By the time a urologist is called, 37 percent of patients are injured.
Even the first attempt can cause injury.
By the sixth attempt, injuries can be significant.
Vision can changes these outcomes.
Bleeding after blind catheter passage may be a superficial mucosal tear or a more serious injury. Did you notice the torn and flapping urethral mucosa? The urothelium is just 3 to 4 cell layer thick! Even a passage of a flexible cystoscope can cause a mucosal tear. This video is the first and second pass with a flexible scope.
A prospective analysis of consultation for difficult urinary catheter insertion at tertiary care centres in Northern Alberta This study examines the condition of how a patient presents when a urologist is called. Excluded were all patients who were successfully placed prior to needing the urologist, including those placements made by a urologic nurse. Adverse events included: urosepsis, bladder perforation and urethral trauma. Significant urethral injury as a result of catheterization attempts occurred in 32 percent.
Blind catheter placements can cause injuries and complications.
Trauma after six failed attempts.
Side by Side Trauma after Insertion R001
The urethral urothelium is just 3 to 4 cell layers thick and is easily perforated.
The diagram below illustrates the normal male anatomy that must be navigated during Foley catheter placement.
Blind insertions of Foley and intermittent straight urinary catheters are frequently problematic due to points of resistance in the normal male urethra, which is approximately 9 inches (23 cm) long. In sequential order, the points of resistance likely to be encountered are the angled bulbous urethra, external urinary sphincter and prostate, all of which are in close proximity. When significant resistance is encountered, the patient experiences severe pain. The next step becomes a guessing game that varies considerably depending on the experience and training of the provider.
The most common site of catheter resistance in the awake patient is the contracted external urinary sphincter. The healthcare provider must exert a subjective “gentle” pressure on the catheter to successfully navigate the sphincter. If, however, the tip of the catheter is not located on the sphincter, inevitable trauma will occur to the wall of the bulbous urethra and/or prostate.
Trauma can range from mild tears of the mucosa to complete perforation resulting in acute false passages, further decreasing the chance for successful catheterization. If the patient has altered anatomy from prior instrumentation (including catheterizations) or urinary tract surgery, the encountered resistance further challenges and exponentially increases the risk of injury and complications such as urinary tract infection and bleeding (hematuria).
Evidence-based studies have documented that each additional day of indwelling catheter use increases the risk of bacteruria by five percent. Other complications include sepsis, strictures (scarring), and reconstructive surgical repair, all of which increases length stay (LOS) and overall cost of care.
The following video provides another example of the trauma and resulting gross hematuria created through blind placement attempts.
Issues with Blind Placements
A false passage is an unnatural passage leading off from the urethral pathway, often caused by previous instrumentation or catheterizations.
A stricture is a narrowing in the urethra as a result of injury or inflammation. In a sub-set of patients, there may be a pin hole stricture or multiple strictures. With vision, physician or nurse will see that they cannot push the larger catheter through a smaller opening and now know to stop and call for a urologic consult. Knowing when to stop and not cause injuries is just as important as advancing and placing the catheter. Without vision being used during placement, the tissue around the stricture would likely be damaged or perforated causing a false passage during insertion attempts. This damage would require intervention and treatment by a urologist.
With visually-guided placements, you can see the resistance and assess whether you can navigate around abnormal anatomy and place the catheter. With blind insertions, and given how easily the urothelium is perforated, the second, third, fourth or more attempts may cause significant trauma and injuries. Vision changes all of this.
Acute false passage (from Foley trauma)
Healed false passage
Small caliber stricture (size 6-8 fr)
Risk Factors for DUC
Consider using a visually guided catheterization system in high risk patients on the first attempts when:
- Stricture disease
- False passage
- Acute urinary retention
- Failed voiding
- Enlarged prostate
- Prostate surgery
- BPH with obstruction
- Artificial urinary sphincter
- Lower urinary tract surgery
- Prior difficult insertions
- Anticoagulation therapy
- Bladder instillation of BCG and chemotherapy