Harwood-Nuss’ Clinical Practice of Emergency Medicine
4th Edition

Placement of urinary catheters is a common procedure in the emergency department. Indications include the relief of urinary retention, monitoring urinary output during resuscitation, treatment of gross hematuria, and urine cultures. Although ordinarily a simple task, urethral catheter placement can sometimes be challenging. As with any other procedure, there are associated risks and complications. Emergency physicians should be able to utilize different types of catheters, overcome the common difficulties encountered in placing them, and be aware of the acute and chronic complications of urethral catheters.

The tortuous anatomy and common anatomic pathologic conditions of the male urethra can make urinary catheter placement difficult. In each section of the urethra there are specific problems that can be encountered. Meatal stenosis, either from prior infections or from congenital malformation, can be diagnosed when the meatus of the penis is fibrotic and nondistensible. A dilation procedure performed by a urologist may be necessary for catheter placement. Hypospadias, a congenital condition in which the true urethral lumen is on the ventrum of the penis, can make placement difficult. Often there is a blind-ended false lumen on the glans penis and the health provider need only look at the ventral aspect of the penis to find the true lumen. The patient can generally tell the clinician which lumen is the true one. Once the lumen is located, it is usually easily catheterized.

The penile and bulbar urethra are the most common sites of urethral strictures. Strictures are usually noticed when the catheter cannot be advanced more than half way into the bladder. An attempt to force the catheter through a stricture often leads to the creation of false passages in the urethra, which can cause urethral diverticula, infection, and the development of fistulas. If this situation is encountered, further attempts to place the catheter should be discontinued until a urology consultation can be obtained. The stricture may require a dilatation procedure or urethroplasty.

In the prostatic urethra, the lobes of the prostate project centrally, making this the site of the most common problem encountered in the placement of urinary catheters. The incidence of benign prostatic hypertrophy (BPH) increases dramatically with advancing years, and, most men older than age 70 have anatomic changes as well as signs and symptoms of BPH. There are a few easy “tricks” that can help negotiate the tip of the catheter around an enlarged prostate. The coudé (elbowed) catheter has an upturned end that slips over the swollen gland. Other techniques include placing a finger in the rectum and applying gentle pressure to the prostate as the catheter is passed. In addition, injecting a water-soluble lubricant retrograde into the urethra to decrease friction will often help.

Patients with a history of a radical or simple prostatectomy commonly have bladder neck contractures (2). Coudé catheters are similarly helpful with these patients. In all instances when the emergency department placement of a catheter has been unsuccessful, the urologist should be consulted.

Although most difficult catheterizations are in men, difficulties can at times arise in the catheterization of women. Women have short and discrete urethras that are usually less than 2 cm in length, which makes them generally easy to traverse with a standard urethral catheter. At times finding the meatus can be problematic. Some obese women have redundant labia majora, which can make visualization of the urethral meatus difficult. In these cases placing the patient in the frog-leg position, using proper lighting, and having someone retract redundant tissue will aid in the location of the urethra and subsequent placement of the catheter.

Prolapse of the pelvic organs (cystocele, enterocele, rectocele, or uterocele) can sometimes obscure the view of the female meatus, but applying gentle pressure to the offending organ generally brings the meatus into view. Some women have a partially prolapsed urethra called a caruncle which can distort the normal anatomy, but a standard urethral catheter can usually be placed around the caruncle without difficulty.

Complications from the placement of urinary catheters occur, but are uncommon. Applying too much pressure to a catheter that is being impeded by a stricture or large prostate can lead to creation of a false passage by undermining the urethral mucosa. This can cause significant hematuria,
promote stricture formation, and lead to infection and sepsis. It is thus best to avoid applying significant force when placing a urethral catheter. In patients with pelvic trauma, urethral patency should be assured via a retrograde urethrogram prior to the placement of a catheter. Multiple attempts at urethral catheter placement should be avoided to lessen the chance of causing or exacerbating urethral injury.

Occasionally a urethral catheter cannot be removed from a patient because the balloon will not deflate. The easiest maneuver is to cut the valve from the end of the catheter, which often facilitates removal. If that does not relieve the obstruction, a guidewire can be introduced into the balloon lumen of the catheter to attempt to relieve the obstruction. If this fails and the catheter needs to be removed emergently, a urologist may have to perform invasive maneuvers for catheter removal. Puncturing the balloon via the perineum is one such technique, but cystoscopy will also be needed to ensure that fragments of the balloon have not been left in the bladder. Fragments left in the bladder put the patient at risk for bladder stone formation.

Patients with alteration in mental status often pull catheters out of their bladder. Replacing the catheter is usually not difficult. However, consideration must be given to the indication for catheter placement. Repeatedly pulling out a urinary catheter puts the patient in jeopardy of developing incontinence secondary to external sphincter damage and can cause significant blood loss.

Chronic complications seen in long-term urethral catheter placement are urinary tract infections and concomitant bacteremia. Sepsis resulting from a chronic indwelling catheter is thought to be rare (5). When a patient presents with signs and symptoms of a urinary tract infection, the catheter should be changed, since bacteria easily colonize catheters after only several days. Patients who have long-term urethral catheterization should have their catheters changed once a month. It should be noted that chronic catheters are almost universally colonized. As such, antibiotic treatment is usually not started for asymptomatic patients. Many studies have documented the overuse of urethral catheters. Probably the best prevention strategy for catheter-related infection is therefore to limit the use of urethral catheterization to cases in which there is a clear indication (4).

Other problems from long-term indwelling catheters include local infections (orchitis, balanitis, and prostatitis), erosive hypospadias, and bladder stone formation (1). In general, urethral catheters are not the treatment of choice for debilitated or incontinent patients. These patients should be managed either with intermittent catheterization or suprapubic catheters.

Placement of a three-way irrigation catheter may be required in the emergency department patient with gross hematuria who complains of symptoms of bladder obstruction. Significant gross hematuria, particularly when clots are present, should be treated aggressively with placement of a three-way catheter and continuous bladder irrigation. Three-way irrigating catheters, as the name implies, have three ports. One port is for saline or sterile water to be dripped in by passive means such as a “Kelly” bag, a 3 L bag of saline that can be attached to the catheter, or a normal 1 L bag if Kelly bags are not available. The second port is for usual urine drainage, and the third port is to inflate the balloon. There are several types of three-way catheters, ranging from a soft plastic coudé-type to others with large holes at the distal end to help the passage of large clots. When there is significant bleeding and clot formation, one should use a three-way catheter with the largest tolerated diameter.

Patients with a suprapubic tube to drain the bladder are not uncommon in the emergency Department. Suprapubic tubes often become clogged with mucus or debris. Suprapubic tubes require routine replacement every 4 to 6 weeks as a result. The tube can be flushed to attempt to relieve the obstruction, as with a standard urinary catheter. If the suprapubic tube has been in place for longer than a month, it can readily be removed without fear of losing the tract. If the SP catheter needs to be changed, the bladder should be filled with water or normal saline before the tube is removed, thereby providing a method of confirmation to ensure correct placement of the new tube.

It is occasionally necessary to place a suprapubic tube on an emergency basis. This will usually be accomplished by a consulting urologist. Although there are various ways to place a suprapubic tube, most urologists use the percutaneous Selinger technique. Patients who are significantly obese, who have had prior abdominal or genitourinary surgery, or who have had multiple prior suprapubic tubes are not candidates for percutaneous tube placement and will require an open procedure to avoid significant complications.

Ureteral stents are commonly used in urology to facilitate urine flow. The most common indication is for stone disease. These are usually double J stents that have curls both in the bladder and in the renal pelvis. They can readily be seen on X-ray and fluoroscopic examination. Emergency physicians should be aware of their indications, complications, and side effects.

Placement of a stent allows the unimpeded passage of urine and helps the passage of renal lithiasis by passively dilating the ureter. In addition, the stents allow edematous ureters to heal. They can allow small stones to pass without any invasive treatment at all. Patients who have signs and symptoms of infected urine and also have an obstructed kidney (either by stones or strictures, or by other entities) often will be stented emergently to prevent septic sequelae.

Common complications from ureteral stents include infection, migration, obstruction, and encrustation. Bacterial colonization of ureteral stents is common. Should the patient with a ureteral stent manifest symptoms of urinary infection or pyelonephritis, therapy with antibiotics that provide adequate coverage for Pseudomonas aeruginosa should be started promptly (3).

Sometimes the patient’s anatomy does not allow for perfect alignment of the ureteral stent either in the bladder or the renal pelvis. When this happens the stent can migrate either up proximally into the ureter or distally toward the bladder. Stent migration manifests with patient discomfort either from hydronephrosis (flank pain) because the stent is not draining correctly or with irritative voiding symptoms. A simple kidney, ureter, and bladder (KUB) X-ray study can verify the placement of the stent (Fig. 83.1).

Other common complications include stent encrustation and obstruction. If ureteral stents are not removed or changed in 3 months, many patients develop encrustation around the stent, and hydronephrosis or renal failure can result. Urgent consultation for removal or changing of the stent is indicated.

The side effects of ureteral stents are a product of irritating the mucosa of either the renal pelvis or the bladder. Patients commonly complain of flank pain, dysuria, frequency, gross hematuria, and urgency. The symptoms usually abate over time and can be controlled with anti-cholinergics such as tolterodine or
oxybutynin, which may be started in consultation with the patient’s urologist.

The use of a loop of bowel to serve as a conduit for urine is a common urologic practice. Radical cystectomy (removal of the bladder) with urinary diversion to a segment of bowel is used for muscle-invasive bladder cancer and other entities. The majority of patients have an ileal conduit, a short piece of ileum that has been removed from the normal fecal stream and has had the ureters attached to it. The distal end is made into a stoma, and urine is collected via an external urostomy bag. Alternative procedures form neobladders that are orthotopically placed; these patients void in the normal fashion. Still other procedures form catheterizable stomas, usually through the umbilicus, which the patient drains with a straight catheter. Emergency physicians should be aware of the common complications—metabolic and mechanical—that occur, primarily of the ileal conduit. Urologic consultation is usually required, since patients often have complicated urologic histories.

As is the case after any large abdominal or pelvic operation, these patients can develop small bowel obstruction. The most common site is around the mesentery of the ileal loop. Hernias can develop around the stoma (parastomal hernias), and incisional hernias are also possible. Because the ureter is sutured to the bowel, strictures commonly occur at the anastomosis, potentially resulting in hydronephrosis, insidious renal failure, or pyelonephritis and urosepsis. Given that most of the ureteroileal anastomosis are freely refluxing, pyelonephritis is common in these patients; chronic pyelonephritis associated with a conduit can result in renal failure. Conduits are chronically colonized with fecal flora, and, therefore, positive urine culture findings should be treated only if the patient is symptomatic.

The use of a loop of ileum or colon for urinary conduits frequently causes a mild hyperchloremic metabolic acidosis, and some patients require chronic alkali supplementation.

Dehydration may exacerbate this chronic acidosis. If it becomes necessary to monitor the urinary output of a patient with an ileal conduit, the emergency physician can insert a small red-rubber catheter in the stoma to drain and monitor the output. Hydrating the patient with normal fluid that is high in bicarbonate and low in chloride is advisable.

Most patients may be discharged home after successful placement or replacement of a urinary catheter. Patients with infected or obstructed ureteral stents usually require urologic consultation and admission.