Introduction
Patients who undergo surgery for urinary incontinence or pelvic organ prolapse may require catheterization postoperatively because of voiding difficulty. Patients with neurogenic bladders, dysfunctional voiding, or intractable incontinence may require intermittent or indwelling catheterization for long-term management. Three catheterization methods—transurethral, suprapubic, and intermittent self-catheterization—can be used. Surgeons may also attempt voiding trials on their patients postoperatively. Failure to void with voiding trials usually requires catheterization for a period of days to weeks.
Incontinent patients who fail or decline treatment may use protective products to aid with urine loss. These appliances may be preferable when treatment is too risky or 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 between 5% and 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 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 because of increases in 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 mid-urethral, 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 the bladder architecture and function.
Transurethral Catheterization
The first self-retaining transurethral catheter was described in 1937 by 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 , which 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, 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 Fr. 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 transurethral catheter used during and after procedures is 14 to 16 Fr.
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 infections. The risk of infection after incontinence surgery is approximately 33% to 47%. Forty-five percent of the 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 inability to void with catheter use, 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, which colonizes the catheter tubing and bag. Once these organisms have developed, it is impossible to eradicate the organism from the urinary system. These 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.
New Medicare rules, which took effect in October of 2008, deny reimbursement for treatment of inpatient catheter-associated urinary tract infections and any associated complications. Box 43.1 lists the Centers for Disease Control (CDC) Guidelines for prevention of catheter-associated urinary tract infection.
| A. Examples of Appropriate Indications for Indwelling Catheter Use |
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| B. Examples of Inappropriate uses of Indwelling Catheters |
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Recently there have been advances where catheters are impregnated with various metals or antibiotics to try to decrease risk of infection. In a prospective randomized trial by , it was shown that catheters impregnated with nitric oxide decreased the incidence of formation of Escherichia coli biofilms on catheters. In a Cochrane review by , silver alloy–impregnated catheters statistically decreased asymptomatic bacteriuria in patients who were catheterized for 1 week or less. Also, catheters impregnated with minocycline, rifampicin, and nitrofurazone were found to decrease asymptomatic bacteriuria in patients catheterized for 1 week or less. There were no types of catheters that decreased urinary tract infections after 1 week, and no studies found any catheters that actually decreased symptomatic urinary tract infection.
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 list three acceptable indications:
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Retention (leading to problems) that cannot be surgically corrected or managed with intermittent self-catheterization
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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 from transurethral catheterization may occur when there 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 guide wire should be inserted along the valve inflation lumen and be used to perforate the balloon. If these maneuvers do not work, ultrasound-guided needle perforation through the vagina or suprapubically may be performed using a spinal needle.
Suprapubic Catheterization
demonstrated a lower incidence of bacteriuria and shorter time to reestablish normal voiding with suprapubic bladder drainage, compared to 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 urethral 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 h. See Fig. 43.1 for a list of common types of catheters 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, in additional studies and meta-analyses there seems to be 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 recent case series, suprapubic catheters were placed in patients who underwent surgery for stress incontinence using mid-urethral 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 who took antibiotics and groups who 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 recent systematic review and meta-analysis by , it was found that suprapubic catheterization significantly reduces 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. 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. 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. 43.2 A ). The trocar or needle is removed and the catheter secured ( Fig. 43.2 B,C ). The transurethral catheter is then removed. Correct placement can be verified with a cystoscope.
Intermittent Self-Catheterization
The technique of clean, intermittent self-catheterization (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 had 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. 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 because it is seldom used longer than 6 weeks. ISC can be started immediately postoperatively, or a Foley catheter can be used for the first 24 h. In order to use ISC the patient must have the manual dexterity and mental ability to perform catheterization alone. 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 to create a false passage. A recent Cochrane review by ) found little evidence to suggest that the incidence of urinary tract infections is affected by sterile, single-use, clean reused, or coated catheters.
The technique of ISC can be taught to patients preoperatively or postoperatively by direct demonstration ( Fig. 43.3 and Box 43.2 ). 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. Home sterilization with a microwave oven has been described, but whether this technique is of any clinical significance in preventing bacteriuria and infection remains to be shown. Catheterization can be performed anywhere, and the importance of emptying the bladder often enough to keep the urine volumes obtained less than 400 to 500 mL should be stressed to the patient.
