronic urinary retention due toeither bladder outlet obstruction or neurogenicbladder dysfunction is the most common indicationfor urethral catheterization9/29/2014 4 5. to monitor urinary output Urinary diversion by a catheter is used to allow healingafter lower urinary tract surgery/trauma to evacuate the bladder when the urine containsparticulate matter, especially in combination withsimultaneous irrigation (post transurethral resection,clot/purulent material evacuation)9/29/2014 5 6. to collect of microbiologic clean urine (uncooperativepatients because of age or mental status orcomorbidities that prevent voluntary voiding) to measure postvoid residual urine volume samples fordiagnostic purposes to provide access to the bladder for urinary tractimaging studies such as cystography, which requiresthe instillation of radiographic contrast material9/29/2014 6 7. UC with a pressure monitoring catheter is used duringurodynamic testing for physiologic assessment ofvoiding function to allow instillation of pharmacologic agents for localtherapy of some bladder pathologies such aschemo/immunotherapy for transitional cell carcinoma(mitomycin, BCG), interstitial cystitis (dimethylsulfoxide), and intractable hematuria (e.g., alum,formalin instillation)9/29/2014 7 8. Catheter types9/29/2014 8 9. Documentation Details regardingthe catheterisationshould be recordedin the patientsnotes. For furtherinformation pleaserefer to yourhospitals policy andprocedure manual.9/29/2014 9 10. Matters to consider for Catheterization Time and date of catheterisation Type of catheter Amount of water in balloon Size of catheter Expiry date of product Any problems on insertion Description of urine, colour and volume drained Specimen collected Review date(Marsden Manual 2001)9/29/2014 10 11. What you Need for Catheterization 1 Dressing trolley 2. Catheterisation pack including penileclamp 3. Sterile gloves 4. Appropriate size catheter 5. Xylocaine jelly syringe 6. Sterile water for the balloon 7. Syringe 8. Specimen jar 9. Antiseptic solution 10. Waterproof Sheet 11. Extra Jug 12. Light source 13. Tape to secure the catheter to the leg 14. Drainage bag 15 Urine bag holder9/29/2014 11 12. Catheter selection The size and type of urinary catheter used depends onthe indication for catheter insertion, age of thepatient, and type of fluid expected to be drained Catheter size is measured in the Charrire or Frenchscale, whereby one Fr or Ch is equal to 0.33 mm. Thismeasurement indicates the total circumference of thecatheter and not the lumen size. As a general rule, catheter size should be the smallestsize that can accomplish the desired drainage 12 to 14 Fr for clear urine and 20 to 24 for thick pus orblood-filled urine9/29/2014 12 13. The use of feedingtubes as urethral catheters should be discouraged because theirstiffness and length can be a source of complications (ischemiculcers, urethral strictures, and knotting in the bladder)9/29/2014 13 14. MATERIAL Modern urinary catheters are most frequently made oflatex, rubber, silicone, and polyvinylchloride (PVC). Rubber and latex catheters are often chosen for short-termdrainage. Silicone catheters are indicated when there isrubber/latex sensitivity or allergy and are particularlysuited for patients requiring a longer period ofindwelling time.9/29/2014 14 15. Silicone is relatively inert, causing less tissue reaction,and is associated with less bacterial adherence thanother catheter materials (Roberts et al, 1990) Evidence suggests that the use of silicone catheters isassociated with a lower incidence of urinary tractinfections compared with those made of latex (Crnichet al, 2007).9/29/2014 15 16. COATING The application of a viable bacterial coating ontocatheter surfaces as a method of reducing catheter-associatedurinary tract infection (CAUTI) by bacterialinterference is a novel approach that has shownpromise in a small pilot study involving the use ofEscherichia colicoated catheters The rationale is based on natural competition bynonpathogenic bacteria overpowering any pathogenicbacteria that may enter the urinary tract (Trautneretal, 2007). Further study is necessary to confirm if thiswill be an effective strategy.9/29/2014 16 17. NO OF CHANNELS SINGLE LUMEN: simpledrainage orirrigation/instillation DOUBLE LUMEN: to permitaddition of a retentionballoon TRIPLE LUMEN: forsimultaneous drainage andirrigation(to drain thickfluids like pus or blood)9/29/2014 17 18. It should be borne in mind, however, that the additionof a multichannel catheter is accomplished bydecreasing the overall internal diameter or lumen ofthe main drainage channel; a 24-Fr three-way catheter has a smaller internaldrainage diameter than a 24-Fr two-way, which has anarrower lumen than a 24-Fr one-way catheter.9/29/2014 18 19. TIP SHAPE BLUNT STRAIGHT TIP:most common (foley) CURVED TIP (COUDE):high bladder neck,prominent median lobeof prostate END HOLE(COUNCILL): whencatheterization overguide wire is required9/29/2014 19 20. TECHNIQUE OF CATHETERINSERTION POSITION OF PATIENTMale: supineFemale: a frog legposition is most suitableUse of stirrups in veryobese females9/29/2014 20 21. ANESTHETIC If topical anesthesia is to be used, evidence suggests itrequires a minimum of 10 minutes of exposure(depending on the agent), sufficient volume of theagent (20 to 30 mL), and slow instillation time (>3 to10 seconds)(Schede andThroff, 2006; Tzortzis et al,2009) to have the most effect. There is some evidence that cooling to 4 C diminishedthe discomfort of lignocaine gel instillation, probablydue to a cryo-analgesic effect (Thompson et al, 1999;Goel and Aron, 2003).9/29/2014 21 22. ANATOMIC CONSIDERATIONSMALE: 18 to 20 cm in length its diameter variable, amere slit to 6 mm duringthe passage of urine follows a sigmoid curse,a proximal curve at thepeno-bulbar junctionand another at thebulbo-membranousjunction9/29/2014 22 23. FEMALE: LENGTH: 3.5 to 4 cmlong The meatus is usually inan anterior location andthe bladder neck in aposterior location in thehorizontal plane, givingthe urethra a slightposterior inclination9/29/2014 23 24. Structure of Foley Catheter9/29/2014 24 25. PROCEDURE9/29/2014 25 26. 9/29/2014 26 27. 9/29/2014 27 28. 9/29/2014 28 29. 9/29/2014 29 30. 9/29/2014 30 31. 9/29/2014 31 32. 9/29/2014 32 33. 9/29/2014 33 34. 9/29/2014 34 35. Gravity will help the Drainingof BladderGravity is important for drainage andthe prevention of urine backflow.Ensure that catheter bags are alwaysdraining downwards, do not becomekinked and are secured and belowthigh level. Metal or plastic hangersshould be attached to the side of thebed. Cloth bags tied to the bed to9/29/2s01u4 pport the bags are also available 35 36. Rapid draining leads to Complications Rapid drainage of largevolumes of urine fromthe bladder may result inhypotension and/orhaemorrhage.(Upson1995) Clamp catheter ifthe volume drained is1000mls or greater. After20minutes release theclamp and allow urine todrain9/29/2014 36 37. Collection of urine from catheterisedpatients The process of obtaining a sample of urine from apatient with an indwelling urinary catheter must beobtained from a sampling port. The sample must beobtained using an aseptic technique. This port is usually situated in the drainage tubing,proximal to the collection bag which ensures thefreshest sample possible. The use of drainage systemswithout a sampling port should be avoided (Gilbert,2006).9/29/2014 37 38. Specimens for Culturing Shouldnot be Cultured from Urine bags Specimens should not becollected from the tapfrom the main collectingchamber of the catheterbag as colonisation andmultiplication ofbacteria within thestagnant urine or aroundthe drainage tap mayhave occurred.9/29/2014 38 39. Care of Inserted Catheters Every day , wash around the catheter and perineumwith soap and water; rinse and dry these areas well.you may shower while wearing the catheter Sitting in the tub, however , is not recommended.Good personal hygiene pre vents the accumulation ofbacteria, reduces the risk of infection, and preventsodour9/29/2014 39 40. DIFFICULT CATHETERIZATION9/29/2014 40 41. COMPLICATIONS UTIs account for 40% of all nosocomial infections. Themajor risk factor is the use of urethral catheters, which areresponsible for up to (80%) of UTIs in the hospital setting(Ha and Cho, 2006) Risk factors for CAUTIs: patients requiring more than 6 days of catheterization, female gender active nonurinary infection sites preexisting medical conditionsMalnutrition renal insufficiency catheter insertion other than in the operating room drainage tubing or a bag elevated above the level of thebladder(Maki and Tambyah, 2001).9/29/2014 41 42. hematuria, urethral and meatal strictures urethral perforation Allergic reactions including anaphylaxis (Thomas et al,2009; Wyndaele,2002).Especially at risk are patients with long-term indwellingCatheters Malignant neoplasms (2.3% to 10%) stone formation (46% to 53%), bladder neck and urethral erosions (Igawa et al, 2008).9/29/2014 42 43. A unique complication: Inability to remove catheterfrom the bladder, reasons beingDue to encrustations,Entrapment by sutures, orInability to disengage/deflate the retaining balloon9/29/2014 43 44. HOW TO MANAGE THISCONDITION? Encrustations:Mild encrustations-gentle traction will solve theproblemSignificant encrustations-a semirigid ureteroscope andthe holmium:YAG laser to remove the stone fragments9/29/2014 44 45. Entrapment by suture(recent bladder or prostatesurgery) semirigid ureteroscopy along the catheter and usingthe holmium:YAG to release the suture have also beendescribed (Bagley et al, 1998; Nagarajan et al,2005).Because the suture materials used in bladder andprostate surgery are often absorbable, waiting forsuture dissolution is another option.9/29/2014 45 46. Inability to deflate a foley balloon: a stepwise approachis followedOne should first attempt to place another 1 to 2 mL offluid in the balloon to ensure normal balloon contour,which may be important with the large-volumeballoonsthe next step is to cut the inflation portinsert a surgical steel wire (24 or 28 gauge; oftenincluded as an obturator for small-caliber ureteralcatheters) or the stiff end of a 0.035-inch hydrophilic-coatedguidewire through the valve inflation lumen9/29/2014 46 47. ultrasound-guided needle puncture can be conductedwith a lon spinal needle (22 gauge) using either atransrectal, transvaginal, or suprapubic surface probe(Daneshmand et al, 2002)open surgery9/29/2014 47 48. Overinflation of the balloon not recommended-painfulto the patient and may cause bladder injuryand fragmentation and retention of the balloonfragments (Glmez et al,1996) Use of chemical instillations such as ether or tolueneto induce balloon rupture should be discouragedbecause these agents can cause chemical cystitis(Patterson et al,2006)9/29/2014 48 49. REFERENCES Bagley DH, Schultz E, Conlin MJ: Laser division of intraluminal sutures. J Endourol. 12 (4):355-357 1998 9726402 Bjerklund Johansen T, Hultling C, Madersbacher H, et al.: A novel product for intermittent catheterisation: its impacton compliance with daily lifeinternational multicentre study. Eur Urol. 52 (1):213-220 2007 17166653 Chung C, Chu M, Paoloni R, et al.: Comparison of lignocaine and water-based lubricating gels for female urethralcatheterization: a randomized controlled trial. Emerg Med Australas. 19 (4):315-319 2007 17655633 Crnich CJ, Drinka PJ: Does the composition of urinary catheters influence clinical outcomes and the results of researchstudies?. Infect Control Hosp Epidemiol. 28 (1):102-103 2007 17301937 Daneshmand S, Youssefzadeh D, Skinner EC: Review of techniques to remove a Foley catheter when the balloon doesnot deflate. Urology. 59 (1):127-129 2002 11796297 Davenport K, Keeley FX: Evidence for the use of silver-alloy-coated urethral catheters. J Hosp Infect. 60 (4):298-3032005 15936115 De Ridder DJ, Everaert K, Fernndez LG, et al.: Intermittent catheterisation with hydrophilic-coated catheters(SpeediCath) reduces the risk of clinical urinary tract infection in spinal cord injured patients: a prospectiverandomised parallel comparative trial. Eur Urol. 48 (6):991-995 2005 16137822 Ellis H: The Foley catheter. J Perioper Pract. 16 (4):210-211 2006 16669367 Garbutt RB, McD Taylor D, Lee V, Augello MR: Delayed versus immediate urethral catheterization followinginstillation of local anaesthetic gel in men: a randomized, controlled clinical trial. Emerg Med Australas. 20 (4):328-3322008 18782206 Garcia MM, Gulati S, Liepmann D, et al.: Traditional Foley drainage systemsdo they drain the bladder?. J Urol. 177(1):203-207 2007 17162043 Goel R, Aron M: Cooled lignocaine gel: does it reduce urethral discomfort during instillation?. Int Urol Nephrol. 35(3):375-377 20039/29/2014 49 50. Glmez I, Ekmekcioglu O, Karacagil M: A comparison of various methods to burst Foley catheterballoons and the risk of free-fragment formation. Br J Urol. 77 (5):716-718 1996 8689117 Ha US, Cho YH: Catheter-associated urinary tract infections: new aspects of novel urinary catheters.Int J Antimicrob Agents. 28 (6):485-490 2006 17045784 Ho KJ, Thompson TJ, OBrien A, et al.: Lignocaine gel: does it cause urethral pain rather than preventit?. Eur Urol. 43 (2):194-196 2003 12565779 Igawa Y, Wyndaele JJ, Nishizawa O: Catheterization: possible complications and their prevention andtreatment. Int J Urol. 15 (6):481-485 2008 18430150 Jahn P, Preuss M, Kernig A, et al. Types of indwelling urinary catheters for long-term bladder drainagein adults. Cochrane Database Syst Rev 2007;(3):CD004997. Johnson JR, Kuskowski MA, Wilt TJ: Systematic review: antimicrobial urinary catheters to preventcatheter-associated urinary tract infection in hospitalized patients. Ann Intern Med. 144 (2):116-1262006 16418411 Lee SJ, Kim SW, Cho YH, et al.: A comparative multicentre study on the incidence of catheter-associatedurinary tract infection between nitrofurazone-coated and silicone catheters. Int JAntimicrob Agents. 24 (Suppl 1):S65-S69 2004 15364311 Madineh SM: Avicennas canon of medicine and modern urology. Part III: other bladder diseases.Urol J. 6 (2):138-144 2009 19472137 Maki DG, Tambyah PA: Engineering out the risk for infection with urinary catheters. Emerg InfectDis. 7 (2):342-347 20019/29/2014 50 51. Thank you9/29/2014 51