LECTURE: GILLS Rural Urology: Managing Foley’s Catheter Including Non-Deflating Balloons in Rural Areas – Thursday, August 13, 2020

INSERTION OF CATHETER

Insertion of Foley’s catheter is one of the most carried out procedure that can cause serious problems if not done carefully.

The picture given below shows the normal curves of the male urethra [1]. Insufficient lubrication and forcible insertion can cause trauma to the Urothelium causing Urethral strictures especially at the curve. To avoid such injuries, it would be good to have only one curve to negotiate and hence the penis is shifted towards the head end and only the bulbar curve is there for negotiation. At the level of the sphincter patients can often hold tight preventing the catheter from going in. Patient and gentle pressure would help the catheter go past the sphincter without injury.

Points to remember while inserting are

• Antibiotic cover is preferred
• Adequate lubrication
• Position so that there is only one curve to negotiate
• Gentleness and patience

SELF CALIBRATION

Self- calibration or self-catheterization is advised for urethral strictures [2] or neuro- vesical dysfunction. This is not carried out with all the sterile precautions as in hospital setting. However, there are few points to note

• The catheter has to be clean and dry. It is good to have few catheters in stock and hang them to dry so that the inside and outside are dry
• The penis and perineum are clean. A good time is just after bathing
• The bladder has to be full at the start of the procedure and is emptied either with the catheter or passing urine [in case of stricture] after passing the catheter. The reason for this is that the bacteria that were introduced with the catheter are washed away

DRAINAGE AND CLAMPING THE UROSAC

It is never a good idea to clamp the catheter. It should be connected to a urine drainage bag for continuous drainage. However, when there are two catheters [for example SPC and urethral catheter] one of them could be blocked. The points to note are

1. Blocking or tying should be distal to the Foley’s bulb channel. It is preferable to fold and tie with thick silk thread
2. To maintain the curve mentioned earlier the catheter should be fixed with an adhesive with a mesentry to the abdomen. This is important when the catheter drainage is for a long time. The Urosac or the drainage bag should be fixed separately too
3. If for some reason the catheter needs clamping it should be done at the Urosac tubing and not at the catheter tubing.
4. Bubbles and large column of air in the tubing can cause airlock and block catheters. Hence the catheter tubing should be filled with urine and one has to slowly make sure that this is carried out [by folding the catheter as shown]
5. The level of the urine collection bag should be below the level of the bladder. Many patients use a cloth shoulder bag to carry the Urine collection bag when they go for a walk.

ABNORMAL SITUATIONS

The following are helpful to remember when there are problems

1. Patient should have adequate hydration to maintain a good urine output. More precipitations occur with alkaline when there is infection with Proteus Mirabilis.
2. When the catheter is blocked, if irrigation is going on it should be stopped first to prevent the bladder from distending.
3. Twisting and releasing the tubing can create some suction force and could be tried first as the system is still a closed sterile drainage system
4. If the catheter is disconnected sterile drapes and cleaning solution and clamp to fix the tubing should be available.
5. Pushing sterile fluid in has better chance of relieving the block than suction. However, the block can and does recur. For a tight and comfortable fit a 2 ml syringe is the ideal one if Asepto syringe is not available
6. If the bladder is distended and washes does not seem effective it would be a good idea to remove the catheter and allow the patient to pass urine and then reinsert the catheter
7. If long term catheterization is required silicon catheters could be used or catheter balloons could be inflated with Triclosan [which diffuses out and inhibits the enzyme Urease] [3]. Biofilm formation with urine infected with Proteus Mirabilis and alkaline pH contribute to encrustations [4]. Treatment with Septran or Co – trimoxazole for two weeks might be indicated in patients requiring long term catheterization [5]

IN THE OPERATING ROOM

The following information would be helpful in selected situations

1. In difficult situations if the catheter is not going in the Ureterorenoscope could be used to pass a guidewire under vision and then slide the catheter over it. This is especially useful if a larger SPC catheter needs placement. The tip of the catheter could be slit with a number 11 or 15 blade to allow easy passage over the guide wire
2. When it is possible to enter the bladder only with a scope a half round sheath could be used to insert a catheter. 14 F catheter is the one that will go easily with the help of half round sheath.
3. When there is difficulty in passing catheter, a guide wire could be passed inside the lumen to make the catheter stiffer. This would help negotiate flimsy adhesions or stricture.
4. If bladder needs filling and Asepto syringe is not available a 2ml syringe and another larger syringe could be used to fill the bladder

5. Blocking the irrigation port of a three-way catheter could be comfortably done with the needle cover of a disposable needle. It comes in a sterile packing.

NON-DEFLATING FOLEY’S BALLOON

Non deflating Foley balloon is not an uncommon problem. The following could be tried [6]

• Advance further into the bladder and try to deflate
• Cut the balloon port proximal to the valve. This eliminates the malfunctioning valve
• Pass a lubricated fine guide wire through the balloon channel and try and break the balloon
• A 22 G central venous catheter over the guide wire has been suggested but it is an expensive option

• If the above methods fail chemical could be used to dissolve the balloon. The bladder should be filled before doing this. Ether, Chloroform, Liquid Paraffin have been used for this along with other substances like acetone and mineral oil. This is not a good method as it can cause urinary tract infection, irritative voiding symptoms, stone formation, etc.
• Balloon rupture with sharp instrument through transurethral, transvaginal, transperineal and transrectal routes have been advocated.
• The spinal needle could be used transurethral or via lower abdominal wall or perineum to puncture holding the balloon tight against the bladder neck.

• Ultrasound guidance and Ureterorenoscopic guidance could be used when available
• We have also used a bugbee electrode via Ureterorenoscope and cutting current to rupture the balloon.
• Traction, digital rectal palpation and guidance and puncture with spinal needle is a blind successful method

Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is an urologist and laparoscopic surgeon trained at CMC Vellore. He is the Past President and Project Lead for the Project GILLS of the Association of Rural Surgeons of India, the Secretary of the International Federation of Rural Surgeons and board member of the G 4 Alliance. He is also an Adjunct Professor at Karunya University. He has over 400 publications in national and international Journals related to rural surgery and has won many innovations award like the EHA innovation award, Antia Finseth award, the Lockheed Martin award, the Millennium Alliance award, etc., He has few patents and the low cost equipment is listed in the WHO compendium of medical equipment for resource poor setting. He has helped many hospitals start Minimally Invasive Surgeries. The popular innovations that have made MIS possible in rural areas are the Gas Insufflation Less Laparoscopic Surgeries and the Laptop cystoscope.