Blind catheter placements can cause injuries and complications.
Trauma after six failed attempts.
Trauma or injuries can result on the first pass with a catheter or flexible scope, even if the first pass resulted in a successful placement. In the video below, the first pass with a flexible scope resulted in urethral injury involving bleeding. Notice the torn and flapping urethral mucosa (urothelium).
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.
|Acute false passage (from Foley trauma)||Healed false passage|
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.
|Small caliber stricture (size 6-8 fr)||Multiple strictures|
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.