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Catheterisation #4: Troubleshooting

Catheters are common. 15-25% of hospital patients will be catheterised. Competence in catheterisation is assessed at medical school and is a requirement for successful completion of foundation training, yet, in spite of this, inserting catheters correctly and looking after patients with catheters can be challenging for junior doctors.

This series aims to take you though the important basics of catheter insertion, what steps the urologists take when you call them for help and finally to share some useful anecdotal advice learned the hard way from years on the wards.

The Essentials

This is the third in a series on catheterisation. It is preceded by Part #1 and Part #2, and followed by Part #4. This series aims to take you though the important basics of catheter insertion, what steps the urologists take when you call them for help and finally to share some useful anecdotal advice learned the hard way from years on the wards.

After reading the first three installments in this series on catheterisation you should now be reasonably confident in inserting catheters. This fourth installment addresses common issues beyond the technical aspects of catheter insertion.

1. Not sure if it’s in?

If you have inserted a catheter and are not sure it’s in the bladder, or it’s not draining, or something just didn’t feel right, what should you do?

In this situation patients will often have the catheter removed and re-inserted and might undergo this several times before someone is called for advice.

You can try moving the catheter forward into the bladder, which it should do freely, and using a bladder tipped syringe, instill 50-100ml sterile water into the bladder and aspirate back.

If you’re still not convinced, see if you can get your hands on an ultrasound scanner and pass it over the patient’s abdomen. Get someone to show you how your scanner works. You might be able to see the catheter and balloon in the bladder and if you instill fluid at the same time, should be able to see the bladder fill.

2. Bladder spasms

Bladders do not like foreign bodies. When stimulated by having the tip of a catheter rubbing against its mucosa, detrusor muscles can mount forceful and painful contractions in an attempt to empty and expel the irritant.  A sensation of needing to pass urine, intense suprapubic discomfort and bypassing of urine around the catheter is highly suggestive of a bladder spasm. Blocked catheters will also bypass, but in contrast to the intermittent nature of bypassing due to bladder spasms, this tends to be constant and with little or no drainage into the catheter tube. Bladder spasm can be treated with anti-cholinergic medications, reassuring the patient and explaining what is happening as well as only leaving the catheter in for as long as necessary are good ideas too. Smaller catheter and smaller balloons cause less spasm. It may initially seem counter intuitive, but if the catheter is bypassing have a think about deflating the balloon a little to reduce bladder irritation rather than inflating it and trying to occlude the bypassing.

3. Bladder scans

The mobile bladder scanner seen in A&E departments and across hospital wards can be incredibly useful, however the term “Bladder Scanner” might be a misnomer. They are portable ultrasound devices which, when applied to the suprapubic region, can pick up fluid present and estimate its volume on a read out. The scanner will pick up and report any fluid it is pointed at, including ovarian cysts and ascites. They can also be fooled by fibroids. If you are confident the catheter you inserted is in the bladder, but its not draining and the bladder scan shows a high residual, you might not be in the wrong place; think about fluid outside of the bladder,

4. Keeps falling out?

The first question to ask is “was the catheter balloon intact or deflated when the catheter fell out”.  Catheter balloons tend to slowly deflate over time, but if a catheter falls out with a deflated balloon after only recently being inserted this is suggestive of a bladder stone popping the balloon. Get an ultrasound of the bladder.

If the catheter comes out with the balloon inflated, check how much was put in when the catheter was inserted. Most two way catheters are designed to hold 10ml. If the problem continues, a suprapubic catheter may be more appropriate.

5. Painful Catheterisation

Plastic tubes in the urethra can, unsurprisingly, cause a lot of discomfort. They can tug and pull, and in the longer term lead to traumatic urethral damage. Only leave them in for as long as absolutely necessary. If patients are having a hard time with catheter, get a thigh strap. Learn how to put it on properly – it should be secured around the catheter drainage port and not on the tubing of the catheter bag to be effective. In a fix, liberal application of Mefix dressings or pink Elastoplast tape can be used.

This is the fourth and final part of our series on catheterisation. Got something to add? Why not head over to our Community?

Words by Dr. Paul Sturch.


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