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Author: Rob Greig / Editor: Ben Hughes, Charlotte Davies / Codes: SLO1, SLO6, UP3, UP6 / Published: 29/10/2020

Here’s part two of our urological problems in men blog – focussing on catheterisation and problems associated with it.

Acute Urinary Retention (AUR)
Having recently had surgery this is a topic very close to my heart as I went into post-operative retention. It was quite an eye opener, especially since the clinician bladder scanned me at my umbilicus and said there was only 750ml in my bladder. I had 1.7l in my bladder! So, first lesson, if you are going to mess around with bladder scanners ensure you are trained and that you’re pointing the probe in the correct direction!

Personally, it’s PoCUS all the way because you can check also for hydronephrosis (a reason alone to admit an AUR case), however I digress. There’s a guide on how to use POCUS here.

The PSA will be raised in acute retention and has no bearing on the ED management. I’m not saying PSA per se has no role but is beyond the scope of this acute piece. There’s a great RCEM learning piece on Assessment and management of Acute Urinary retention so I won’t go over much from that. However, AUR is responsible for 30K admissions in the UK per annum.

There are 4 basic mechanisms:

  • Increased resistance to outflow e.g. tumour, haematoma, enlarged prostate, urethral stricture.
  • Inappropriate detrusor muscle innervation courtesy of neurological pathology such as stroke, spinal cord injury/lesions and diabetic neuropathy.
  • Bladder over distention post op, chronically and with alcohol use
  • Drugs, and there are many, but commonly anticholinergics, anti-psychotics, tricyclics and opiates

There are a multitude of causes for AUR, ultimately the patient needs a urinary catheter. Now the classic type is the Indwelling Foley catheter via the external urethra, however there’s also the suprapubic route and what’s not done as frequently is offering the chance for the patient to self-catheterise – trust me, I have been there, and it really isn’t that bad.

‘Standard’ Male Urethral Catheterisation
All ED doctors should be au fait with the insertion of a Foley catheter, but these are some tips for insertion:
* double check first that you haven’t got a female catheter and to be fair it’s far safer that EDs only stock male catheters.

• I double glove, first layer to clean patient and then remove, under layer for insertion.
• I use “betadine, so I can see what’s clean” – yes there is debate about water/normal saline.
• If there’s a prior history of “prostatism” (which is an old fashioned term, now termed lower urinary tract symptoms or LUTS), I use two syringes of Instillagel.
• Retain an Instillagel syringe for a later purpose
• Clean field dressing, I find using the plastic covering of the catheter tiresome and sometimes you need a good grip.

Instillagel infiltration:
• Instillagel should be placed initially at the meatus (having cleaned under the foreskin if present). Give it 30 seconds before inserting the full syringe hub.
• Insert the instillagel syringe so that its shoulders abut against the glans and effectively seal around the meatus. Instil the gel slowly. Then hold the glans/external meatus closed. Remember to retain one empty instillagel syringe.
• Milk the instillagel down to the base of the penis. You will feel bubbles in the urethra near the base – so often it fails to get deep enough which then defeats the point of having a lubricating gel at the prostate. Wait one minute. The urethra will be numb and lubricated.

Catheter insertion:
• Hold the penis stretched, up and in the anatomical (erection) position, I find this helps with Benign Prostatic Hypertrophy cases.
• Push the catheter down with a slight twisting motion, clockwise or anticlockwise. You will hit the prostate, sometimes the patient tenses up pubococcygeus, they feel a sensation in the perineum/anus. Explain it’s normal and get them to relax their buttocks, keep advancing. Sometimes asking them to “bear down” as if they were going for a poo, helps with the relaxation.
• Push the catheter all the way to the hilt, do not stop until at the hilt.
• THEN, use the left over sterile Instillagel syringe to aspirate urine because sometimes the thick gel blocks the narrow catheter channel.
• So, you have confirmed you have the tip in the bladder by aspiration of urine with the instillagel syringe. Then inflate the balloon (with the sterile water provided in the pack) and pull back to engage against the bladder neck. If difficult to inflate balloon or very painful then you may be inflating it in the prostatic urethra.
(Note some cathers have a prefilled catheter balloon where you squeeze the water from the reservoir at the connection end)
• Next take the sterile water syringe that inflated the balloon and take a clean sterile urine sample for testing, attach the drainage bag, ideally an hourly bag. Retain that syringe too.
• Either clean the patient up or give them towels to clean themselves up, the gel especially oozes out for a while afterwards.
• Record the residual volume 10 minutes after insertion, the rest is likely to be the post-obstructive diuresis.

Residual volume discussion: Volumes over 1000ml are interesting to urologists as likely to suggest a degree of chronicity and so more likely to have a post-obstructive diuresis which might need managing if the patient cannot maintain hydration orally. Less seems to impress them less. However urinary output post-AUR is interesting: a diuresis of >200ml/hr for 2hrs warrants admission or >3000ml/24hrs.

U&Es: take these, admit if acutely abnormal. Also act as a base line if the patient develops post-AUR diuresis.

If you’re looking at sending the patient home, I would consider using a flip-flow valve instead of a leg bag especially for the <65 year olds with whom there had been no prior LUTS. They must open the valve every 3-4 hrs if they don’t get the urge to pass urine.

The flip-flow valve has the advantage of training the bladder or patient to feel normal sensation from the bladder. This of course won’t happen if the patient has a neurogenic cause for retention.

Also, if sending home give the patient a tube of Instillagel to lubricate and keep clean the external meatus as the catheter chafes against the meatal mucosa.
All units should have their own community follow up for discharged newly catheterised patients.

Suprapubic Catheterisation
Firstly, this is a technique you must be trained in. This is not a read and do technique. You must be familiar with the contraindications, and the use of PoCUS here is ideal – eyeball how big the bladder is and if there are loops of bowel in the way.

Sometimes you cannot pass a suprapubic catheter, or the patient has had a suprapubic in prior and during a change of catheter the catheter track has been lost (if that occurs you need to wait/confirm that the bladder is full before reinserting).

• Contraindications – fem-fem crossover grafts, known bladder cancer, pregnancy.
• Relative contraindications – lower midline laparotomy as bowel might be plastered to anterior abdominal wall, anti-coagulation, haematuria as might have bladder cancer

• Consent patient. Ensure they have either Entonox or Penthrox®
• Get plenty of towels down, one on each side and one above and below suprapubic zone.
• Double glove, betadine the anterior wall and consider using Entonox or Penthrox as anxiolysis.
• The insertion point is 2 finger breadths above the pubic symphysis superior border. Use 2% Lidocaine with Adrenaline infiltration down to the bladder, aspirate urine to confirm.
• Get the Suprapubic kit laid out and close to hand. Invariably it will be the Cook Peel Away® system but there is a Seldinger set too, e.g. there’s one by Braun and MediPLus (the Mediplus link has a nice instruction video).
The Seldinger technique which appeals to non-surgically minded Drs, intuitively its safer but there is no evidence to prove either way is superior. In Jersey we exclusively stock Seldinger Suprapubic catheters.
• The Cook Peel Away® system involves the insertion of a trocar within a peel away sheath – check that the catheter you intend to insert fits down said sheath prior. You cut down with a scalpel to the rectus sheath in the midline, then take the trocar and pierce through the anterior abdominal wall aiming in the direction of the sacrum until you feel a sudden give – the trocar will now be within the centre of the bladder. This will be uncomfortable for the patient, so having Entonox or Penthrox on board is useful. You remove the central trocar.

• Urine tends to fountain out the top, hence the towels, so get your thumb over the port. Then quickly insert the catheter down the peel away tube, to the hilt. Then, aspirate, confirm catheter is in correct place and inflate balloon. Then pull back on the catheter to engage against bladder wall and it will push the peel-away unit out in part. Then pull on the two peel-away sections to split the tube in half, these then come out from the cystostomy with ease. Connect the catheter to the bag.
• Give patient some oral analgesia as this will be uncomfortable and a little Instillagel at the cystostomy site helps too.

A good get out of jail card is the supra-pubic aspiration if SPC is contraindicated or difficult or bladder not that full. Get a 50ml Luer lock syringe, long needle, 2 finger breadths above symphysis, aspirate until dry, will buy you hours and even 50 ml decompression will relieve pain.

Self/Patient catheterisation aka “In-Out Catheter”
There are some simple kits around and this concept is worth bearing in mind for the post op day cases that go into retention secondary to typical abdominal pain or opiates. In the world of patient consent, this is an alternative treatment and there are some really easy to use kits these days.

The SpeediCath flex kit comes pre-lubricated with male & female screw ends allowing the catheter to be closed after using. The tip of the catheter is small and firm like a Tiemann’s catheter with a ball tip. The patient inserts the catheter and drains urine from the male end.

The thought of asking a patient to self-catheterise may seem abhorrent, but actually it’s not that bad, especially when one is in retention and has tried every trick in the book to pass urine. This approach is ideal for the post op day case cases with no prior retention. Alternatively, a clinician could insert the “in-out” catheter, but the small diameter lumen means that a full bladder takes a while to drain. Therefore, insert and get the patient to hold until draining stops.

Haematuria – to Irrigate or Not to Irrigate that is the question…
Now this is something that I see a lot of. I find it handy having a great friend who’s a urologist and can get patients into clinic fast but there isn’t much written about how to deal with this day-to-day on the ED shop floor.

It’s now called Visible and Non-Visible Haematuria. This blog is for the big stuff: visible haematuria from Blush wine, to Rose to Burgundy coloured urine.

The approach is fairly sensible: if the patient presents with visible haematuria the clinician needs to check the patient’s coagulation screen and FBC. Note that if the patient is on a Direct Oral Anticoagulant (DOAC), they can have a normal coagulation screen and be fully anticoagulated. I have written about this in other Twitter blogs: unless the patient has a mechanical heart valve, I would reverse the anticoagulant and admit, simply because the reversal agent doesn’t ‘truly’ reverse – they tide you through the terminal half-life of the anticoagulant and there’s a good chance a retained clot could form.

A patient presenting with Visible Haematuria, who is able to pass urine still with normal vitals can go home; encourage oral fluids and start a urine focused antibiotic and refer to urology for follow up – it’s often a UTI that triggers the haematuria but the patient may still have a urological tract pathology such as a tumour that will require further investigation such as USS and cystoscopy.

If you have the skills, a PoCUS scan of the bladder will help rule in a bladder haematoma or any bladder pathology (I have found many and it’s straightforward if the bladder is full). If the patient has a bladder haematoma, it’s not an immediate need to admit for irrigation catheter; a lot of post TURP cases have haematuria and bladder haematomas that clinically don’t get detected (akin to the non-symptomatic post TKR below knee DVTs that are present in the immediate 48hrs post TKR). Merely advise the patient that they need to return to ED/Urology if they have a sudden difficulty in passing urine.

If the patient has a history of Visible Haematuria followed by AUR, they need an 3-way irrigation catheter. I tend to double Instillagel these cases, because the catheter is much larger, they will need admission. Once the 3-way catheter is in then perform a bladder washout with a 50ml bladder syringe to remove large clots. If clots remain then then so will the haematuria.

Once the clots are aspirated the irrigation is to stop clots forming in the bladder until haemostasis occurs. Urologists dislike it if a patient has 12 hours of irrigation without an initial washout and clot aspiration (I did not know this!) as the haematuria will continue and the patient will likely to need theatre for solid clots that have been ‘tickled’ by the irrigation but not removed with the syringe.

Blunt trauma Visible Haematuria in a well patient:
I will also give a mention to the blunt trauma to the renal angle that results in visible haematuria, e.g. playing football and get a knock to the flank.
This is quite common and often abates, going from red wine discoloration through to blush/rose over a short period of time with plenty of oral fluids. I would arrange a formal USS and urology follow up as a precaution which the patient can cancel if the haematuria abates and the USS is normal.

That being said renal trauma guidelines stipulate CT with contrast – we believe that is over kill in a haemodynamically normal patient with normal Renal USS.

Bypassing Catheters

  • Often the lumen is blocked with sediment or lumen too small. Balloon not fully inflated, or the catheter end is too low down the leg causing a negative pressure.
  • If bypassing caused by blocked catheter then on PoCUS a large bladder will be seen.
  • If bypassing caused by partially inflated balloon, then the balloon volume will be less than 10ml and you won’t see on PoCUS a nice circular balloon image.
  • If bypassing caused by catheter attached too low down the leg this will be alleviated by attaching higher up the leg or simply attach a flip-flow valve. Is the bag below the level of the patient’s bladder? (if the bag is more than 30cm away from the bladder, there is an increased negative pressure which may increase the risk of blockage or bypassing – the negative pressure sucks bladder epithelial tissue into the tip thus blocking the drainage lumen – RCN Catheter Care document, excellent read). So flushing a bypassing catheter is unlikely to help!


Blocked catheters
This is a fascinating YouTube video on blocked catheters. Sometimes you just can’t win, and patients get recurrent blocked catheters. I elect to replace if possible, rather than flush simply because the biofilm, encrusted debris, bladder pseudo-polyps or impaction on bladder wall may recur rapidly or just float around in the bladder and block the catheter later, so flush the catheter and bladder, allow to drain and then replace. (If recurrent blockages in LTC then worth a urology review for cystoscopy to rule out bladder stones.)

Cases where patients are having multiple early changes may benefit from a new style of catheter, not a Foley catheter (80 year old tech) but the Flume Catheter. See image above and click the link for a review of this new style of catheter where the tip doesn’t protrude from the balloon. There is also something called the EZ Catheter, but it looks like it’s in the development only stage.

The author points out that at this stage The Flume catheter doesn’t have a CE mark, but the manufacturer hopes to have that by 2021.

You may ask whether you should flush a blocked catheter. Flushing is normally harmless, and the catheter might be just blocked by a small bit of calcification. Certainly worth trying before replacing the catheter. If a flush fails, the catheter will need replacement, and if the catheter is regularly blocking outpatient urology referral will be useful.

Antibiotics and new catheters and catheter changes (!!!)
Well flip a coin quite frankly! The evidence fluctuates but is weak – most guidance is against. NICE guidelines suggest antibiotics if >2 attempts, frank haematuria post catheterisation and history of UTI post change.
Please follow local guidance and genuinely question how a bolus of 80mg Gentamicin is useful in any way, shape or form.

Further Reading
Urinary retention reference and module
SAQs one and two
Haematuria module
SAQ three and four