31.5.7 Urethral Catheterization

Original Article

 

Urethral Catheterization

Urethral Catheterization, Still a Dilemma!!

Muhammad Khalid1, Amjad Ali Siddiqui1, Muhammad Asif1, Muhammad Zulfiqar Anjum2 and Muhammad Hammad Hassan1

ABSTRACT

Objective: To highlight the mechanism of iatrogenic urethral injury, lack of skills in catheterization among junior doctors and prevention strategies for urethral injury.

Study Design: Prospective observational analytical cross sectional study.

Place and Duration of Study: This study was conducted at the Urology Department of Tertiary Care Teaching Hospital, Dera Ghazi Khan from February 2019 to February 2020.

Materials and Methods: We recruited145 male patients referred from emergency& in-patients of this hospital, who had  iatrogenic urethral  injury due to faulty techniques of insertion  or  removal of Foley  catheter. While the patients who pulled out Foley  catheter themselves in altered state  of consciousness, <18 years and female patients were excluded. A questionnaire was designed for collecting patient demographics, mechanism  of Foley catheter related Urethral  injury, setting of incidence of urethral  injury, grade of healthcare professional performing catheterization &management of injuries.

Results: The ages of the patients ranged from 21 to 80 years, with mean age 64.4 ± 5.2.Out of 145 patients who had iatrogenic urethral injuries related to Foley catheterization,110(76%) patients had urethral injury because of Foley balloon inflation in urethra and in 10 (7%) patients Foley catheter was  removed without deflating it’s  balloon. Whereas 25(17%) patients had multiple manipulation/attempts of urethral catheterization which lead to injury.

Regarding the grade of health care professional. Out of 145 iatrogenic urethral injuries, 77(53%) catheterization was performed by house officers, 53 (37%) catheterization   by PGR/MO and 15(10%) by  paramedical/nursing  staff. The major reasons for catheterization 61(42%) were measurement of urine output  followed by catheterization for urinary retention due to enlarged  prostate were 54(37%).

Conclusion: Urethral catheterization still a dilemma, and associated with iatrogenic urethral injuries which is mostly done by junior doctors explaining their lack of the essential skills and knowledge  about technique of catheterization, its removal  and penile anatomy. This study highlights the imminent need for more intensive training and better simulation models for UC insertion.

Key Words: Iatrogenic, Urethral Injury, Foley Catheter, Lack of Skills, Prevention of Urethral Injuries

Citation of article: Khalid M, Siddiqui AA, Asif M, Anjum MZ, Hassan MH. Urethral Catheterization, Still a Dilemma!! Med Forum 2020;31(5):30-35.

 

 

INTRODUCTION

Indwelling urinary  catheters have been an integral part of medical care since the invention of  Foley catheter in the 1930s by Frederick Foley who designed a rubber tube with a separate lumen which was and still used to inflate a balloon which holds the Foley  catheter to be kept in the urinary bladder.16% to 25% of hospitalized patients have an indwelling Foley catheter1,2,3.

 

 

1. Department of Urology / Pediatric Surgery2, Dera Ghazi Khan Medical College, DGK.

 

 

Correspondence: Dr. Amjad Ali Siddiqui, Assistant Professor Urology, Dera Ghazi Khan Medical College , DGK.

Contact No: 0313-6789544

Email: dr.amjadrafiq@yahoo.com

 

 

Received:    March, 2020

Accepted:    April, 2020

Printed:        May, 2020

 

 

 

Annually more than five million patients have been inserted Indwelling urinary catheters, 4% in the patients who  need care at  home  to 25% inthe patients at hospital.4 Although Urethral catheterization is a frequently performed urological procedure, it  can lead to significant morbidity and even mortality.5Routine insertion of Foleys urethral catheters can be  challenging  or even difficult in certain  condition e.g such as urethral strictures, severe phimosis and false passages in urethra that increase the chances of urethral  injuries.6.Many medical devises are used specifically by a trained personnel but  this is not always  true in  case of Foley catheter where  diverse healthcare professionals of all  grades and skills  e.g. urologist, non-urological physicians, surgeons, interns, post graduate trainee ,paramedical and nursing staff perform the catheter insertion7,8          

Junior doctors specially house officer deals patient more frequently  at the first encounter so they should be safe, confident, safe and competent enough at performing Foley catheterization  at the end of their training.9 A study conducted in a  Irish teaching hospital reported that three quarters of catheterization associated injuries occurred when the procedure was performed by interns7.

Improper techniques of urethral catheter insertion lead to urethral injury in male patients, which are preventable. However these iatrogenic injuries often over looked despite that an approximately 0.3% of hospitalized patients suffer these injuries causing significant patient morbidity, cost of treatment and complications.10,11,Foley catheter-related urethral injury occurs by diverse mechanisms. To recognize and to prevent them, two main mechanisms found responsible. One of them is Foley catheter insertion and other is removal of it .Significant urethral trauma can occur when the Foley catheter balloon is inappropriately filled in the urethra, which is relatively non-distensible organ, instead of inflation of balloon in urinary bladder; or when the  catheter and  already filled catheter balloon is accidentally pulled out of the bladder either  by patient himself or by untrained medical and paramedical staff without deflation ..12,13

The incidence of iatrogenic Foley catheter related injuries  found to be  6.7/ 1000 Foley scatheters inserted. 11An American study reported an incidence of 3.2 cases per all 1000 male admissions to a single hospital.10Research in a single institution in Ireland revealed that of 864 inpatient referrals to a urology department, 6% related to urethral injury resulted from male catheterization by clinicians other than urologists.7

Catheter insertion in males is difficult as structure and length of male urethra may render  it vulnerable to injury a fact that remains unrecognized by many health care providers, with added difficulty due to  enlarged prostate or  urethral stricture being  common in  males .Iatrogenic urethral injury associated with catheter insertion may have devastating long-term sequelae for example, urethral strictures, leading  to difficult catheterization& consequently more chances of injury. .What are the ways to manage difficult Foley,s  catheterization are not well known ,thereby increasing the risk of complication. 14,15,16

The proportion of morbidities of iatrogenic injury to  urethra, manifesting as penile and perineal pain, bleeding, urinary retention, urinary infection and/or urethral scarring, is not known but it is likely substantial.17.Moreover, Urethral trauma can result in increased invasive procedures, such as suprapubic catheterization, flexible cystoscopy, urethral dilatation, as well as future difficulty with catheterization/ urethral stricture leading to recurrent urinary retention and urinary tract infection.11

MATERIALS AND METHODS

Participants Recruitment: This study was conducted from February 2019 to February 2020 in the urology department of tertiary care teaching hospital Dera Ghazi Khan .After approval of the Local Ethics Committee, we recruited145 male patients referred from emergency& in-patients of this hospital, who had  iatrogenic urethral  injury due to faulty techniques of insertion  or  removal of Foley  catheter. While the patients who pulled out Foley catheter themselves in altered state  of consciousness, <18 years males and female patients were excluded.

Data Collection Procedure: A questionnaire  designed to gather data relating to patient demographics, mechanism  of Foley catheter related Urethral  injury (inadvertently inflation of balloon in urethra, removal of balloon without deflation  or multiple attempts of Foley catheterization), setting of injury (urethral injury  happened inside the hospital or outside the hospital), grade of healthcare professional performing the Urethral catheter (house officers, medical officers ,paramedical/nursing staff) management of urethral  catheter  injuries and  associated complications. Proforma also included information regarding  whether it is first catheterization  or  previously catheterization done and the most common indications of the catheterization were also noted.

The questionnaire was filled by the attending urology doctor by history form patients and his attendants, physical examination, checking the medical record of the patients, discussing with doctor who initially  performed urethral catheterization.

At the time of initial  evaluation either senior urology medical officers or consultants identified the injury and complications. Standardized definition of iatrogenic UC injuries was used from previously published studies11Urethral catheter insertion injury  defined as  reported  by the physician requesting for consultation of  difficult/ failed  catheter placement with subsequent poor catheter drainage, inability to place a catheter despite repeated attempts, haematuria , along  with  penile swelling and inadvertently inflating the balloon in the urethra (noticed by urologist). Additionally, certain conditions, as urethral and/or perineal pain, blood at the urethral meatus,a non-draining catheter that could not be irrigated, retrograde/antegrade urethrogram demonstrating urethral traumaand cystoscopic  evidence of urethral injury  were noted by urology team.

Immediate complication like penile/peri-urethral swelling, urethral bleeding, urinary retention, perineal /penile pain were notes .All patients were managed with empirical broad-spectrum antibiotic. Management strategy was noted as well.

Data Analysis: The general descriptive statistics were calculated for all variables of interest, including, age, mechanism of injury, grade of health care professional who performed  catheterization , setting of injury ,the reason of catheterization, catheterization  performed  first time or multiple times.

 

RESULTS

Age: The age of the patients ranged from 21 to 80 years, with mean age of the patients 64.4 ± 5.2.

Mechanism of catheterization leading to injury: Out of 145patients who had iatrogenic urethral injuries related to Foleycatheterization,110(76%) patients had urethral injury because of Foley balloon inflation in urethra and in 10 (7%) patients Foleycatheter was  removed without deflating it’s balloon. Whereas 25(17%) patients had multiple manipulation/attempts of urethral catheterization.

Figure No.1: Mechanism of injury

Setting of incident of  urethral injury: Out of 145 iatrogenic urethral injuries, 85(59%) occurred in emergency patients ,and 60 (41%)  from in-patient . Out of 145patient with urethral injury  for 95(66%) patients  it was their first catheterization whereas 50(34%)patients had previous history of multiple catheterization.The major reason of catheterization was  measuring urine put (n=61,42%) followed by, for retention due to enlarged prostate (n=54,37%).Other indications mentioned in table.

Table No.1: Setting of incident of  urethral injury

 

Categories

Frequ-ency

(n=)

%ages

 

Catheterization  happened in

Emergency

85

59

Indoor / Inpatient’s

60

41

Catheterization episode

First time

95

66

Recurrent

50

34

Reason for catheterization

Retention due to Enlarged prostate

54

37

For measuring urine out put

61

42

Retention due to Vesical  stone 

14

10

Retention /difficult urination due to Stricture urethra

16

11

Grade of health care professional performing urethral catheterization: Out of 145 iatrogenic urethral injuries, house officers did 77(53%)  traumatic catheterization, 53 (37%) injuries  by PGR/MO and 15(10%) by  paramedical/nursing  staff.

Table No.2: Grade of healthcare professional

 

Categories

Frequency

(=n)

%age

Catheterization   process performed by

House  officers

77

53

PGR/MO

53

37

Para-medical/

nursing

15

10

Injuries, associated Complications and their management: All patient  presented with cluster of symptoms due to urethral injury e.g. urinary retention followed by haematuria/penile bleeding, perineal or periurethral  edema  and genitalia pain.122(84%) patients were managed by placing supra pubic catheter under USG guidance who had absolute urinary retention. Few patients (n= 15/10%) with partial retention or severe difficulty in passing urine were successfully and gently attempted  per urethral catheter by a urology team with  adequate lubrication and analgesia.

While 8 (6%) Patients have undergone cystoscopy and catheterization as  suprapubic catheter was not possible because of low capacity bladder (inadequate bladder filling);where  cystoscopy  showed false passages.

Table  No.3: Management of urethral injuries

 

Categories

Frequency

(F=n)

%age

Management

Re catheterization

15

10

Suprapubic cystostomy

122

84

Cystoscopy & catheterization

8

6

 

During follow up Patients who had supra pubic cystostomy were advised to have retro grade urethrogram  after 6 weeks and  mostly found to have urethral stricture and for them we have to do  internal optical urethtrotomy/urethral dilatation. Few patients presented with late complication like recurrent urethritis, epididymorchitis and even  prostatitis

DISCUSSION

Urethral cauterization (UC) is  performed routinely  in hospital / clinic settings. Approximately 25% patients admitted in hospitals are catheterized during their inpatient stay. The incidence of iatrogenic UC injuries found is 6.7 per 1000 catheters inserted.10 Total Incidence of 3.2 cases per all 1000 male admitted to  hospital were observed in an American study..17In a Polish  study , conducted between 1995 and 1999, 32.9% urethral injuries resulted from Foley  catheterization18

Mechanism of injury: Trauma results from inappropriate or vigorous force applied  during Foley  catheter insertion, or  from inflation of the balloon while still in the urethra  or inadvertently removing  the catheter without balloon deflation as mention in current study. Although life-threatening complication are un-common, iatrogenic urethral injury is  associated with devastating consequences  e.g. urethral strictures, urinary  incontinence etc . Males are more commonly affected due to their longer urethra. 19        .

Wu AK, Alex et al  observed that  inflation of balloon in urethra have high pressure in the urethra almost two times greater than when the  balloon is  filled in  urinary bladder .As urethra is  relatively non distensible organ, as compared to bladder so more injures happen in urethra. It was also found in their study that balloon pressure is high in the distal part of uretha( e.g fossa navicularis  than proximal urethra.).Interestingly Foleys  balloon with larger filling volumes  need   more force to  extract from the bladder when  it is filled completely. Itjustifies the  injury of urethra when inserting catheter incorrectly or removing the cathter without deflation of balloon. 20. 21

Setting of injury : In  current study most  Foleys catheterization 85(59%)were done in emergency, where patients are usually  attended  by junior   doctors and  paramedics at the very first; It is not uncommon for them to  attempt  insertion of catheter  which if failed  then repeated attempts with  same  or  different catheter done , or another doctor tried to insert Foleys catheter. So multiple  catheterization attempts  leads  injury  the urothelium, which is a  delicate structure being  3 to 4 cell layered only. Repeated unsuccessful attempts cause lots of physical and psychological distress  and causing  further difficulty in Foley catheterization &future reconstruction as well.22    

Difficult catheterization also leads to  urethral injuries as in case of enlarged prostate &urethral stricture  where forceful manipulation  or multiple attempts  can lead to significant urethral  morbidity.19, 15As in current  study 16patients (11%)had  history of stricture urethra  and 54(37%)patients   were catheterized   for enlarged prostate ,both can lead to difficult catheter insertion &  consequently  urethral injury.15,21

Similarly  Previous catheterization also pose  difficulty  in Foley catheter  insertion leading to  multiple or forceful  attempts ,so  more risks of urethral injuries ,as  in our study 50(34%)patient  had history of previous catheterization. Additionally   management of Iatrogenic urethral injuries involves  more invasive procedure like suprapubic cystostomy  and even cystoscopy  that leads to increase hospital stay and  cost of treatment as well.

Grade of health care professional:Insertion of Foleys a Catheter  is being  carried out  by different medical staff  with  variable skills, experience & knowledge  about it.7

We found in current study  that Foley catheter insertion  done  mostly by house  officers and post graduate residents(PGRs)/MOs,77(53%) &53 (35%) respectively of the tertiary hospital ,that signifies the lack of anatomical  knowledge of male urethra &lack of  confidence  in skills for insertion catheter. Iatrogenic urethral injuries also done by non doctors. i.e. paramedical / nursing staff. This deficiency leads to urethral injuries and it complications in our study.Lots of  published literature  discuss about the junior doctor’s attitude ,knowledge and skills for Foleys catheter. An Irish study reported that 864 referral to urology  6% of the urethral injuries were caused  by catheterization  done by non-urologist physicians23 Increasing clinical experience is thought to reduce the chance of causing an iatrogenic UC injury. Interestingly, the current  study demonstrated that 53 (35% ) UC injuries were caused by PGR or MOs, more experienced grades of doctors who are routinely in involved in UC. These findings suggest that correct technique and appropriate training of those routinely involved in these procedures, as well as auditing of iatrogenic injuries with a view to focused training sessions is necessary in the future.

In a recent study at a tertiary  care medical centre ,concluded that  house officers have inadequate  supervision, training, confidence and knowledge  for  Foley catheter insertion and it  reflects  74% incidence of  iatrogenic urethral injuries  by  house officers. 23,24,

several studies  observed   that junior doctors have low confidence and less exposure while in medical school  in inserting Foley  catheter.25 This lack of confidence and insufficient experience is reflected by the fact that one in five first-year U.K. interns had never performed male catheterization and nearly half (45%) had never performed a female catheterization after one year of medical practice.26

Training or education in surgical subspecialty specially urology is very limited regarding the clinical rotation and  at medical college level Increased syllabus of medical students doesn’t let the medical students to learn skills in this overlooked subspecialty, that leads  to lack  of skills during internship.27That ,s why  who did  not get clinical rotation in urology, obviously  will  not  get skills and knowledge about urethral catheter training. Beside this another hurdle for training   that patients are  very reluctant to get  examined specially their genitals ,by  junior doctors which is very common specifically  in private hospitals. In USA , during a single academic year it was found that  there was only a median of nine-third-year medical students   got clinical rotation  in urology.28

Prevention of the foleys catheterization complications: Studies on iatrogenic UC injuries tend to focus on interns and interventions for prevention are usually aimed at this grade of healthcare professional. So at the end of the  study prevention strategy was planned to avoid  injuries and their morbidity. Most important point of strategy was to plan a formal lecture & videos including anatomy of male urethra along with step by step practical demonstration  of catheterization procedure, with particular emphasis on the key points of lubrication, position of the penis and the extent to which a catheter should be inserted. The importance of history taking prior to the insertion should be stressed and conditions and scenarios that are associated with increased risk of urethral injury upon catheterization should be discussed. Hopefully  it  will decrease the  incidence of Foleys catheter related injuries and associated morbidities.

Literature  reviewed emphasised that Foley catheter training should start in medical school so when internship is started  which is very hectic and they can’t focus on  catheter training , they would be already  competent in this skill. Secondly junior doctors  and para  medicals should be supervised by seniors  for , proper techniques of catheterization is essential to prevent urethral injuries in patients.

New techniques of  Foley urethral catheterization are under survey which include   guide wires, urethral balloon dilation, directed hydrophilic mechanical dilators and direct vision endoscopic catheter systems insertion.In view of the significant morbidity caused by Foleys catheters, there is  need to provide a research agenda for developing a safer alternative29

devised by Davis et al provides a protective mechanism  a novel safety syringe catheter to reduce UC injuries by controlling the threshold inflation pressure and is being currently tested in the clinical setting.30

CONCLUSION

Urethral catheterization still a dilemma, and associated with iatrogenic urethral injuries ,which is  mostly done by junior doctors  explaining their lack of the essential skills and knowledge  about technique of catheterization , its removal  and penile anatomy. This study highlights the imminent need for more intensive training and better simulation models for UC insertion. We also emphasize the role for the development of safer urinary catheters in the near future.

Author’s Contribution:

Concept & Design of Study:

Muhammad Khalid

Drafting:

Amjad Ali Siddiqui, Muhammad Asif

Data Analysis:

Muhammad Zulfiqar Anjum, Muhammad Hammad Hassan

Revisiting Critically:

Muhammad Khalid, Amjad Ali Siddiqui

Final Approval of version:

Muhammad Khalid

Conflict of Interest: The study has no conflict of interest to declare by any author.

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