Male Urethral Catheterization
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《新英格兰医药杂志》
To the Editor: A simple procedure can have devastating consequences when performed incorrectly. The Video in Clinical Medicine demonstrating male urethral catheterization (May 25 issue)1 covers many important points well: the routine use of viscous lidocaine, the need for complete advancement of the catheter before balloon inflation, and the need to use large catheters in men with benign prostatic hypertrophy. Any procedure consists of a series of well-orchestrated small steps. For this reason, I would add the following:
First, to avoid a breach in sterile technique, the lidocaine should be opened on the sterile field and administered with the clinician's dominant hand after, rather than before, the glans has been sterilized. Second, the catheter should be inserted while unattached to the bag; this step enhances tactile feedback and will help the novice learn how normal prostatic resistance feels. The need for a closed drainage system is an issue only after the sterile procedure is completed. Third, after the catheter has been advanced to the balloon port, the release of manual pressure should not cause the catheter to recoil. This simple test confirms the absence of intraurethral coiling, providing a second fail-safe measure against intraurethral inflation of the balloon. Fourth, the raised rubber bump on the proximal portion of the drainage port of a coudé catheter corresponds to the direction of the tip. Directional cues can be lost after the tip has been inserted, and this landmark can be used in making adjustments.
David Canes, M.D.
Lahey Clinic Medical Center
Burlington, MA 01805
david.canes@lahey.org
References
Thomsen TW, Setnik SG. Male urethral catheterization. N Engl J Med 2006;354:e22 (Web only). (Available at http://nejm.org/cgi/content/short/354/21/e22.)
The authors reply: We would like to elaborate on several of the issues Canes raises. Viscous lidocaine is likely to be most effective if left in the penile urethra for 5 to 10 minutes before catheterization, allowing time for adequate anesthesia of the mucosa.1,2 Injecting the lidocaine before sterilization3 and having the patient compress his urethra with his own hand2 have been mentioned in descriptions of the procedure, although this practice might theoretically increase the risk of iatrogenic infection. Ideally, the lidocaine should be injected after sterilization and allowed to remain in the urethra for an extended period. However, busy clinicians often forgo this step and insert the catheter immediately after administering the lidocaine.
Maintenance of a closed drainage system is of paramount importance in preventing urinary tract infections during penile catheterization, and the use of catheters with preconnected, sealed junctions to the drainage tubing has been shown to decrease the incidence of nosocomial infection.4 At our institution, we use such devices and do not routinely disconnect the sealed junction before catheterization. In the video, a coudé catheter was used; therefore, the preconnected Foley catheter was removed and replaced before the procedure was begun.
Todd W. Thomsen, M.D.
Gary S. Setnik, M.D.
Mount Auburn Hospital
Cambridge, MA 02138
tthomsen@mah.harvard.edu
References
Carter HB. Basic instrumentation and cystoscopy. In: Walsh PC, Retik AB, Vaughan ED, et al., eds. Campbell's urology. 8th ed. Philadelphia: Saunders, 2002:113.
James RE, Palleschi JR. Bladder catheterization. In: Pfenninger JL, Fowler GC, eds. Procedures for primary care. 2nd ed. St. Louis: Mosby, 2003:874.
Cancio LC, Sabanegh ES Jr, Thompson IM. Managing the Foley catheter. Am Fam Physician 1993;48:829-836.
Platt R, Polk BF, Murdock B, Rosner B. Reduction of mortality associated with nosocomial urinary tract infection. Lancet 1983;1:893-897.
First, to avoid a breach in sterile technique, the lidocaine should be opened on the sterile field and administered with the clinician's dominant hand after, rather than before, the glans has been sterilized. Second, the catheter should be inserted while unattached to the bag; this step enhances tactile feedback and will help the novice learn how normal prostatic resistance feels. The need for a closed drainage system is an issue only after the sterile procedure is completed. Third, after the catheter has been advanced to the balloon port, the release of manual pressure should not cause the catheter to recoil. This simple test confirms the absence of intraurethral coiling, providing a second fail-safe measure against intraurethral inflation of the balloon. Fourth, the raised rubber bump on the proximal portion of the drainage port of a coudé catheter corresponds to the direction of the tip. Directional cues can be lost after the tip has been inserted, and this landmark can be used in making adjustments.
David Canes, M.D.
Lahey Clinic Medical Center
Burlington, MA 01805
david.canes@lahey.org
References
Thomsen TW, Setnik SG. Male urethral catheterization. N Engl J Med 2006;354:e22 (Web only). (Available at http://nejm.org/cgi/content/short/354/21/e22.)
The authors reply: We would like to elaborate on several of the issues Canes raises. Viscous lidocaine is likely to be most effective if left in the penile urethra for 5 to 10 minutes before catheterization, allowing time for adequate anesthesia of the mucosa.1,2 Injecting the lidocaine before sterilization3 and having the patient compress his urethra with his own hand2 have been mentioned in descriptions of the procedure, although this practice might theoretically increase the risk of iatrogenic infection. Ideally, the lidocaine should be injected after sterilization and allowed to remain in the urethra for an extended period. However, busy clinicians often forgo this step and insert the catheter immediately after administering the lidocaine.
Maintenance of a closed drainage system is of paramount importance in preventing urinary tract infections during penile catheterization, and the use of catheters with preconnected, sealed junctions to the drainage tubing has been shown to decrease the incidence of nosocomial infection.4 At our institution, we use such devices and do not routinely disconnect the sealed junction before catheterization. In the video, a coudé catheter was used; therefore, the preconnected Foley catheter was removed and replaced before the procedure was begun.
Todd W. Thomsen, M.D.
Gary S. Setnik, M.D.
Mount Auburn Hospital
Cambridge, MA 02138
tthomsen@mah.harvard.edu
References
Carter HB. Basic instrumentation and cystoscopy. In: Walsh PC, Retik AB, Vaughan ED, et al., eds. Campbell's urology. 8th ed. Philadelphia: Saunders, 2002:113.
James RE, Palleschi JR. Bladder catheterization. In: Pfenninger JL, Fowler GC, eds. Procedures for primary care. 2nd ed. St. Louis: Mosby, 2003:874.
Cancio LC, Sabanegh ES Jr, Thompson IM. Managing the Foley catheter. Am Fam Physician 1993;48:829-836.
Platt R, Polk BF, Murdock B, Rosner B. Reduction of mortality associated with nosocomial urinary tract infection. Lancet 1983;1:893-897.