Somehow on call July 1st a second straight year. I still have much to learn but just wanted to share some knowledge nuggets for any incoming residents (and perhaps save my fellow urologists a consult or two)
Introducing Foley’s folly: A foolproof guide to catheterization. 🧵1/13
Indications? Namely urinary retention. Sometimes UOP monitoring only when absolutely necessary.
Incontinence should not be a sole reason to place a catheter.
Condom caths or Purewicks are feasible options to avoid placing a catheter!
Absolute contraindications? Suspected/confirmed urethral injury, recent bladder neck closure/repair.
Relative contraindications? Recent urethral surgery or h/o urethral strictures.
This stresses the importance of obtaining a full urological history!
Another absolute/relative contraindication is presence of an artificial urinary sphincter (AUS)!
First of all, ensure that the AUS is in the open position.
Recommend calling Urology if unsure or needing cath drainage.
Cath with AUS can lead to a cuff erosion = BAD!
Urinary retention = Large bladder volume WITH discomfort.
Anchoring a cath is a patient-centered discussion.
I generally like giving a shot with 1x straight cath then anchor if they fail again.
Optimize the patient!
Ambulate, address constipation, remove anticholinergics.
Don’t remove a catheter too early!
Stretched bladder → decreased overlap of actin/myosin → no binding → no squeeze
It may take time (rest) to regain this action back.
Again, optimize the patient as above! And add Flomax!
Also… please don’t start a void trail at 7 PM…😭
Male difficult foley?
Uro will always ask “Did you try an 18 Fr coudé?”
Smaller 14 Fr may seem more logical to get past the enlarged prostate but those will just buckle and risk causing a false passage.
A larger coudé will have the oomph to get past the curve of the prostate!
For an male cath placement, be sure to hub the catheter! You may end up blowing up the balloon in the prostate = BAD!
If uncircumcised, be sure to cover back the foreskin! Or else it can lead to a paraphimosis = BAD!
Slow and steady pressure is key to all successful catheters!
Female difficult foley?
Obesity, prolapse or de-estrogenization can make visualization difficult
The most important tip is EXPOSURE! Get others to help if needed.
You can also use a flipped grey basin under the butt to give an anterior hip tilt and expose the urethra better.
If exposure is truly difficult, place a cath on the top of your index finger and try to guide along the anterior portion of vagina into the urethra.
For a female cath placement, no need to hub the catheter. Insert an extra inch or two after urine return then inflate the balloon.
Difficult foley removal?
Doesn’t exist. Jk…
Ensure balloon is completely empty.
Consider cutting the balloon port as this should help drain too.
Sometimes deflating too much can leave a ridge, creating resistance. Just need a little more traction or 0.5cc back in balloon.
Lastly… For gross hematuria…
Toss out that 16 Fr 3 way catheter! The inner lumen will be tiny.
Go for the 22 Fr or 24 Fr.
And NEVER start CBI unless you know for sure the patient’s clots are all cleared.
Honestly, if a patient needs CBI, best to get Uro involved!
Catheter are basic but can also be dangerous in the wrong hands.
As much as we dislike the “difficult foley” consult, we understand the need sometimes to provide advice and help out.
As long as you do your due diligence, we are here to help with your plumbing needs🚰
/end🧵
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