Characterization and Outcomes of Iatrogenic Urethral Catheterization Injuries

INTRODUCTION

Iatrogenic injury during urethral catheterization is a common reason for inpatient urologic consultation and is associated with increased morbidity and resource utilization. Literature defining the patient population, interventions, or outcomes associated with traumatic catheterization is scarce.

METHODS

We performed a retrospective review of consults for adult urethral catheterization at a single tertiary care center (July 2017-December 2019), with focus on patient characteristics and complications. Traumatic urethral catheterization was defined as catheterization by the primary team with at least 1 of these conditions: gross hematuria, meatal blood, or cystoscopic evidence of urethral trauma. Characteristics collected included urologic history, catheterization circumstances, procedural intervention, and subsequent visits.

RESULTS

Three hundred urology consults for urethral catheterization were identified, including 98 (33%) traumatic events (5.3 incidents/1000 catheters placed). All traumatic catheterization consults were in men (median age 69 years). Most (71%) patients sustaining injury had significant urologic history (eg, benign prostatic hyperplasia, urethral stricture). Sixty-three (64%) consults were determined to be uncomplicated (not requiring any procedural intervention for catheter placement). Gross hematuria was the most common sequela (50% of patients). The 30-day catheter-associated urinary tract infection rate was 13%, and 2 patients developed sepsis. Complications required a total of 52 additional hospital admission days, 19 of which were intensive-care level, as well 113 outpatient urology visits.

CONCLUSIONS

Traumatic urethral catheterization is associated with increased need for procedural intervention, risk of catheter-associated urinary tract infection, and additional resource utilization. Further studies on traumatic catheterization are needed to guide systemic efforts for minimizing injury and cost.

The effect of acute urinary retention on the results of transurethral resection of the prostate

INTRODUCTION

Acute urinary retention (AUR) is one of the most severe symptoms of Benign Prostatic Hyperplasia (BPH). There are some studies in the literature describing the risk factors for the development of AUR in BPH patients. However, the studies that summarize the effect of AUR on Transurethral resection of Prostate (TUR-P) surgery results are limited. The aim of this study is to assess the effect of AUR on TUR-P results.

METHODS

Between 2018 and 2020, patients who underwent TUR-P for AUR or lower urinary tract symptoms (LUTS) were included in the study. The inclusion criteria were, men over 50 years old with a BPH diagnosis and who underwent monopolar TUR-P by a single surgeon. The exclusion criteria were; patients who had prostate cancer, multiple sclerosis, or neurogenic bladder were diagnosed or had previous lower urinary tract surgeries such as TUR-P, TUR-Bladder, Urethrotomy, had a chronic indwelling catheter, and patients who did not accept immediate TUR-P and preferred trial without catheter (TWOC) protocol. The age, PSA, prostate volume, pre- and post-operative flow rates, duration of hospitalization, and complications were recorded. Two groups were constituted for comparison such as AUR and Elective Group and p values <0.05 were considered significant.

RESULTS

There were 14 and 46 patients for AUR and Elective Groups respectively. The age, pre-operative prostate volume, free and total PSA values, postoperative complication rate, and re-hospitalization rate were significantly higher in the AUR-Group. However, there were no differences between groups in terms of pre-operative medication, duration of hospitalization, and post-operative uroflow maximum flow rate.

DISCUSSION

Patients who underwent TUR-P after AUR have a higher risk for complications and re-hospitalization. Care should be taken in these patients and patients should be warned about the risks.

The effect of refined nursing education on improving the urination of patients after renal biopsy

BACKGROUND

To investigate the clinical effect of better nursing education on patients' postoperative urination after renal biopsy.

METHODS

In this study, patients who underwent renal biopsy in the Department of Nephrology at our hospital were selected as the observation group (July-December 2018, n = 120) and control group (January-June 2018, n = 110) and received refined nursing education and routine nursing education, respectively. Postoperatively, the causes of dysuria after puncture, the degree of postoperative pain, and the urination mode were compared between the two groups.

RESULTS

Six patients in the observation group and 23 patients in the control group needed urethral catheterization, accounting for about 5% and 15.2%, respectively. Therefore, the postoperative catheterization rate in the observation group was significantly lower than the control group, with a statistically significant difference.

CONCLUSION

The refined nursing education proposed in this study can effectively improve urinary dysfunction after renal biopsy and has a clinical promotional value.

Retrospective evaluation of the effect of inhalant anesthesia on complications and recurrence rates in feline urethral obstruction

OBJECTIVES

The aim of this study was to evaluate the use of inhalant anesthesia vs sedation for urinary catheter placement in male cats with urethral obstruction. The primary outcome measures were the incidence of complications related to catheterization, the incidence of recurrent urethral obstruction (rUO; both during hospitalization and within 1 year) and survival. The secondary aim of this study was to evaluate the association between baseline serum biochemical concentrations and antispasmodic medications with complications and short-term rUO.

METHODS

We carried out a retrospective review of records from a university teaching hospital from 2009 to 2020. Cats were included if diagnosed with a urinary obstruction, based on the presence of a large, painful and non-expressible bladder, a urinary catheter was placed and hospitalization occurred for a minimum of 24 h. Collected baseline data included age, breed, weight, serum biochemical concentrations and if cats underwent sedation or inhalant anesthesia for urethral catheterization. For the comparison of inhalant anesthesia or sedation, univariate logistic regression was used.

RESULTS

There was no statistically significant difference in complications or the recurrence of obstruction in cats with urethral obstruction that underwent inhalant anesthesia compared with sedation. All serum biochemical concentrations were significantly associated with survival. Decreased serum ionized calcium was found to be statistically significantly associated with higher complication rates (P = 0.0086), as well as short-term recurrence of obstruction (P = 0.004). Increased serum potassium concentrations were found to be statistically significantly associated with the risk of short-term recurrent urethral obstruction (P = 0.0345). No significant difference was found between the use of antispasmodic medications with short-term recurrence.

CONCLUSIONS AND RELEVANCE

No significant difference was found between complications or recurrence rates when comparing the use of inhalant anesthesia to sedation protocols. Baseline serum biochemical data were significantly associated with complications, survival and short-term recurrence rates.

The impact of short term, long term and intermittent E. coli infection on male C57BL/6J mouse prostate histology and urinary physiology

Prostatic inflammation and prostatic fibrosis are associated with lower urinary tract dysfunction in men. Prostatic inflammation arising from a transurethral uropathogenic E. coli infection is sufficient to increase prostatic collagen content in male mice. It is not known whether and how the sequence, duration and chronology of prostatic infection influence urinary function, prostatic inflammation and collagen content. We placed a transurethral catheter into adult male C57BL/6J mice to deliver uropathogenic E. coli UTI189 two-weeks prior to study endpoint (to evaluate the short-term impact of infection), 10-weeks prior to study endpoint (to evaluate the long-term impact of infection), or two-, six-, and ten-weeks prior to endpoint (to evaluate the impact of repeated intermittent infection). Mice were catheterized the same number of times across all experimental groups and instilled with sterile saline when not instilled with E. coli to control for the variable of catheterization. We measured bacterial load in free catch urine, body weight and weight of bladder and dorsal prostate; prostatic density of leukocytes, collagen and procollagen 1A1 producing cells, and urinary function. Transurethral E. coli instillation caused more severe and persistent bacteriuria in mice with a history of one or more transurethral instillations of sterile saline or E. coli. Repeated intermittent infections resulted in a greater relative bladder wet weight than single infections. However, voiding function, as measured by the void spot assay, and the density of collagen and ProCOL1A1+ cells in dorsal prostate tissue sections did not significantly differ among infection groups. The density of CD45+ leukocytes was greater in the dorsal prostate of mice infected two weeks prior to study endpoint but not in other infection groups compared to uninfected controls.

Semen collection by urethral catheterization and electro-ejaculation with different voltages, and the effect of holding temperature and cooling rate before cryopreservation on semen quality in the Japanese macaque (Macaca fuscata)

In the Japanese macaque, semen has been collected by electro-ejaculation (EE), using the higher voltage stimuli compared to other species including genus Macaca. Semen coagulate immediately after ejaculation, which makes difficult to produce high-quality semen for artificial insemination. Recently, semen collection using urethral catheterization (UC) has been reported in carnivore and this technique may allow semen collection without coagulation in a less invasive manner. Further, the temporal preservation temperature and cooling rate of semen during cryopreservation affect post thawing sperm quality. In this study, to improve semen quality and quantity, as well as the animal welfare, semen collection was performed by EE with high (5-15 V) or low (3-6 V) voltage, UC and a combination of the two (EE-UC). It has been suggested that a high voltage is necessary for semen collection, but 10 V stimulation was effective enough and 15 V is for additional sperm collection. Also, liquid semen was collected by EE-UC and this could increase the total number of sperm. Further, to improve the post thawing sperm motility, semen was kept at four temperatures (4, 15, 25 and 37˚C) for 60 min, and processed with two cooling procedures (slow cooling before second dilution and fast cooling after second dilution). Holding semen at 25˚C and fast cooling after the second dilution maintained progressive motile sperm rate. The present results will contribute to the improvement of semen collection and animal welfare of Japanese macaques.

Can detomidine replace medetomidine for pharmacological semen collection in domestic cats?

Among the different methods used for semen collection from domestic cats, the pharmacological collection by urethral catheterization becomes disruptive. Medetomidine is the elected α²-adrenoceptor agonist for that, but in several countries, it is not commercially available. This study aimed to evaluate the efficacy of detomidine compared to medetomidine in collecting semen by urethral catheterization in domestic cats. Urethral catheterization was performed on 13 mongrel cats using a disposable semi-rigid tomcat urinary catheter. Of the 19 semen collections performed with medetomidine induction, 94.7% were successful, while with detomidine induction, only 56.3% of 16 were successful. The values semen samples variables were as follows for volume - 10.56 ± 0.4 vs 8.88 ± 0.5 mL, motility - 171.67 ± 0.79 vs 49.77 ± 3.45%, vigor - 4.1 ± 0.03 vs 3.10 ± 0.1 and concentration - 3.24 ± 0.19 vs 2.15 ± 0.13 ×10⁹ sperm/mL respectively for medetomidine and detomidine group. The failure in semen collections with detomidine was mainly due to azoospermic samples, poor urethral relaxation, insufficient volume, or contamination of urine. The sperm concentration was also lower in the detomidine group (P <0.05) when compared to medetomidine. However, when the volume of semen collected was compared, we found no statistical differences. Despite its low performance in collecting semen from cats, detomidine may be an alternative when medetomidine is not accessible.

A comparison of urethral catheterization duration - three weeks versus two weeks after bulbar urethroplasty

OBJECTIVE

To determine the incidence of bacteriuria, urinary tract infections (UTI), and significant extravasation of contrast on initial postoperative pericatheter retrograde urethrogram (pcRUG) after bulbar urethroplasty in relation to duration of urethral catheterization (DUC) of three weeks versus two weeks after surgery.

METHODS

Retrospective chart review of 100 bulbar urethroplasty patients between January 2015 and November 2015 were compared with 50 prospective bulbar urethroplasty patients from June 2017 to February 2018 operated at the same university hospital. All patients in the retrospective cohort had catheter removal three weeks after surgery, while patients in the prospective cohort had catheter removal two weeks after surgery. Patient groups were compared using t-test and Fischer's exact test.

RESULTS

There was a higher incidence of UTI in patients with a DUC of three weeks after open urethroplasty compared to patients with two weeks DUC (p = 0.03). Occurrence of extravasation on initial pcRUG or asymptomatic bacteruria did not differ between the two groups.

CONCLUSION

The findings in this study suggest that a DUC of two weeks may be more favorable compared to a DUC of three weeks.

A Nurse-Driven Protocol for Foley Catheter Utilization Decreases the Incidence of Traumatic Foley Catheterization

Background: Traumatic urethral catheterization is a common reason for urologic consultation in hospitalized patients. The purpose of this study was to determine if a protocol designed to decrease Foley catheter use was effective and if implementation of the protocol decreased the incidence of Foley catheter-associated trauma. Methods: In an effort to decrease catheter use, our institution adopted a nurse-driven Foley catheter protocol in May 2015 that allowed nurses to remove Foley catheters that did not meet criteria. We conducted a retrospective medical records review of patients who had Foley catheter-associated trauma occurring between February 2013 and March 2018 and compiled data concerning Foley catheter use. Using t test statistical analysis, we compared rates of Foley catheter use and Foley catheter-associated trauma before and after protocol implementation. Results: During the 62-month study period, we documented 83 cases of Foley catheter-associated trauma. Prior to protocol implementation, our institution had mean of 2,903 patient-catheterization days per month. Following protocol implementation, the mean decreased to 2,604 patient-catheterization days per month (P<0.01). Prior to protocol implementation, the mean incidence of Foley catheter-associated trauma was 1.81 traumas per month. Following protocol implementation, the mean incidence decreased to 0.97 trauma per month (P<0.05). Conclusion: Implementation of the protocol was successful in decreasing Foley catheter use as well as Foley catheter-associated trauma.

A Foley folly: Unintended proximal urethral catheterization and balloon inflation causing urethral injury during suprapubic cystostomy exchange

Urinary catheter dysfunction is a common emergency department presentation for patients with neurogenic bladders. Many of these patients have cystostomies requiring routine suprapubic catheter exchange. On complication of outpatient catheter replacement, patients are often sent to the emergency department (ED). We describe the case of an 81-year-old male presenting with painless hematuria and blood from the urinary meatus after undergoing routine cystostomy exchange. During Foley replacement, the suprapubic catheter entered the proximal urethra and the balloon was inflated while in the prostatic urethra, leading to urethral injury and cystic clot formation. Emergency physicians should be aware of this rare complication of suprapubic catheter placement.

Urethral catheterization as an alternative method for collecting sperm in the black-footed ferret (Mustela nigripes)

The endangered black-footed ferret (BFF; Mustela nigripes) is an important example of the benefits of assisted reproduction in species conservation with both semen evaluation and artificial insemination using fresh and frozen sperm being successfully incorporated into the breeding program. Currently, electroejaculation (EE) is routinely utilized for semen collection in BFFs, a technique that requires custom equipment and experienced operators, and does not consistently yield viable samples in this species. In this case study, we evaluated the feasibility of urethral catheterization (UC) for semen collection, a method predominately tested in domestic and non-domestic felids, on four occasions (three BFF males). After general anesthesia with a combination of ketamine, midazolam and α2-agonist dexmedetomidine (thought to promote semen release into the urethra), a lightly lubricated, flexible feeding tube was passed into the urethral opening and advanced ~7-8 cm into the urethra. A syringe attached to the feeding tube was used to apply mild negative pressure to collect sperm. Semen samples were successfully collected on all four attempts. Sperm characteristics ranged as follows: 10.5-26.0 × 10⁶ sperm/ml concentration, 50-90% motility and 36-61% normal sperm morphology. This is the first report of the use of UC as a potential alternative to EE in the BFF, a more field-friendly technique that is less invasive and more consistent for obtaining samples free of urine contamination.

A Rare Case Presentation: Intravesical Catheter Knotting

Urethral catheterization is a common invasive procedure applied for several purposes on children. Voiding cystourethrogram (VCUG) is a diagnostic fluoroscopic procedure, which is commonly used in assessing urinary tract infections in children and which requires urethral catheterization. We report a case of intravesical catheter knotting, which is a rare complication of VCUG.

Adverse Events Following Diagnostic Urethral Catheterization in the Pediatric Emergency Department

OBJECTIVES

The purpose of this study was to assess adverse events associated with diagnostic urethral catheterization (UC) in young children and to determine their impact on the patient and their family.

METHODS

This was a prospective cohort study conducted in the emergency department of a tertiary-care pediatric hospital. All 3- to 24-month-old children with fever who had a diagnostic UC were eligible. Parents who consented to participate were contacted by phone within 7 to 10 days after the UC to answer a standardized questionnaire inquiring about complications. The primary outcome was the occurrence of an unfavourable event in the seven days following UC, defined as painful urination, genital pain, urinary retention, hematuria or secondary urinary tract infection. Secondary outcomes included the need for further medical care and the need for parents to miss school or work.

RESULTS

Of the 199 patients who completed the study, 41 (21%) reported a complication: painful urination in 19 (10%) children, genital pain in 16 (8%), urinary retention in 11 (6%), gross hematuria in 9 (5%), and secondary urinary tract infection in 1 (0.5%). Three (1%) parents reported the need for further medical care and three (1%) missed work. Two independent variables (male sex and age 12-23 months) were associated with a higher risk of adverse events.

CONCLUSIONS

Urethral catheterization is associated with adverse events in 21% of young children in the week following the procedure. Accordingly, this procedure should be used judiciously in children, considering its potential to cause unfavourable events.

The effect of urethral catheterization on the level of prostate-specific antigen

Background:

The normal prostate-specific antigen (PSA) level in patients with urethral catheterization is a controversy. We designed this study to investigate the effect of nontraumatic urethral catheterization without urinary retention on serum PSA.

Materials and Methods:

Seventy patients scheduled for urethral catheterization before elective surgeries were randomly selected and included in the study. They were categorized into two age groups: 40–60 years (Group A) and over 60 years (Group B). Total PSA, PSA density, and free/total PSA were assessed before and after catheterization.

Results:

The PSA levels showed no statistically significant rise after urethral catheterization. The average of PSA level was 1.01 and 1.6 in A and B Groups, respectively, and changed to 1.38 and 1.80 in A and B Groups 1 day after catheterization (P > 0.05). Free/total PSA was 28.75 and 26 in A and B Groups before catheterization and changed to 28.35 and 27.5 in A and B Groups after catheterization (P > 0.05).

Conclusion:

Nontraumatic urethral catheterization has very little effect on PSA level and in patients with urethral catheter routine evaluation of PSA rising should be considered.

Using central venous catheter for suprapubic catheterization in cardiac surgery

Suprapubic catheterization is an alternative method for urinary drainage that is used when transurethral catheterization fails. Traditionally, inserted large-bore suprapubic catheters may cause fatal complications. During the past decade, we used a small central venous catheter (CVC) suprapubicly in 16 male patients for the purpose of urinary drainage, when transurethral catheterization failed. The procedure is performed in no more than 10 minutes. Success rate was 100% and this approach did not lead to any complications. In conclusion, placing a CVC for suprapubic drainage is a safe method with a high success rate and we recommend it in patients with failed transurethral catheterization after a few attempts (2–3 attempts).

Pro: endoscopic realignment for pelvic fracture urethral injuries

Patients with pelvic fracture urethral distraction injuries may benefit from early endoscopic realignment. Realignment is associated with a low risk of immediate complications and has a high success rate for achieving catheter placement. Review of over thirty studies assessing for subsequent urethral stenosis, including at least a dozen that directly compare realignment to suprapubic diversion along, conclude that there is a benefit averaging at least 35% in favor of realignment. Furthermore, realignment may result in easier subsequent urethroplasty and possibly shorter stenoses.

Presentation and prognosis of female acute urinary retention: Analysis of an unusual clinical condition in outpatients

OBJECTIVES

Acute urinary retention (AUR) in females is a poorly defined condition with undetermined epidemiology. This study aimed to evaluate female AUR in an outpatient population.

PATIENTS AND METHODS

One hundred and thirty-eight adult female outpatients who presented to the emergency room with symptoms of urinary retention were retrospectively analyzed. The women who were ultimately diagnosed with true, complete AUR were systematically reviewed for clinical characteristics and management.

RESULTS

In this outpatient cohort with urinary retention complaints, only 23% of the patients were diagnosed with objective AUR. Detailed medical and urological history in addition to urogenital, neurological, and pelvic examinations was essential; urine analysis and pelvic ultrasonography were necessary as baseline investigations. Further radiological and urodynamic tests were required in a minority. Specific etiology was established in 77% of the patients, whereas there was more than one probable cause in 16% of the patients, and no specific cause was found in 6.5% of the patients. Bladder decompression and correction of the underlying cause helped 92.6% of the reviewed patients to eventually achieve spontaneous micturition.

CONCLUSIONS

The proportion of true, complete AUR among female outpatients presenting to the emergency department was 23% following urological evaluation. Acute condition was resolved by urgent catheterization in all, and the majority of women had eventually resumed spontaneous voiding.

Catheterization of the urethra in female pigs

Female pigs are commonly utilized as an animal model for biomedical research and require urethral catheterization. Sixteen pigs were anaesthetized for research purposes and required the placement of a urethral catheter. Post-mortem examination of the vaginas revealed the urethral opening to be consistently halfway from the mucocutaneous junction of the vulva to the cervix. A shallow diverticulum was also observed on the ventral floor of the urethral opening. To optimize conditions for success the pig should be carefully positioned supine, a vaginal speculum and light source should be used, the pig should be adequately anaesthetized, and the anatomy of the vagina should be reviewed.

Suprapubic Bladder Aspiration or Urethral Catheterization: Which is More Painful in Uncircumcised Male Newborns?

BACKGROUND

The aim was to compare the intensity of pain caused by suprapubic aspiration (SPA) and urethral catheterization for urine sampling in premature infants.

METHODS

A prospective randomized controlled design with 80 premature infants in Alzahra University Hospital, Isfahan, Iran was conducted. Premature newborns who needed urine samples for microbiologic analysis were randomly assigned into two groups: SPA group and urethral catheterization group. Newborn faces and upper parts of the body were videotaped during the study and the pain was assessed during urine collection using Premature Infant Pain Profile (PIPP) score. Furthermore, crying time compared between groups.

RESULTS

The mean crying time was significantly higher in SPA than urethral catheterization group (77 vs. 34.4 s) (P < 0.001). The PIPP score was significantly lower in urethral catheterization group (13.4) than SPA group (11.5) P < 0.001. The success rate of SPA was 53% compared with 71% success rate of urethral catheterization.

CONCLUSIONS

SPA is more painful than urethral catheterization in premature male infants as assessed by PIPP score and is more likely leads to procedure failure.

Critical urologic skills and procedures in the emergency department

The evaluation and management of genitourinary emergencies is a fundamental component of the training and practice of emergency physicians. Urologic procedures are common in the emergency room. Emergency physicians play a vital role in the initial evaluation and treatment because delays in management can lead to permanent damage. This article discusses the most common urologic procedures in which emergency physicians must be proficient for rapid intervention to preserve function and avoid complications. An overview of each procedure is discussed as well as indications, contraindications, equipment, technique, and potential complications.