Clinical Application of Urologic Catheters, Devices and Products

Purpose The authors aim to equip the reader with a simple to reference text packed with clinical information on all types of urologic devices in a concise yet comprehensive fashion, which is unique compared to other urologic texts. This book gives the provider a basic understanding of the wide array of catheters, devices, and products, as well as indications for advanced applications of these items. The authors met their objectives while filling a necessary void in the urologic literature.

v There are many "tools" essential to the practice of urology, a surgical specialty that manages patients with acute and chronic genitourinary conditions.Urology providers encounter patients who need to drain a kidney(s), ureter(s), or bladder, or who are managing or preventing urine leakage, or are supporting a vaginal prolapse.But the dilemma for most clinicians is not being aware of available urology tools, such as catheters and other devices and products, and not keeping current with new technological changes to these essential urologic tools.
As a multidisciplinary team with expertise in this area, we felt that a textbook would fill this crucial gap in knowledge by providing extensive information on these tools.This textbook is our collaboration on the "nuts and bolts" of using catheters, devices, and products in men and women with emphasis on urologic use.You will find a comprehensive overview of urologic tools with practical information on the indications, types, sizes, and materials, adverse events and complications, patient education, best practices and evidence-based research, and regulations for use.
This book is unique from other urologic textbooks--which, in most cases, only mention these tools within a chapter on a specific urologic condition (e.g., obstructive uropathy, nephrolithiasis, incontinence)--because it devotes entire chapters to indwelling, intermittent, and external catheters, stents, and tubes, drainage bags, external barrier and internal occlusive urethral devices, intravaginal devices and products, penile compression devices, perineal skin care, and incontinence absorbent products.The book's uniqueness extends to its design as a "picture book," including numerous pictures and illustrations of all aforementioned tools.Additionally, the book includes patient instructions for the application and care of a specific catheter, device, or product, as well as best practices for clinical care.
The book contains eight chapters authored by multidisciplinary professionals with expertise in urologic catheters, devices, and products, including urologists, physiatrists, registered nurses, nurse practitioners, physician assistants, and an individual with expertise in marketing incontinence products.Chapter One describes the use of indwelling urinary catheters (IUCs), transurethral and suprapubic, and details the current evidence-based and regulatory guidelines on the use of IUCs, with specifics on complications such as catheter-associated UTIs.Chapter Two reviews intermittent use of urinary catheters (referred to as intermittent catheterization or IC) by patients performing catheterization during their daily lives.With approximately 12,000 new cases of spinal cord injuries per year, and many more with neurogenic lower urinary tract dysfunction, the first-line bladder management in these patients is intermittent catheterization.The technological advances in catheters used for IC are rapid and evolving.Chapter Three reviews external catheters and pouches, primarily used in men with urinary incontinence.Chapter Four discusses specific catheters and devices, such as dilators, filiforms, stents, and nephrostomy tubes, used to relieve obstruction in the urinary tract.Many of the catheters and devices discussed in Chapters One through Four use some type of urinary drainage bag, which is the topic of Chapter Five.The final three chapters provide further information on devices and products: Chapter Six describes absorbent products used by patients with urinary incontinence before and after treatments; Chapter Seven provides a comprehensive review of many urologic and pelvic devices, including urostomy appliances, penile compression devices, 1 Description Indwelling urinary catheters (IUC) are used in selected patients for urinary retention, prevention of upper urinary tract deterioration, comfort in terminally ill patients, and many other indications.IUCs can be made from various materials and come in an array of sizes, shapes and designs allowing for easier insertion, improved patient comfort, and a potential reduction in associated complications.However, despite their widespread use, very little research has been conducted on these commonly used catheters.With recent regulatory and financial pressures directed toward reducing catheter-associated urinary tract infections (CAUTIs) in hospitals, attention has been refocused toward the use of an IUC in this setting.Now, more than ever, research is being conducted to see what measures can be initiated to reduce hospital acquired CAUTIs.Such measures include catheter checklists with algorithms to decrease unindicated catheter use and enhance appropriate and timely removal of catheters when no longer required.

History
Urological problems are protean and have been documented in written human history predating ancient Egypt.In fact, the Hippocratic Oath, recited by the majority of medical school graduates in the United States (US), refers specifically to only two types of clinicians, one of which are "practitioners" of "stone" known in ancient Greece as "lithotomists," but today are known as urologists.
Urinary catheters have been utilized as early as 3000 B.C.The ancient catheters were made out of simple materials such as gold, copper, tin, papyrus, oiled onion stems, and dried reeds, depending upon the natural resources available [1].Malleable urinary catheters were available by the eleventh century.Benjamin Franklin, the inventor that he was, worked with a silversmith to design a flexible silver catheter for his brother who suffered from kidney stones [2].It was not until the eighteenth century that urinary catheters were first fashioned from rudimentary rubber materials.Such catheters were not optimal because they became friable and fractured once inside the bladder due to the higher body temperature [3,4].
Urinary catheters were modernized with the process of vulcanization of rubber, thus stabilizing them at higher temperatures.In the 1930s, Dr. Frederick B. Foley introduced the current iteration of the modern day IUC which was made from latex rubber with a non-disintegrable inflatable balloon at one end.This has been commonly referred to as a Foley or Foley catheter.The design of the balloon (called a retention catheter) allowed for the catheter to remain in place (indwelling in the bladder) with a reasonable degree of patient comfort.Furthermore, such a fixed position permitted external collecting devices (e.g., drainage tubing and bag) to be connected to the catheter.Eventually, the concept of a closed sterile drainage system was introduced which reduced the risk of urinary tract infection (UTI) associated with IUCs.

Catheterization Descriptions
Indwelling catheters are either inserted urethrally (transurethral) or suprapubically (through the abdominal wall).Suprapubic catheterization usually is indicated after bladder, urethral or pelvic surgery, or following genitourinary trauma.In practice, urethral catheterization is the typical approach because the procedure can be organized and managed by registered nurses (RNs) whereas suprapubic catheterization requires specialist involvement for insertion [5].Both methods of indwelling catheterizations are associated with complications.
A closed sterile bladder drainage system includes a balloon-retention catheter, pre-sealed collecting system that includes a drainage tube ending in a drainage bag (see Fig. 1.1 Components of a closed IUC system).Sealed systems use a plastic covering (called a "Tamper-Resistant Seal") that seals the junction where the catheter is attached to the drainage system.They are designed to prevent inadvertent opening of the closed drainage system.However, prepackaged systems may also have the potential disadvantage of allowing only the prepackaged catheter to be inserted [6].Maintaining a closed sealed IUC system may be impractical and unrealistic in patients managed by long-term catheterization who regularly switch from leg bags or belly bags to bedside bags, and in some patients with short-term IUCs.
Though there are many types of urinary catheters, this chapter will discuss only IUCs, those utilized for acute and/ or chronic bladder drainage.Catheters used for intermittent catheterization are discussed in Chap.2; catheters used externally for incontinence are discussed in Chap.3; catheters and stents which are utilized in the upper urinary tract are discussed in Chap.4; urinary drainage bags are found in Chap.5; and urethral inserts are found in Chap.7.

Urinary Retention
A very common indication for urinary catheter placement is urinary retention (UR).Urinary retention is the accumulation of urine in the bladder that occurs due to the inability of the bladder to completely empty (void).UR can be either acute or chronic.Acute UR may have a sudden onset and short duration (a few hours, not days).Typically, the individual cannot urinate at all, even with a full bladder.Acute UR is a potentially life-threatening condition that requires immediate emergency treatment.Chronic UR is manifested by incomplete emptying of the bladder, with or without volitional voiding, resulting in an elevated post-void residual (PVR) urine volume.It is usually not associated with pain and can be a long-lasting condition.Incomplete bladder emptying refers to the sensation or symptom that the bladder does not feel empty after voiding is finished [7].In some cases, there are few if any symptoms or signs of UR and this is particularly relevant in the patient with impaired sensation (peripheral neuropathy secondary to chronic diabetes, spinal cord injury, etc.,) or cognitive dysfunction.Chronic UR is seen in patients with neurogenic lower urinary tract dysfunction (NLUTD) (e.g., multiple sclerosis, stroke, spinal cord injury) and those with overflow incontinence related to poor bladder contractility or bladder outlet obstruction.Typically, individuals with chronic UR can urinate, but are unable to completely empty their bladder and may be unaware they have this condition until they develop another urinary problem.See Table 1.1 for signs and symptoms of UR.
There is no standard definition of partial UR either clinically or within the research realm; therefore, the precise urinary volume that constitutes a diagnosis of UR is not available.Furthermore, the literature does not specify a specific volume above which catheterization is necessary or even recommended.Indeed, such a determination is made by individual practitioners on a case-by-case basis.For example, some patients will maintain PVRs of several hundred milliliters (mLs), but have no symptoms or related complications.In such individuals, catheterization of any kind is not indicated.On the contrary, other individuals will carry a minimal PVR of less than 100 milliliter (mL), but have significant symptoms or complications (e.g., UTIs) that warrant the initiation of some type of catheterization regimen.

Prevalence
An IUC is a very commonly used indwelling device in hospitalized patients.IUCs are inserted in approximately 12-16% of adult patients and up to 25% of all patients [8].Their use is greater in high acuity patient units, with critical care and intensive care units (ICU) having the highest.At least 8-23% of patients admitted through the emergency room receive an IUC [9][10][11].Nearly 50% of surgical patients remain catheterized beyond 48 hour (h) postoperatively.Approximately 50% of medical patients do not have a clear indication for an IUC.Unfortunately, it is not uncommon for clinicians to overlook in the hospitalized patient indications for timely catheter removal which may contribute to prolonged unnecessary urinary catheterization and risk of infection (e.g., CAUTIs) or other related complications.Multiple studies show that between 21% and 55.7% of urinary catheters are placed in patients who do not have an appropriate indication and may not even need one [12].
The prevalence of urinary catheter use in residents in long-term care (LTC) facilities in the US is estimated to be 5-7% [13].
In the community, the prevalence of IUC is difficult to determine since many of the long-term IUC patients are lost to urologic follow-up and are managed by home care nurses or allied professionals.In 2007, a National Home and Hospice Care Survey reported catheter prevalence in home care setting (excluding hospice) at 9% (n = 4683) or 135,000 people with catheters out of the 1.5 million home care patients (http://www.cdc.gov/nchs/fastats/homehealthcare.htm).
While short-term and long-term IUC terminology exists, the length of time associated with short-term versus longterm IUCs is not standardized.Short-term catheterization has been cited to vary from 14 to 30 days; meanwhile, the exact definition for long-term IUC remains quite variable [14].Nevertheless, many experts consider a long-term IUC to be one that is in-situ for more than 30 days.

Indications
Indwelling catheter overuse occurs when a device is in place without an appropriate indication.There are two ways of reducing IUC use: first by minimizing the initial placement of IUCs, second by reducing the duration of each catheterization.Urinary catheters have various medical indications but the most common is short-term drainage of the urinary bladder.Adequate bladder drainage is necessary for a variety of reasons including monitoring urine output for acute medical conditions and following surgical intervention; prevention of upper urinary tract deterioration, comfort at the end of life; and many other situations.
In selected patients with chronic incomplete bladder emptying, long-term IUCs may be indicated under certain circumstances.Incomplete bladder emptying may result in complications such as recurrent UTIs, sepsis, bladder stones, pain, or refractory lower urinary tract symptoms (e.g., overflow incontinence, urinary frequency, urgency, pain, etc.).For patients, where other treatments such as surgery or intermittent catheterization are either unwanted or unable to be initiated, an IUC may be an alternative.In such cases, IUCs are a treatment of last resort, only after other measures have been carefully considered and deemed inappropriate.In such individuals, the catheter should be changed approximately every 4-6 weeks.Careful surveillance of the bladder (via cystoscopy) for malignant changes and, urethral erosion due to the catheter, stones or other complications is warranted in such patients on an annual or bi-annual basis.
For some patients with upper tract deterioration, due to elevated bladder storage pressures (e.g., poor compliance from prior radiation therapy, neurogenic disease, etc.), an indwelling catheter may have a role.The indwelling catheter permits low pressure, unimpeded drainage of urine from the upper urinary tract through the bladder and then directly into a collection receptacle.
The indications for short-term versus long-term IUC differ.These indications will not be discussed in detail but it is  Adapted from [8,14,130] important to recognize that an IUC should be indwelling for the shortest amount of time possible.The CDC HIPAC guideline and other evidence-based clinical practice guidelines have developed criteria for appropriate (see Table 1.2) and inappropriate (see Table 1.3) IUC indications.Although these were developed primarily for the acute care setting, they have application to all care settings [8].

Types
There are two routes for IUC insertion into the bladder: per urethra or transurethrally (see Fig. 1.2) or through a lower abdominal suprapubic incision (see Fig. 1.3) (often referred  to as an "SP tube").The most common route is transurethrally.In both sexes, the catheter is placed into the urethral meatus (opening), traverses the length of the urethra, and then enters the bladder.The return of urine from the external end of the catheter confirms proper location in the bladder.As noted previously, the IUC is held in place by a balloon located at the tip of the catheter that is inflated once the catheter is in the bladder (see Fig. 1.4).Suprapubic catheters are inserted directly into the bladder percutaneously, 2-3 centimeter (cm) above the suprapubic bone in the office, or in the operating room (see Fig. 1.5a-c.Sites of SP insertion) [15].The entrance into the bladder through the skin is known as a cystostomy.

Materials
Catheters are made from various materials and coatings can be applied to the surface of the catheter to improve their biocompatibility, ease their insertion, and minimize infections.Catheter materials and coating can be significant factors when selecting an IUC as each have their advantages and disadvantages.Table 1.4 outlines the advantages and disadvantages for each of the different types of materials used in the manufacture of IUCs.Latex allergy is an important consideration as many urinary catheters are constructed from latex or a related material.Latex catheters are made by immersing a catheter into liquid latex.These catheters cause a latex allergy in 8-17% of medical professionals.In patients, prevalence is higher in those with spina bifida or spinal cord injury (47%).Latex allergy prevalence in the general population is 1-6%.Ideally, manufacturers should eliminate the use of latex and any other potentially anaphylactic or irritating materials in order to minimize such complications associated with urinary catheterization [16].For patients with a latex allergy, a 100% silicone catheter could be an option, whereas a red rubber catheter could not, since it is made out of latex.Silicone catheters are extruded as a continuous tube, cut to a specific length, and the tip and opening are bonded to each end.Silicone catheters have smooth surfaces and are usually not modified, whereas latex catheters are often coated with silicone or polytetrafluoroethylene (PTFE) to help reduce friction.Silicone is a less flexible material than latex which can cause increased discomfort during placement and following insertion.In addition, silicone catheter balloons have "memory" when deflated, which leaves an uncomfortable ridge or cuff on the catheter end, resulting in pain with removal (Fig. 1.6: Deflated silicone catheter with ridge at the location of the deflated balloon).Despite these • Thin-walled, more rigid catheters with a wider lumen diameter that does not allow buildup of protein and mucus (biofilms) • Inert product that is clear or white in color.
• Non-allergenic, non-coated • Superior resistance to kinking • May be preferable for more prolonged catheterization to reduce the risk of encrustation as there is a long lifetime between encrustations and blocking • Latex-free which allows hospitals to ensure a "latex-reduced" environment • Some patients report silicone catheters feel smoother and experience less pain with catheter insertion Usually the outer wall and inner drainage lumen of these catheters are impregnated with an antibacterial agent (e.g., rifampin, minocycline, nitrofural), which exudes from the catheter over a period of days after insertion [23].Antibiotic impregnated catheters, have been shown to reduce bacteriuria in hospitalized patients that have the catheters placed for less than a week [24].But in 2012, nitrofural impregnated catheters were taken off the market.Thus, the utility of either of these two types of catheters in patients requiring longterm bladder drainage, as compared to standard (less expensive) catheters is unknown.

Designs
Catheters come in varying sizes and shapes.The vast majority of IUCs are 41-44 cm in length although specialized catheters that are longer and shorter also exist.Catheter diameter is also variable (Fig. 1.7: Varying Catheter Diameters).J.F.B Charriere, a French instrument maker, standardized a system of catheter sizing with respect to diameter.The French catheter scale, French gauge (Fr or F) or Charriere (Ch), is based on the cross-sectional diameter of the catheter in millimeters.The cross-sectional diameter of a urinary catheter is equal to three times the diameter.For example, a 30 French (Fr) catheter is 10 millimeter (mm) in diameter.
In general, urinary catheters range in diameter size from 8 Fr to 36 Fr, although some highly specialized catheters may be smaller or larger than this range.Since urethral mucosa contains elastic tissue, which will close around the catheter once inserted, the catheter chosen should be the smallest catheter size that will adequately address the indication for insertion.The routine use of large-size catheters (>16 Fr or larger) is not recommended because IUCs with larger diameters can cause more erosion of the bladder neck and urethral mucosa.They can cause stricture formation, and do not allow adequate drainage of periurethral  When deciding which size catheter to use, it is important to consider the patient's gender, the purpose of placing the catheter, and the patients' anatomy.The goal of most catheterizations is to facilitate maximal drainage with minimal patient discomfort and complications.Generally, a 14 Fr is a reasonable compromise for most situations however, other clinical situations, as noted above, may require larger or smaller catheters.For example, if the catheter was placed to promote hemostasis within the urethra, a larger diameter catheter would provide some potential compression to the urethral lumen to minimize some types of bleeding.In addition, larger catheters are more likely to provide improved drainage in the setting of urinary tract debris (sediment, blood clots, stones, etc.).The British Association of Urological Surgeons Suprapubic Catheter practice guidelines [26] recommend a 16 Fr catheter as the minimum diameter catheter suitable for long-term use of a SP catheter.Larger catheters are associated with more discomfort on insertion and are less flexible resulting in relatively greater patient discomfort while in situ.
The distal end of most IUCs contain two ports (lumen/ channel or dual lumen).One is a funnel shaped drainage port to allow efflux of urine once the catheter is placed and the other port is the inflation/deflation port for infusion of water into the retention balloon (Fig. 1.8: Distal end of two channel/lumen catheter).The infusion port for the balloon is usually labeled with the size of the balloon and the size of the catheter (see Fig. 1.9: Balloon port noting catheter and balloon size).Catheter sizes are color-coded at the balloon inflation site for easy identification (see Fig. 1.10).Certain very specialized catheters have a third port (triple lumen) which is also funnel shaped (Fig. 1.11a-d: threeway catheters).This third port allows fluid to flow into the bladder through the catheter in order to "wash" the bladder of blood and debris under certain clinical circumstances.This type of catheter is termed a three-way catheter and is used for continuous bladder irrigation or CBI, usually after some type of lower urinary tract surgery (most often transurethral resection of the prostate [TURP] or for instillation of medication).Standard intravenous tubing and an adaptor can be inserted in the third lumen to allow for infusion of irrigant solution (Fig. 1 can also be used to accurately measure body temperature in the bladder as the third lumen may have a built in temperature-sensing thermometer (see Fig. 1.11c,d).

.11b). Three-way lumen catheters
In general, one should utilize the smallest size catheter that can serve the purpose needed.Larger catheters can lead to catheter obstruction and provide increased pressure at the meatus causing urethral erosion in both men and women [2] (Fig. 1.12 Beginning of a distal urethral erosion down glans, Fig. 1.13a-b Male urethral ventral erosion resulting in hypospadias, Fig. 1.14a-b Female urethral ventral erosion).Of note, there is no evidence to show smaller catheters are associated with a reduction in UTIs.

Balloon Specifics
The balloon of the catheter rests at the base of the bladder, obstructing the internal urethral orifice.Catheter retention balloons range in size from 3 cubic centiliter (cc) for pediatric patients to 60 cc in adults.In general, the smallest balloon size should be used whenever possible.Larger balloons (30-60 cc) are generally used to facilitate drainage or provide hemostasis when necessary, especially in the postoperative period (Fig. 1.15: Varying sizes of inflation balloons).Balloons should be filled with the manufacturer's specified amount of sterile water, which can be found printed on the inflation valve or on the catheter package.Only sterile water should be used to inflate the balloon, as saline may crystallize in the balloon port, obstructing it and, preventing balloon deflation and IUC removal [27].The specified amount of inflation ensures a symmetrical shape and allows for the catheter to maintain position in the bladder while minimizing patient discomfort (see Fig. 1.16 Comparison between instillation of 5 mL versus 10 mL).Over inflation of the balloon can result in balloon rupture, as well as patient discomfort, and may lead to uneven inflation causing the catheter tip to rest against the bladder wall and resulting in irritation and spasm.Several catheter materials have been found to lose water from the inflated balloon over time with 100% of silicone catheters losing as much as 50% of their volume within 3 weeks [28].The surface area, appearance, and diameter of the balloon change following deflation.There is commercially available catheter with dual or two balloons at the end of the catheter (Poiesis Duette Dual-Balloon catheter).The balloon at the tip is intended to reduce the risk of trauma to the urothelium.The drainage eyes perforate a short section of catheter between the two balloons, and the proximal balloon of which serves as the retention device.One disadvantage of the dual balloon is that it may trap more urine in the bladder at the end of drainage, increasing the risk of bladder infection.There is little information on clinical use of dual balloon IUCs.
The balloon channel incorporates a valve to prevent the sterile water from escaping when the syringe is detached.
To remove a catheter, one must first deflate the retaining balloon by withdrawing the water from it with a Luer Lock syringe.This opens the valve in the inflation connector when it is attached.
Occasionally, the inflation balloon of an IUC will not deflate, thereby preventing removal.This can occur for various reasons, including debris in the inflation channel or balloon, a faulty syringe or catheter, the kinking of the catheter or other factors [31].This situation requires careful assessment of the causative factors.Removing a catheter with an inflated balloon is not medically appropriate as it can cause significant urethral trauma.The balloon must be deflated prior to removal.Maneuvers to deflate the recalcitrant catheter balloon are found in Table 1.5.

Catheter Tips and Eyelets
The catheter tip extends beyond the balloon at the end of the catheter.There are 1 or 2 eye-holes, or eyelets, also termed drainage holes (see Fig. 1.17), cut into the tube adjacent to the tip to allow urine to drain.Smooth eyelet surfaces are important as rough surfaces encourage the deposition of bacterial biofilm.Sharp edges to the drainage eyes can cause bleeding from the urethral lining when introducing or withdrawing the catheter.Different catheter tips are available to allow for the least traumatic insertion and maximal drainage.These are listed in Table 1.6.For example, Coudé tip (pronounced "coo-DAY") or curved-tip catheters, which have a 45° curve over the terminal 2 cm of the tip, can be used to ease catheter placement in a man with an enlarged prostate, urethral stricture, or false passage.Such a Coudé-tipped catheter allows easier passage through the "J-shaped" curvature of the male urethra, and allows for smooth insertion through the prostate and bladder neck (see Fig. 1.18a-b).For insertion, the Coudé tip catheter is angled upward (toward the 12 o'clock position) at the tip (see Fig. 1.19).
Council tip catheters, which have an eyelet at the very tip of the catheter, allow for placement in difficult cases where the catheter is required to be placed over a wire.The council tip catheter is passed over a previously placed guidewire traversing the entire urethra that was temporarily put in the bladder via direct visualization with cystoscopy (Fig. 1.20 catheter tips).If one does not have a council tip catheter, a standard IUC can be converted to a council tip with a council tip catheter maker (Fig. 1.21 Council tip catheter maker).Insert a 10 cc Luer Lock syringe at the balloon lumen port and gently aspirate the fluid, which will deflate the indwelling balloon.The volume may be < 10 ccs.If there is concern that all fluid has not been aspirated, remove the syringe, squirt out all aspirated fluid and re-attach and draw back again until no fluid is seen coming out.
• Avoid forcefully retracting the plunger of the attached syringe as a vacuum may be created causing the balloon channel inside the catheter to collapse and seal itself Initial solutions for a balloon that will not deflate, no fluid is aspirated 1. Re-engage and reposition the Luer Lock syringe.If not fully and properly engaged, the balloon will not deflate 2. Stretch or milk the catheter in hopes of dislodging debris in the deflation channel 3. Try wiggling and turning the catheter while gently pulling the plunger 4. Instill 1-2 mL of additional sterile water into the inflation channel to dislodge debris • Be careful to not overinflate and "pop" the balloon as a burst balloon results in balloon fragmentation, patient discomfort and likely will require cystoscopy to remove the resulting residual balloon pieces in the bladder 5. Try a different/new syringe as syringe may be faulty 6. Do not cut the catheter or balloon inflation valve as this rarely is effective and results in a compromised catheter, which is even more difficult to remove 7. Check if patient is constipated as hard stool can cause pressure on the urethra preventing balloon deflation Invasive techniques to deflate the balloon 1. Pass a very thin long guidewire needle in the balloon channel until it touches the balloon.Do not try to puncture the balloon.
If there is any obstruction in the inflation channel, the balloon will be deflated spontaneously or the removal of the wire will induce deflation 2. Using ultrasound, locate the balloon inside the bladder and puncture it suprapubically 3. Use a finger puncture set (like the ones used for prostate biopsies) to locate and puncture the balloon through the rectum (in the male) or the vagina (in the female) 4. Overinflate the balloon past its maximum, so it will burst Any maneuvers that result in balloon rupture may be associated with retained fragments of the balloon within the bladder that requires subsequent cystoscopy in order to retrieve the balloon pieces Fig. 1.17 Eyelet at catheter tip

Transurethral
There are significant differences in the anatomy and the catheterization procedure between males and females.As noted previously, the female urethra is considerably shorter than the male urethra and is much less likely to have anatomic obstruction.The length of the female urethra is only 3-4 cm compared to 15-20 cm or longer in the male.The lumen of the female urethra is almost always collapsed throughout the day, and only expands and dilates during voiding when fluid is passing through it or if a catheter is inserted.Due to different anatomy and urethral lengths in men and women, different maneuvers can be used to facilitate insertion of an IUC.The female urethra is lined proximally with transitional epithelium with squamous epithelium nearer the meatus.The epithelium is flat and ribbon-like.The lamina propria lies under the epithelium and contains a rich vascular network of blood vessels that is influenced by circulating estrogens, which makes it elastic and able to stretch.It is this ability to stretch that allows the catheter to pass through the urethra.Like the female urethra, the male urethra is lined with transitional epithelium proximally, apart from a small area of squamous epithelium close to the urethral meatus (see Fig. 1.24).Directly below the epithelium lies a thin layer of tissue rich in blood vessels but relatively inelastic.Many blood vessels from the corpus spongiosum end just below the mucosa, explaining the tendency to bleed with mild luminal trauma.Injury to the epithelium also provides an entry port for bacteria, which are readily transported via the corpus spongiosum to the blood.Scar tissue is easily formed as a result of trauma to the urethral lining resulting in urethral stricture formation.
In females, urethral catheter placement is generally simple, straightforward, and uncomplicated.Perhaps the most challenging aspect of female urethral catheterization is the localization of the urethral meatus in an obese patient.Urethral obstruction due to stricture is exceedingly rare in females.In addition, the short female urethral length permits ease in catheterization.Women should be placed in the supine or lithotomy position with knees separated to reduce fecal contamination [32].The female meatus is found in the midline just below the clitoris and above the hymenal ring (see Fig. 1.25).Gentle retraction of the labia majora cephalad and laterally will expose the meatus even in the most obese patient who may have a slightly receded urethra.As noted, obese patients with a large pannus or patients with poor hip and leg mobility, may present a catheterization challenge.The use of leg or gluteal lifts such as that shown in Fig. 1.26 can make this procedure easier.Also, in such situations, a two-person catheterization team, one individual to hold the patient in position and/or to assist with the equipment, and the other to actually perform the catheterization can greatly facilitate the procedure.
In the male, urethral catheterization can sometimes be challenging.The male urethra is much longer (15-25 cm) than the female urethra and has a curved course (sometimes called a "J" curve) as it descends in its last 4-5 cm proximally through Any difficulty in catheterization of a male or a female should mandate consultation with a specialist (urologist or urology nurse) early in the process before irreversible damage is done to the urethra.Table 1.7 provides several maneuvers for difficult catheterization in male and female patients.

Suprapubic (SP) Catheterization Tubes
SP tubes are used either for short-term postoperative bladder drainage following gynecologic or urologic procedures, or long-term catheterization in which other methods of management (intermittent catheterization, urinary diversion, etc.) are either contraindicated (e.g., sacral pressure injury) or otherwise impractical.Lavelle [33] accessed the quality of life of 128 patients with an SP catheter (54 females, 35 males).They were carefully selected patients with NLUTD who had failed other options.Over 80% considered the SP catheter to have improved their quality of life around bladder management.Table 1.8 outlines the advantages and disadvantages of suprapubic catheters.Suprapubic catheters are usually inserted during an outpatient surgical procedure.These catheters should be placed with extreme caution in all individuals, but especially in those with relevant prior lower abdominal or pelvic surgery, due to the possibility of bowel adhesions interposed between the skin incision and the bladder, resulting in the increased risk of bowel injury.Additional risks of SP tube in placement include: misplacement of the catheter, bleeding, and incisional hernia.Unrecognized bowel injury is a catastrophic and potentially fatal risk of SP tube placement.Once the SP tube is placed in the operating room under general or regional anesthesia, an epithelialized tract forms over the ensuing 4-6 weeks from the abdominal skin all the way to the bladder.Such a mature epithelialized tract allows subsequent simple removal and replacement of the SP tube without the need for anesthesia or guidewires.A SP catheter does not require sutures to hold the tube in place as it is secured in place by virtue of the inflated retention balloon, similar to an intraurethral IUC.Table 1.9 provides steps for changing a SP catheter.

Catheter Changing Schedule
The optimal interval to change IUCs is not well defined.The time to change can be based on clinical indications such as infection, obstruction, or when the closed system is compromised [8].According to a Cochrane review by Cooper [34], found insufficient evidence to support the conclusion that the presence of bacteria in urine was reduced when catheters were replaced monthly (with no clinical reason to do so) compared to when catheters were replaced only when a clinical reason existed.However, current clinical practice is to change/replace chronic IUCs with a new catheter system every 4-6 weeks to minimize stone formation, biofilm development, and to examine the tube entry site for infection, erythema, or skin breakdown.

Lubrication
Urinary catheters must be lubricated prior to insertion.Lubrication reduces the risk of urethral trauma and pain on catheter insertion, and reduces discomfort and friction, which, in turn, may reduce infection.Protecting the sensitive urothelium from trauma with an unbroken film of lubricant can reduce damage to the urethra.It is recommended that clinicians use a suitable lubricant from a single-use container when inserting urinary catheters to minimize the risk of infection and trauma to the urethra.Many clinicians, especially urology specialists, advocate use of an anesthetic gel (lidocaine gel 2%) prior to catheterization, particularly in male patients.This lubricant serves three important purposes: (1) it provides local anesthesia, (2) promotes pelvic muscle relaxation, and (3) in men, helps to "open" the urethral lumen when the lubricant is held in the urethra using mild compression at the fossa navicularis (just below the glans penis) (see Fig. 1.24).Lidocaine can cause Procedure for difficult male catheterization 1. Lubricating the urethra prior to attempted catheterization can alleviate pain and decrease sphincter contraction that creates resistance to the catheter placement • Gently and slowly instill 10-20 mL, of anesthetic gel (2% lidocaine) or water soluble gel into the urethra.The average male urethra volume is 20 mL • Can use a mixture of 10 mL plain lubricating jelly with 10 mL of 2% lidocaine injected together into the urethra.This makes the mixture longer lasting as lidocaine gel dries out quickly 2. If uncircumcised, retract the foreskin to prep the glans; use a gloved hand to hold the penis still.If penile edema or a buried penis is present, minimize edema by wrapping penis with gauze and apply an elastic compression dressing for 20 min.Expose a buried penis by having an assistant press down firmly around the base of penis 3. Hold penis at 45-90 degree angle to straighten urethra and to eliminate the pendulous curvature of the penis 4. Start with a 16 Fr or 18 Fr catheter.An adult male external meatus should allow a catheter as large as a 24 Fr to pass as the smallest part of the urethra has a caliber of 32 Fr or greater 5. Gently and slowly insert the catheter with your dominant hand, concentrate on your fingers feeling the catheter as it inserts.The bulbo-membranous urethra is the most likely segment to traumatize 6. Encourage patient to take deep breaths and exhale slowly as this helps to relax the sphincter and urethra.The patient may also be instructed to attempt to void without straining as this relaxes the membranous urethra 7. Instruct patient to keep buttocks on the bed and avoid straining while the catheter is being placed 8.If resistance is met at the external sphincter (membranous urethra), the patient should be instructed to attempt to void without straining.This will relax the sphincter 9. Proper position of the catheter is determined by urine return from the drainage port.Advance the catheter an additional 1-2 cm.This maneuver ensures that the balloon inflates in the bladder and not in the urethra 10.If balloon is difficult to inflate or the patient complains of pain with inflation, deflate balloon fully and reposition catheter 11.If unable to pass 16 Fr catheter, switch to larger catheter or an 18 Fr Coudé tip IUC, curved tip pointing up toward the head of the patient (12 o'clock position) during insertion (see Fig. 1.19).
Procedure for difficult female catheterization 1. Position with knees flexed and legs relaxed to opposite sides (frog position) if possible to improve visualization.To further improve visualization, elevation of the pelvis and legs is helpful.Consider use of leg lifts, perineal lift or upside down fracture pan under the buttocks to lift perineum 2. A portable light is recommended to optimize vision 3. Multiple assistants or a speculum can assist with retracting the labia anteriorly and cephalad to expose the meatus 4. In obese patients, additional personnel may be needed to assist with lifting pannus up or spreading labia as meatus may be difficult to visualize 5. Use one gloved hand to prep the urethral meatus in a pubistoward-anus direction; hold the labia apart with the other gloved hand 6. Lubricate catheter only.Can inject anesthetic gel, but will make vulva slippery, increasing difficulty with catheterization

Fig. 1 . 1
Fig. 1.1 Components of a closed sealed catheter drainage system-Courtesy of C.R. Bard, Inc, and Diane Newman

•
Placement and routine use in ICU or elsewhere-without an appropriate indication • As a substitute for nursing care of the patient with UI when nurses can turn/provide skin care with available resources, including patients with intact skin, incontinence-associated dermatitis, pressure injury stages I and II, and closed deep-tissue injury • As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void and/or can provide a suitable clean-catch specimen • For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or contiguous structures, prolonged effect of epidural anesthesia, etc.) • Placement to reduce risk for falls by minimizing the need to get up to urinate • Patient or family request when no expected difficulties managing urine otherwise in non-dying patient, including during patient transport • Patient ordered for "bed rest" without strict immobility requirement (e.g., lower-extremity cellulitis) • Preventing UTI in patient with fecal incontinence or diarrhea or management of frequent, painful urination in patients with UTI.Fecal incontinence and diarrhea should be managed using a fecal containment device

Fig. 1 . 6
Fig. 1.6 Deflated silicone catheter with ridge at the location of the deflated balloon-Courtesy of Eric Rovner

Fig. 1 .
Fig. 1.12 Beginning of a distal urethral erosion down the glans-Courtesy of Diane Newman

Fig. 1 .
Fig. 1.15 Catheter balloons inflated-Courtesy of Eric Rovner Urinary catheter placement is a skill acquired by many clinicians during training.The importance of performing this seemingly simple task correctly cannot be overemphasized.Patient safety and comfort should be maximized at all times.Many patients are anxious regarding catheter placement.Patients should be counseled regarding the indication for catheter placement and reassured regarding comfort, duration of catheterization and removal.Each step of the catheterization should be explained to the patient prior to or during the procedure.Appendix 1 is a guide to routine transurethral catheterization developed by the Society of Urologic Nurses and Associates.Figure1.22 displays a closed system indwelling catheter tray that contains all the supplies necessary for aseptic insertion of an IUC.Catheter trays have recently been developed that contain a packet for perineal care precatheterization with instructions (See Fig.1.23).

Fig. 1 .
Fig. 1.26 (a) Leg and (b) pelvic lifts to improve meatal visualization during catheterization-Courtesy of Diane Newman

Table 1 .1
Signs and symptoms potentially suggestive of urinary retention

Table 1 .3
Inappropriate uses of indwelling urinary catheters

Table 1 .2
Appropriate indications for indwelling urinary catheter • Management of acute urinary retention or bladder outlet obstruction -Acute urinary retention without bladder outlet obstruction (e.g., medication-related urinary retention) -Acute urinary retention with bladder outlet obstruction due to non-infectious, nontraumatic diagnosis (e.g., exacerbation of benign prostatic hyperplasia) -Chronic urinary retention with bladder outlet obstruction preventing intermittent catheterization • Urine output measurement in critically ill patients -Hourly measurement of urine volume required to provide treatment (e.g., management of hemodynamic instability, hourly titration of fluids, drips (e.g., vasopressors, inotropes), or life-supportive therapy -Daily (not hourly) measurement of urine volume that is required to provide treatment and cannot be assessed by other volume and urine collection strategies (acute renal failure work-up, or acute IV or oral diuretic management, IV fluid management in respiratory or heart failure) • Single 24-h urine sample for diagnostic test that cannot be obtained by other urine collection strategies • Reduce acute, severe pain with movement when other urine management strategies are difficult (e.g., acute unrepaired fracture, dying patient) • Assist in healing of stage III or IV or an unstaged pressure injury or similarly severe wounds of other types that cannot be kept clear of urine despite wound care and other urinary management strategies • Improve comfort in end-of-life care when urine collection by catheter addresses patient and family goals in a dying patient • Perioperative use in selected surgical procedures (e.g., prolonged duration of procedure, large volume fluid infusion) and should be removed in post-anesthesia care unit • Urologic/other surgeries (e.g., gynecologic, colorectal) performed on contiguous structures of the genitourinary tract such as bladder or urethra for which a prolonged period of drainage is necessary for healing -When placed just for bladder decompression/filling such catheters can usually be removed at the end of surgery or when the patient is ambulatory postoperatively -When used for reconstructive surgery (urethroplasty, urethral diverticulectomy, urethrovaginal fistula, vesicovaginal fistula, bladder trauma, radical prostatectomy, bladder surgery, augment/partial cystectomy/neobladder, etc.) a catheter may be needed for as long as 7-21 days for proper wound healing and adequate urinary

Table 1 .6
Various types of catheter tips and indications for use

Table 1 .7
Procedures for performing difficult catheterization

Table 1 .
7 (continued) 7. If unable to see urethral meatus: • Clean area with betadine and look for a wink or crevice that indicates the meatus • Use finger and palpate superior aspect of vagina, push up and pull forward on urethra • If catheter is incorrectly inserted in the vagina, leave catheter in place and attempt re-catheterization using a new sterile catheter insertion tray 8.If meatus is receded back into the anterior vaginal wall, or in an obese woman, where visualization of the genitalia is a problem: • Consider using a Coudé tip catheter • Place a finger against the anterior vaginal wall, press up into the urethra and guide the catheter insertion • Place tip of catheter just under clitoris and slide catheter down, pressing against the vaginal tissue at approximately a 30-degree angle pointing up.Slide until dimple of meatus is located Adapted from Leanne Schimke MSN, CRNP, CUNP Table 1.8 Advantages and disadvantages of a suprapubic catheter