In group 2, the incidence of clot retention decreased two fold in comparison to traditional gravity-dependent bladder flow system. We did not observe any adverse effects such as bladder perforation due to our high-pressure, high-flow system. A pressurized irrigant system has better visualization during endourologic procedures, and prevents clot formation after open prostatectomy, TURP, and TURB without any adverse effects.
Three-way Foley catheters are used when irrigation of the bladder is anticipated to prevent or manage blood clots in the bladder. Effective bladder irrigation influences patient safety and clinical outcomes. The incidence of clot retention after TURP was reported to be 3. In this 2-year prospective study conducted between March and April , our new delivery system was used routinely for our admitted patients.
Before this period, the traditional gravity system was used routinely for all admitted cases, of which, cases were underwent open prostatectomy, TURP, and transurethral resection of the bladder TURB , and cases underwent an endourologic procedure such as cystoscopy, ureteroscopy, or transurethral lithotripsy TUL.
In this system, a plastic connector was inserted into the irrigant bag with 1 L of normal saline, and its drainage terminal was connected to a Foley catheter or an endourologic instrument such as a cystoscope or ureteroscope.
This system works only with gravity. It is clear that the drainage velocity of the irrigant fluid depends on the height of the irrigant bag. The eligible cases for our new system were divided into two groups who used our instrument in the same way in two situations: the first group underwent endourologic procedures such as cystourethroscopy, internal urethrotomy, and ureteroscopy, or some situations in the TUL procedures cases ; the second group used the system to increase flow rate and bladder irrigation after open prostatectomy, TURP, and TURB cases.
The duration of use for the new system depends on the severity of bleeding. When bleeding is increasingly severe, or for a more clear vision, we increased flow rate by hand pumping a sphygmomanometer bulb to increase pressure in the irrigant bag Figures 1 — 3.
This hand pumping is performed by the scrub nurse in the operating theater or recovery room. After clearing the drainage fluid, the irrigant system was changed to the gravity flow system. The major issue in the endourologic procedures is clear vision. This new system was used in endourologic cases. We had two cases 0.
The maximum and average flow rate of the system were evaluated. The number of our eligible cases before and after introducing our system, and the rate of its complications. Using 3-way Foley catheters is an essential part of routine urological practice. They are available in different sizes: 20, 22, or 24 F. In our daily practice and in the presence of significant bleeding, a size of 22 F catheter or greater is used. Three-way catheters require good irrigation and drainage flow characteristics to optimize a continuous flow system.
All catheters with the size of 22 and 24 F have equivalent irrigation and drainage properties. The flow rate of the various 3-way catheters assessed is proportional to the size of the catheter when the drainage port is used for irrigation. This does not hold true when the irrigation channel is used. Larger catheter size does not equate to better irrigation or drainage when continuous irrigation is performed.
For this reason, we designed a new high-flow, high pressure, hand pumped delivery system. Whitaker 12 emphasized the flawed design of many available 3-way catheters, claiming that the input tube is compromised to achieve a wider output tube.
He stressed that more efficient drainage is rooted in the irrigation flow rate because faster flow prevents blood clots from forming and accumulating in the bladder. Only small increases in the size of the irrigation lumen can double the irrigation flow rate without a significant decrease in the drainage tube lumen. Large-bore catheters are considered the best choice for effective removal of blood clots.
Suprapubic tube placement can have a significant adverse outcome, such as a bowel perforation, if not performed correctly. These catheters are contraindicated in the setting of bladder cancer, unavoidable bowel loops in the anticipated field of passage, uncorrected coagulopathies, presence of a subcutaneous vascular implant in the suprapubic area i.
Replacement of a suprapubic tube within the first two weeks of placement should only be performed by personnel knowledgeable of these catheters usually the person that placed it initially. A newly formed cystostomy tract is very easy to lose if the catheter is not replaced quickly and correctly.
Subsequent to the first change, if done carefully, almost anyone can successfully replace suprapubic tubes. The catheter should be replaced with a same-size catheter used previously and 5-mL or mL balloons should generally be utilized.
One should prepare and cleanse the suprapubic site with the old catheter in place. The old suprapubic tube balloon is then deflated and removed. Briefly examine the old suprapubic tube to visually identify the distance between the catheter tip and its exit point at the skin the internal portion might be lighter in color compared to the external portion which will be darker due to oxidation.
The cystostomy site should then be prepared, cleansed and prepped with antiseptic solution. Lubricating jelly is applied to the new catheter tip and an attempt should be made to pass the catheter in a distance, similar in length to the placement of the previous suprapubic tube. If passed too far beyond the bladder neck, the balloon may be inflated in the prostate or urethra; if not passed far enough, the balloon may be incorrectly inflated in the suprapubic tract itself, not the bladder.
There should not be any pain when inflating the retention balloon. Pain with inflation of the retention balloon or feeling resistance during balloon inflation are usually indicators that the catheter may not be in the correct position. Irrigation of the catheter just after placement confirms correct placement if the catheter can be irrigated easily.
This also rinses out debris and mucus from the bladder. It is not uncommon to see granulation tissue at the cystostomy tract on the lower abdominal wall. Silver nitrate sticks can be used to cauterize this tissue to prevent bleeding. Mucous-like drainage around the catheter at the suprapubic site is usually of no concern, unless associated with overlying erythema or other signs of infection, and can be managed with routine hygiene measures.
If a suprapubic tube is removed in planned or unplanned fashion , it should be replaced quickly as the suprapubic tract, even when mature, can quickly close within hours and prevent simple replacement, necessitating another surgical procedure to replace it. Familiarity with the fundamental principles underlying bladder drainage is important to all medical providers caring for patients in clinical environments where catheters are being placed, replaced, and removed.
While urologists should always be a resource for questions related to catheters, patients receive better care and suffer less morbidity when the entire medical team has good understanding of how and when to safely achieve bladder drainage. Seth A. Summer Fellowships. Archived Webinars. Medical Student Curriculum: Bladder Drainage This document was amended in August and originally to reflect literature that was released since the original publication in August Learning Objectives Describe the indications for catheter placement i.
Indications for Foley Catheter Placement Knowing when to place a Foley catheter is just as important as utilizing proper technique for its insertion. Acute urinary retention, defined as the sudden, complete inability to void, is often associated with suprapubic pain and tenderness. Chronic urinary retention or incomplete bladder emptying is clinically associated with urinary frequency, overflow incontinence, or impaired renal function. It is usually caused by prostatic enlargement, outflow obstruction such as from strictures, or atonic bladder disorders.
When present, bilateral hydronephrosis is frequently associated with chronic urinary retention. Gross hematuria and clot retention have a multitude of possible etiologies, but common causes include prior traumatic Foley catheterizations, prostate enlargement, or a bladder tumor. Urosepsis with incomplete bladder emptying. High voiding pressures such as from an obstructing prostate or neurogenic bladder. Use in lengthy surgical procedures where it is anticipated that the bladder would otherwise become overdistended and possibly damaged.
Clinical situations where strict fluid inputs and outputs are required and the voiding record cannot otherwise be reliably determined. Contraindications to Foley Catheter Placement: Urethral catheter placement is absolutely contraindicated in cases of known or suspected urethral injury, such as in the setting of a pelvic fracture.
The Different Catheter Types Catheters come in sizes that measure the outside circumference in mm. Catheter size 10 fr 12 fr 14 fr 16 fr 18 fr 20 fr 22 fr 24 fr Plastic ring color Black White Green Orange Red Yellow Purple Blue Different Catheter Types include: Straight Catheters- this is a traditional simple catheter, and often the type that is provided within in-patient catheter insertion kits.
Most catheters are made of silicone or latex but some straight catheters are also made from vinyl which tends to be stiffer and more rigid. This is also the type of catheter used for intermittent self-catheterizations and for urethral self-dilations that some patients are asked to perform periodically for urethral strictures. During placement of a coude catheter, the tip of the catheter should be facing pointed towards the ceiling or patient's face, assuming the patient is supine.
These hematuria catheters also come in larger sizes Fr to prevent obstructions from blood clots; and they have larger associated balloons approximately 30 cc to allow for tamponade of the prostate when the catheter is placed on traction. In general, hematuria catheters are used when a patient has significant gross hematuria that cannot be easily cleared with hand irrigation alone.
The initiation of continuous bladder irrigation, usually in the form of normal saline, requires close monitoring to ensure inputs and outputs are roughly equivalent. CBI should not be started if there is a known, large organized blood clot in the bladder that cannot be evacuated or if the patient has a large bladder perforation.
Suprapubic Tubes- These urinary drainage catheters require the percutaneous placement of a Foley or similar catheter through the lower abdominal wall directly into the bladder. Although it involves a surgical procedure, placement of a suprapubic tube is often preferred in situations where urethral catheterization is difficult or impossible, or if the patient requires a permanent indwelling Foley.
Suprapubic tubes are generally more comfortable for patients than urethral Foley catheters and are easier to change, espeically in patients with contractures and other bodily deformities. Any catheter can be either of latex yellow-colored or silicone clear- or blue-colored. Silicone catheters should be used in patients with latex allergies or sensitivities.
It should be noted that with some silicone catheters, after inflation of the balloon, upon deflation there will be an irregular "lip", which can cause discomfort upon removal. Standard Technique for Adult Foley Catheter Placement Standard sterile technique for placing a Foley catheter involves the following steps: Identify yourself and explain to the patient what you are about to do and why.
Wash your hands and ensure you have properly identified the patient. Make sure you have the right type and size Foley catheter kit, then open it up.
Some kits may have extra cleaning pads, soap or prep solution. You may use non-sterile gloves for this preliminary cleaning and to reduce the foreskin in an uncircumcised male.
Put on a pair of sterile gloves and drape the patient. Start with laying a sterile sheet between their legs and putting on an overlying cover drape with a hole in it, which is centered on the external genitalia.
This second, central drape can be difficult to place and maintain in female patients. Make sure you have all necessary supplies ready and at hand. For example, open and place the lubricant on the sterile field so it is accessible to the catheter. Remove the cap to the syringe with sterile water and secure it to the balloon port. Open any packaging on the Foley or antiseptic solution applicators.
Do not use an antiseptic prep to which the patient has a known allergy and use only pure silicone catheters for patients with latex sensitivity.
With your non-dominant hand, separate the labia in a woman or place the phallus on stretch in a male. From this point on, all catheter insertion activities will be done with just one hand. With your dominant hand, clean off the urethral meatus with betadine or the antiseptic cleaning agent provided. This is usually performed three times.
Do not let go of the penile shaft with your non-dominant hand until the catheter has been completely advanced into the bladder. Grab the catheter near the top and coat the tip of the catheter with sterile lubricant and advance the tip of the catheter into the meatus. Advance the catheter by grasping it near the urethral meatus and pushing it in gently; about 1 inch at a time, then repeat until fully inserted; in a female, this is about one inch past the return of urine and in a male, this is until the hub is at the meatus.
If the catheter is grasped too far away from the penis, the Foley will buckle and not advance. There may be some resistance at the level of the membranous urethra or prostate. Most of the time, this can be managed by slow, steady pressure and gently rotating the catheter right and left until the tissues relax and the catheter can pass.
Do not force the catheter if it will not pass easily with just gentle pressure. Look for at least some urine return. Inflate the catheter balloon with sterile water usually 10 cc.
We do not use normal saline to inflate the catheter balloon, as salt crystals could theoretically precipitate in the balloon, valve or balloon channel making deflation of the balloon difficult when removing or replacing the Foley. If there is strong resistance to balloon inflation or if the patient indicates pain, stop and check the position of the Foley.
This can be done clinically by catheter repositioning or by irrigation of the drainage port. Replace the foreskin in an uncircumcised male. Important Points Never inflate the balloon in a man if the catheter is not fully inserted to the hub.
The catheter should stay in place without being held manually. If it tends to push itself out, it may not be properly in place in the bladder. Always expect some urine return if the catheter is in the bladder.
Even an empty bladder generally has at least a little urine. If there is no urine return, and the catheter is inserted to the hub, irrigate the catheter lumen with normal saline as this is safer than sterile water if it extravasates.
Balloon inflation needs to be routine; if it is unusually difficult or hard, deflate it, as you may not be in proper position.
Once the balloon is inflated, the catheter should be somewhat mobile when pushed further into the bladder. By closing this banner or interacting with our site, you acknowledge and agree to this.
Legal Notices. Irrigation is a procedure used to wash out your bladder. The bladder will be irrigated flushed with saline salt water to keep the urine draining freely through the catheter and to keep the catheter from getting plugged.
As you are healing, it may be necessary to irrigate the bladder five times a day, but eventually will be needed to be done only once a day. Here are two recipes for normal saline used for irrigation.
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