Difficult Foley Catheterization

Excerpt

The placement of a Foley catheter is a common clinical intervention performed to allow for external urinary drainage. It is estimated that over 100 million urinary catheters are sold globally every year, with about 30 million used just in the United States.

Urinary catheterization may be performed to relieve bladder outlet obstruction, such as benign prostatic hyperplasia, strictures of the bladder neck or urethra, to treat acute urinary retention, or to adequately drain a hypotonic neurogenic bladder. Routine urinary drainage in perioperative periods or intensive care settings allows for improved bladder drainage, urine chemistry evaluations, and fluid monitoring. Urinary catheterization may be performed to obtain an uncontaminated specimen for culture, irrigate clots or blood from the bladder, instill therapeutic agents intravesically, and evaluate the bladder fluoroscopically or during urodynamic studies.

While most patients tolerate urinary catheterization with minimal discomfort or complications, some patients will endure difficult, painful, or traumatic insertions. Such discomfort is often unnecessary, and multiple attempts at catheter insertion risk significant injury to the urethra, prostate, or bladder. Improper and sub-optimal techniques for addressing difficult urinary catheterizations can lead to bladder distension, reflux, patient discomfort, detrusor damage, unnecessary therapeutic delays, serious urological complications, avoidable urinary infections, permanent scarring, and prolonged hospital stays.

Both normal and abnormal anatomic variations can contribute to failed attempts at urinary catheterization. A patient's urologic history will identify prior surgical or radiological interventions that may impact anatomic relationships important to urinary catheterization. Prior instrumentation, trauma, and sexually transmitted infections can also lead to anatomic changes that could pose a challenge for Foley placement.

A difficult catheterization can be anticipated and properly addressed with a better understanding of patient-reported symptoms, a detailed genitourinary review of systems, obtaining a good urological history, and a thorough physical examination. A risk prediction model to estimate the likelihood of difficult Foley urethral catheterization that will likely require extensive urologic instrumentation has been developed, although it lacks validation. It is also unclear how useful it would be in actual clinical practice.

Education on available techniques, tools, and instruments to assist in performing urinary catheterization can improve successful Foley placements even in difficult patients, minimize preventable urethral trauma, reduce the rate of catheter-related urinary tract infections (CAUTIs), and avoid unnecessary urological consultations. This review article aims to educate and empower readers on the anatomical and physiological basis for difficult urethral catheterizations and outline a practical, reasonable approach to Foley placement when difficulty is anticipated, or several attempts have already been unsuccessful.