Urinary Catheterization

1. Urinary Catheterization

2. Anatomy and Physiology

3. Bladder - Anatomy

4. Neuroanatomy of Voiding

5. Neuroanatomy of Voiding • Frontal lobe • Micturition center • Sends inhibitory signals • Pons (Pontine Micturition Center) • Major relay/excitatory center • Coordinates urinary sphincters and the bladder • Affected by emotions • Spinal cord • Intermediary between upper and lower control

6. Peripheral Nervous System • Somatic (S2-S4) • Pudendal nerves • Excitatory to external sphincter • Parasympathetic (S2-S4) • Pelvic nerves • Excitatory to bladder, relaxes sphincter • Sympathetic (T10-L2) • Hypogastric nerves to pelvic ganglia • Inhibitory to bladder body, excitatory to bladder base/urethra

7. Normal Voiding • SNS primarily controls bladder and the IUS • Bladder increases capacity but not pressure • Internal urinary sphincter to remain tightly closed • Parasympathetic stimulation inhibited • PNS • Immediately prior to PNS stimulation, SNS is suppressed • Stimulates detrusor to contract • Pudendal nerve is inhibited  external sphincter opens  facilitation of voluntary urination

9. Innervations of the Lower Urinary Tract Function Balance between suprasacral modulating pathways, sacral cord and the pelvic floor Emptying phase: “Voiding Reflex” Series of coordinated events involving outlet relaxation, detrusor contraction Storage phase: “Guarding reflexes” constant afferent input to maintain continence

10. Bladder Dysfunction

12. Functional Classification • Failure to store • Because of bladder • Because of outlet • Failure to empty • Because of bladder • Because of outlet • Combination

13. Pathophysiology of Voiding • Brain lesion above pons destroys master control center • Ex – stroke, brain tumor, hydrocephalus, CP…. • Result – urge incontinence, night incontinence, coordinated sphincter • Spinal cord lesion, myelomeningocele, MS • Detrusor hyperreflexia • Spastic bladder • Areflexic bladder

14. Pathophysiology of Voiding • Lumbosacral spinal lesion • Ex – spinal tumor, sacral SCI, herniated disc, lumbar laminectomy, radical hysterectomy, pelvic trauma • Result – areflexic bladder • Peripheral nerve injury • Ex – AIDS, diabetes, polio, Result – urinary retention

15. Medication Options

16. Bladder Management Options

17. Management Options

18. Management Options

19. Management Options

20. Electrical Stimulation

21. Bladder Augmentation • Procedure that increases bladder capacity using intestinal segments • Ileum, colon, or stomach are used • Goals • Decreasing intravesicle pressure • Restore urinary continence • Preserve upper urinary tracts by alleviating reflux and hydronephrosis • Can combine with a continent abdominal stoma • Consider in patients with • Intractable involuntary bladder contractions causing incontinence • Patients who are able and motivated to perform CIC • Reflex voiders wishing to convert to CIC • Females with paraplegia

22. Urinary Diversion • Diverts the urine flow from the bladder • Secondary form of bladder management when primary methods have failed • Ureters transected just above the bladder and connected to a segment of intestine (terminal ileum) which is in turn brought to the skin of the lower abdominal wall • External appliance used as collection device • Considered if: • Lower urinary complications secondary to indwelling catheters • Urethrocutaneous fistulas, perineal decubitus ulcers • Urethral destruction in females • Hydronephrosis secondary to a thickened bladder wall and for hydronephrosis secondary to vesicoureteral reflux or failed reimplant. • Bladder malignancy requiring cystectomy

23. Recommendations

24. Recommendations • Recommendation 1: Intermittent catheterization is the preferable method for bladder emptying for men and women who have adequate hand function or a willing caregiver to perform the catheterization and have bladders that do not empty adequately. • Recommendation 2: Intermittent catheterization should be ideally performed every 4 to 6 hours to keep bladder volumes below 400ccs.

25. Recommendations from the PVA Guidelines • Recommendation 5: Consider sterile catheterization for those individuals with recurrent symptomatic infections occurring with clean intermittent catheterization. Rationale: Lower infection rates can be achieved with sterile techniques and with pre-lubricated self contained catheter sets

26. Recommendations from the PVA Guidelines • Recommendation 5: Risk of symptomatic infection is at least comparable and may be less in individuals with indwelling catheters than those managing their bladders with clean intermittent catheterization.

27. Recommendations from the PVA Guidelines • Recommendation 6: Patient should beadvised of long-term complications of indwelling catheterization, including: • Bladder stones • Kidney stones • Urethral erosions • Bladder cancer • Epididymitis • Recurrent symptomatic urinary tract infections

28. Genitourinary Assessment of Function

29. Assessment of Function • U/a and c & s • BUN & Cr • if compromised renal function is suspected • Postvoid residual urine • If high, the bladder may be contractile or the bladder outlet may be obstructed

30. Advantages Simple Eval kidney, parenchymal loss, abnl echogenicity Eval for hydronephrosis, stones Disadvantages Low sensitivity for small stones Ureters not evaluated well Renal/Bladder US • Mainstay of screening in many institutions

31. Advantages Functional info No nephrotoxic reactions Low radiation Disadvantage Less anatomic info Cannot detect stones Nuclear Renal Scan

32. KUB • Historically, routinely used to detect renal and bladder stones • Disadvantages • Poorly sensitive to stones • “KUB not justified in routine f/u of urinary tract in SCI” • Tins et al. Spinal Cord 2005

33. Secondary Conditions • Increased risk of • Bladder infection • Kidney infection • Hydronephrosis • Urethral trauma/laxity

34. Urinary Stones and SCI • Higher incidence, especially in first 6 mos • 3-6% upper tract • 11-15% bladder • Etiology • Stasis • Calcium metabolism • Infection • Diagnosis • CT is gold standard

35. No Indwelling Catheter For You!

36. Red Rubbers, $.50 Sterile single use catheters $1.00 No-touch kits with collection bags $4.00 No-touch catheters $2.00 “Bitch catheter”

37. Ultimately, we do what is right for each of our patients,just like we would treat our own family

38. UTI • Indications to treat - No catheter & three of the following present… • Fever (increase in temp >2 degrees F (1.1 degrees C) or rectal temperature >99.5 degrees F (37.5 degrees C) or single measurement of temperature >100 degrees F (37.8 degrees C) );14 • New or increased burning pain on urination, frequency or urgency; • New flank or suprapubic pain or tenderness; • Change in character of urine (e.g., new bloody urine, foul smell, or amount of sediment) or as reported by the laboratory (new pyuria or microscopic hematuria); and/or • Worsening of mental or functional status (e.g., confusion, decreased appetite, unexplained falls, incontinence of recent onset, lethargy, decreased activity).

39. UTI • Indications to treat – w/ catheter & two of the following • Fever or chills; • New flank pain or suprapubic pain or tenderness; • Change in character of urine (e.g., new bloody urine, foul smell, or amount of sediment) or as reported by the laboratory (new pyuria or microscopic hematuria); and/or • Worsening of mental or functional status. • Local findings such as obstruction, leakage, or mucosal trauma (hematuria) may also be present.

40. UTI Follow up • Recurrent UTIs • Predisposing Factors • structural abnormalities - a referral to a urologist • poor perineal hygiene • PRIMARY - reconsider the relative risks and benefits of continuing the use of an indwelling catheter.

41. Neurogenic Bladder What is a neurogenic bladder? • A medical term for overflow incontinence, secondary to a neurologic problem • However, this is NOT a type of urinary incontinence

42. Urinary Catherization • Equipment: • Straight catheters • Box of supplies: foley, 3 way foley, cath kits with sterile gloves, drainage bags with urin Bag, Drape and towel • Tape • Skin so soft lubricant • Overbed table • Good lighting

43. Complication of catheterization 1. Infection- (primary cause) 2. Uretheral tares 3. Ruptured bladder 4. Bladder spasm 5. Possible allergic reaction to tape or latex

44. Urinary Catherization • Purposes of catherization: 1. Relief of discomfort due to bladder distention 2. Assess amount of residual urine 3. Obtain a urine specimen 4. Empty bladder prior to procedure 5. Manage incontinence 6. Provide for bladder irrigation 7. Prevent urine coming in contact with wound 8.facilitate accurate measurement of output in critically ill clients 9. Self catherization for management of neurogenic bladder

45. Types of Equipment: • Catheters 1. Sizes – range from 8 to 18 French indicates diameter. 2. Types a. Straight- single use for intermittent catherization ; has 1 opening b. Foley- inflatable balloon (5cc-30cc), known as indwelling or retention catheters, has 2 openings c. Continuous catheter-3 openings or lumens (1 to drain urine, 1 for filling balloon, and 1 for irrigation), used for periodic or continuous bladder irrigation d. Coude’- curved tip, used on male clients with enlarged prostates or for obstruction

46. e. Suprapubic-inserted through abdominal wall over suprapubic bone and into bladder . f. Condom catheter- used for incontinence, also known as a sheath or Texas catheter (pg1098) Drainage Bags: 1. Regular 2. Urometer 3. Leg bag Psychological Implications • Maintain privacy • Anxiety- need for explainition

47. Cultural Considerations • Gender. • Explain the procedure to client • Meticulous hygiene observed (Muslims use left hand for unclean procedures) • Strict Sterile procedure need to be observed

48. A.In and Out Catherization (no ballon) 1. After client voids, I&O cath to determine amount of residual urine after a foley catheter has been removed 2. Use straight catheter 3. If over 200 cc obtained then physician may order retention catheter (foley catheter) B. Indwelling catherization (Foley) has ballon 1. Need for extra lighting 2. Follow procedure as outlined during practice 3. Discuss taping for male and female- pressure on penile- scrotal angle can lead to necrosis 4. Collection of specimen from port on drainage bag tubing 5. If getting no urine, insert catheter a little more 6. After getting urine, insert catheter another inch

49. 7. Catheter care- once every 8 hours as outlined by policy (peri-care with soap, water, rinse- for uncircumsized males remember to pull back foreskin for cleaning and return to previous position) 8. Encourage fluid intake 2000cc-3000cc per day ( if not on fluid restriction) in order to maintain catheter patency 9. Removal of indwelling catheter- clean gloves, towel, chux, and syringe to accommodate removal of saline in balloon ( never cut)- instruct client to bear down. Note amount of voiding & time after removal of catheter. 10. Equipment changes- foleys should be changed every 10 to 30 days in order to prevent bladder neck necrosis- change bags as needed.

50. Documentation • Size of catheter and balloon • Amount ,color, odor and consistency of urine • How client tolerated procedure