Introduction
Patients who undergo surgery for urinary incontinence or pelvic organ prolapse may require catheterization postoperatively because of voiding difficulty. Patients with neurogenic bladder, dysfunctional voiding, or intractable incontinence may require intermittent or indwelling catheterization for long-term management. Three catheterization methods—transurethral, suprapubic, and intermittent self-catheterization (ISC)—can be used. Surgeons may also recommend voiding trials for their patients postoperatively. Failure to void with voiding trials usually requires catheterization for a period of days to weeks.
Incontinent patients may use protective products to aid with urine loss. These appliances may be helpful when medical or surgical management is not entirely successful, or when treatment is not an option or is more objectionable to the patient than continued incontinence. This chapter will discuss indwelling catheterization, voiding trials, and various protective products.
Bladder drainage
Obstetricians and gynecologists often encounter the need for bladder drainage in patients after surgery and obstetric deliveries. Urinary retention is common after anesthesia and surgery, with a reported incidence of as high as 70%. General anesthesia can cause bladder atony by relaxing smooth muscle cells and by interfering with autonomic detrusor regulation. Intrathecal anesthetics interfere with the micturition reflex by blocking the afferent nerve supply to the bladder. Local anesthesia does not interfere with voiding function. Surgery for stress incontinence or pelvic organ prolapse also increases this risk by increasing urethral resistance to flow, which places the patient at risk for postoperative retention requiring temporary or prolonged bladder drainage. The risk of this retention after midurethral, vaginal, and retropubic procedures ranges from 3% to 25% and may be up to 47% for pubovaginal sling procedures. Adequate postoperative bladder drainage is important because overdistension is not only uncomfortable, but may lead to infection, as well as difficulty in resuming normal voiding. If overdistension or retention persists, patients may experience secondary myogenic damage attributable to changes in bladder architecture and function.
Transurethral catheterization
The first self-retaining transurethral catheter was described in 1937 by Frederic Foley. A saline-inflated intravesical balloon holds the catheter in place. The transurethral catheter is commonly used after many gynecologic procedures. In a prospective cohort study by that evaluated urinary retention after laparoscopic and vaginal surgery, 21% of the study population developed urinary retention, with the risk of retention greater in vaginal hysterectomy versus laparoscopic hysterectomy. In another study, conducted by , it was found that urinary retention was increased in patients who underwent high-grade cystocele repairs, levator plication, and Kelly plication.
Transurethral catheters may be used for short periods of time and are made of silicone/silastic or latex. Catheters are measured using the Charriere or French scale, where 0.33 mm equals 1 French. The rule of placing a catheter is to use the smallest catheter that will still allow for unobstructed drainage. In female patients, the usual size of transurethral catheter used during and after procedures is 14- to 16-French.
The major difficulty with use of transurethral drainage is the potential for infection. Urinary tract infections account for about 40% of hospital-acquired (nosocomial) infections, and about 80% of urinary tract infections occurring in hospitals are associated with urinary catheters. Pelvic surgery is frequently complicated by urinary tract infection. The risk of infection after incontinence surgery is approximately 33% to 47%. Some 45% of women who undergo obliterative procedures for prolapse develop urinary tract infection within 3 months of surgery. Factors that are associated with development of a urinary tract infection after surgery for prolapse and/or stress urinary incontinence include postoperative catheterization because of inability to void, longer operative times, history of recurrent urinary tract infection, and concomitant procedures. Bacterial colonization of a closed system is unavoidable, with a rate of 5% to 10% per day. The bacteria within the catheter system form an ever-changing biofilm that colonizes the catheter tubing and bag. Once these biofilms have developed, it is impossible to eradicate the organism from the urinary system, and the biofilms will persist until the catheter is removed. It is not recommended to treat asymptomatic bacteriuria in the presence of an indwelling catheter. Urinary tract infections will be eliminated in one third of patients who have their Foley catheter removed.
Medicare rules that took effect in October of 2008 deny reimbursement for treatment of inpatient catheter-associated urinary tract infections (CAUTIs) and any associated complications. Box 39.1 lists the Centers for Disease Control and Prevention guidelines for prevention of CAUTI.
Examples of appropriate indications for indwelling catheter use
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Patient has acute urinary obstruction or bladder retention
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Need for accurate measurement of urinary function in critically ill patients
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Perioperative use for selected surgical procedures
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Patients undergoing urologic surgery or other surgery on contiguous structures of the genitourinary tract
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Anticipated prolonged duration of surgery (catheters inserted for this reason should be removed in the postanesthesia care unit)
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Patients anticipated to receive large-volume infusions or diuretics during surgery
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Need for intraoperative monitoring of urinary output
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To assist in healing of open sacral or perineal wounds in incontinent patients
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Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures)
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To improve comfort for end-of-life care if needed
Examples of inappropriate uses of indwelling catheters
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As a substitute for nursing care of the patient or resident with incontinence
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As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void
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For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or contiguous structures, prolonged effect of epidural anesthesia, etc.)
There have been some advances, such as the development of catheters impregnated with various metals or antibiotics to try to decrease risk of infection. In a prospective randomized trial performed by , it was shown that impregnation with nitric oxide decreased the incidence of formation of Escherichia coli biofilms on catheters. In a Cochrane review by , silver alloy–impregnated catheters did not statistically decrease CAUTI. Catheters impregnated with nitrofurazone were found to reduce the risk of symptomatic CAUTI and asymptomatic bacteriuria in patients catheterized for 1 week or less, although the overall benefit was small. No catheters decreased the rate of urinary tract infections beyond 1 week of catheterization.
Other problems with prolonged use of transurethral catheters include periurethral discomfort and irritation of the trigone, against which the balloon rests. Once the catheter is removed, repeated catheterization is needed if the patient does not void spontaneously.
Indwelling urethral catheters are generally contraindicated for long-term control of urinary incontinence in women. The Omnibus Reconciliation Act of 1987 lists three acceptable indications:
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Retention (leading to problems) that cannot be surgically corrected or managed with ISC
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Prevention of contamination of skin wounds with urine
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The care of impaired or terminally ill patients for whom bedding and clothing changes are disruptive
The risks of long-term urethral catheterization include chronic urinary tract infection, urethral abscess and fistula, bladder stones, bladder spasms, bladder neck erosion, leakage around the catheter, and blockage caused by calcium encrustation.
An infrequent complication of transurethral catheterization that may occur is difficulty removing the catheter from the bladder. This may occur because of encrustation, entrapment by sutures, or inability to deflate the balloon. Reasons for inability to deflate the balloon include problems with the valve mechanism, crystallization of the balloon, or problems with the balloon channel. If this occurs, the first thing to do is try to inflate the catheter balloon with an additional 1 to 2 mL of fluid. If this does not work, then the balloon port may be cut; if the port is the problem, this will allow the balloon to empty its contents. If the balloon continues to remain inflated, there is a problem with the inflation lumen of the catheter; therefore, a surgical steel wire or the stiff end of a guidewire should be inserted along the valve inflation lumen and be used to perforate the balloon. If these maneuvers do not work, a spinal needle can be inserted vaginally or suprapubically under ultrasound guidance and used to perforate the balloon.
Suprapubic catheterization
demonstrated a lower incidence of bacteriuria and shorter time to reestablish normal voiding with suprapubic bladder drainage compared with transurethral drainage after surgical procedures for incontinence. Other studies have supported these findings. Suprapubic catheters have been shown to decrease urethral injury and stricture with long-term use compared with transurethral catheterization and have similar rates of upper tract injury and bladder calculi. Suprapubic catheters also improve patient comfort and ease of nursing care. However, there are few data comparing suprapubic catheters with transurethral catheters with respect to quality of life and user preference. These catheters allow patients to control voiding, and they eliminate the need for transurethral catheterizations to check postvoid residual urine volumes. This makes them preferable for longer-term (more than a few days) use and for use in patients in whom postoperative retention is expected, such as the elderly. Suprapubic tubes are used less frequently than in the past because of their invasive nature, and because most patients who undergo prolapse and incontinence surgery generally do not need a catheter for longer than 72 hours. See Fig. 39.1 for common types of transurethral and suprapubic catheters that are available.
As with transurethral drainage, the main problem with suprapubic catheterization is infection, but to a lesser degree. When suprapubic tubes were used for long-term drainage in patients with spinal cord injuries, 51% developed infections, and 100% had asymptomatic bacteriuria. However, additional studies and meta-analyses seem to show a lower risk for infection from suprapubic tubes versus transurethral catheters. There are other risks associated with suprapubic catheter use. Urinary deposits and blood clots may obstruct the smaller-caliber catheters, necessitating frequent irrigation. The invasive nature of insertion can lead to rare complications such as hematuria, cellulitis, bowel injury, urine extravasation, and catheter fracture. However, suprapubic catheters can be useful in patients who undergo gynecologic procedures that require long-term bladder drainage. In a case series, suprapubic catheters were placed in patients who underwent surgery for stress incontinence using midurethral slings. These patients were able to measure their voiding function and conduct voiding trials at home, which was convenient and time-saving for the patients. In a randomized double-blind trial by , it was suggested that prophylaxis with nitrofurantoin until the catheter was removed decreased the rate of positive urine cultures, without selection for resistant organisms; however, after 6 weeks postoperatively there was no difference between groups that took antibiotics and groups that did not take antibiotics.
Contraindications to suprapubic insertion, especially closed insertion, include extensive abdominal adhesions from previous surgeries, ventral hernia, extensive intraoperative bladder reconstruction, carcinoma of the bladder, and postoperative anticoagulation therapy. Despite these potential problems, suprapubic catheters are preferred to transurethral catheters when prolonged drainage is anticipated or when significant dissection around the urethra has been performed. In a systematic review and meta-analysis by , it was found that suprapubic catheterization significantly reduced postoperative urinary tract infections, although there was increased risk of iatrogenic injury and catheter-associated complications.
Suprapubic catheters can be inserted using an open or closed technique. Cystotomy into the bladder dome under direct visualization is the safest method for use during open abdominal approach surgery. It is preferred when distension of the bladder is difficult, when gross hematuria is present, when there has been a recent cystotomy, or in the presence of gynecologic malignancy. To perform this procedure, the bladder is filled with saline. A stab incision is made through the skin above or below the surgical incision (the suprapubic catheter incision should be separate from the surgical incision) with a scalpel. The catheter and introducer are passed through the skin, muscle, and fascia. The bladder is then punctured through the dome, taking care to avoid large vessels. The catheter is advanced through the sheath or over the needle guide, which is simultaneously withdrawn. Efflux of urine or saline should be ensured. If the catheter has a balloon, it is inflated. The catheter is sutured in place on the skin.
Closed insertion can be performed using a variety of catheters, including an ordinary Foley catheter through an introducer, when there is no abdominal incision (see 
for closed insertion technique). To insert a catheter, the surgeon should place the patient in the Trendelenburg position and fill the bladder through a transurethral catheter or cystoscope with at least 400 to 500 mL sterile saline or water until the bladder is easily palpable abdominally. This positioning helps ensure that no bowel lies between the bladder and the anterior abdominal wall. After the usual skin prepping, the needle or trocar should be inserted through the skin and fascia into the bladder, at a point no more than 3 cm above the pubic symphysis, and at an angle directed downward toward the pubic symphysis ( Fig. 39.2 A). The trocar or needle is removed, and the catheter is secured ( Fig. 39.2 B and C). The transurethral catheter is then removed. Correct placement can be verified with a cystoscope.
Intermittent self-catheterization
The technique of clean ISC was evaluated initially by in patients with incontinence or voiding dysfunction because of neurogenic bladder disease. ISC allows the patient to insert a short plastic catheter into the urethra as needed to empty the bladder. Studies suggest that women using ISC after hysterectomy have lower bacteriuria rates than women with a transurethral Foley.
The rationale for nonsterile, clean ISC is based on the theory that functional abnormalities of the lower urinary tract lead to infection. Decreased blood flow resulting from overdistension is cited as one of the most common causes of infection. The benefits of eliminating overdistension outweigh the disadvantages of intermittent insertion of a nonsterile catheter. Each catheterization event carries a 3% to 4% infection rate, and bacteriuria occurs in most patients within 2 to 3 weeks. Despite this, clinical studies of ISC have shown its safety with long-term follow-up in children with neurogenic bladder dysfunction. Ninety percent of these children were free of major kidney infection after 10 years, despite a 56% rate of intermittent bacteriuria. Since then, ISC has been evaluated in patients with spinal cord injury and multiple sclerosis. A recent review of ISC in spinal cord patients suggests that prophylactic antibiotics should only be used for a short time during the initiation of ISC. Elderly persons have experienced infection rates of up to 12.5% per year with ISC. The frequency of catheterization is the most important factor as far as prevention of infection. There is no difference in colonization or infection rates between sterile catheters and clean catheters. Meatal cleansing offers no advantage either.
The complication rate for postoperative use of ISC should be lower than that for long-term ISC because it is seldom used for longer than 6 weeks. ISC can be started immediately postoperatively, or a Foley catheter can be used for the first 24 hours. To use ISC the patient must have the manual dexterity and mental ability to perform self-catheterization. The bladder capacity should be at least 100 mL. Complications other than infection are rare; they include retention of the catheter and perforation of the urethra, creating a false passage. A Cochrane review by found little evidence to suggest that the incidence of urinary tract infections is affected by sterile, single-use, cleaned and reused, or coated catheters.
The technique of ISC can be taught to patients preoperatively or postoperatively by direct demonstration ( Fig. 39.3 and Box 39.2 ). The patient should be supplied with a device to measure urine and with short plastic or rubber catheters. There are newer hydrophilic low-friction catheters that may be more comfortable than the standard plastic catheters. Patients should be instructed to carry catheters at all times, with separate containers for clean and used catheters. Catheterization can be performed anywhere, and the importance of emptying the bladder often enough to keep the urine volumes obtained below 400 to 500 mL should be stressed to the patient.
