We initiated the technique in 2011, and started compiling data 4 years later. From January 2015 to April 2018, a total of 764 consultations were called into the urology service for assistance, due to the inability of the primary team to successfully insert an indwelling urinary catheter. Of these, the urology service was able to successfully insert 526 catheters on the first attempt (68.8%); another 204 patients (26.7%) required the use of our described protocol; 29 (3.8%) needed the assistance of bedside flexible cystoscopy for the guidewire placement; and 5 (0.7%) needed to go to the OR for suprapubic tube placements or endoscopic manipulations, due to failure of our procedure. No complications such as bleeding, additional false passages, or bladder or rectal injuries were encountered from the bedside maneuver.
As the US population ages, the number of patients with urologic conditions has increased dramatically.1,2 In contradistinction, the number of practicing urologists is forecasted to diminish, based on the average practitioner age of 55 years and the decreasing number of graduating urology residents.3,4 Hospitals and medical practices have come to rely on PAs and NPs to fill the gap between the increased demand and shrinking urologist workforce.5,6 New York Presbyterian Queens has recorded a significant increase in the number of inpatient consultations requesting assistance with difficult indwelling urinary catheter placement, from 114 in 2015 to 315 in 2017. Clinicians must have a method that is simple, can be taught to PAs, and does not require advanced surgical experience or equipment.
Little is taught about urinary catheter placement in nursing, PA, or medical schools. Indwelling urinary catheters are needed to address urinary retention or monitor a patient's urine output. Often, the task is delegated to the nurse, medical student, PA, or resident in training. Typically, by the time the urology service is consulted, several attempts at catheter placement have failed. Repeated and unsuccessful trials at blind urinary catheterization result in psychologic and physical stress for the patient, urethral injury, potential urethral stricture, and challenging subsequent management.7,8 Improper insertion of catheters also can significantly increase healthcare costs because of increased interventions and added days of hospitalization. Complications from improper catheter placement include bleeding, sepsis, Fournier gangrene, and bladder and rectal perforations, and can lead to medical malpractice lawsuits.7-10
Failure at initial catheterization of a normal urethra may simply be the result of poor or improper technique, or anxious and combative patients.7,8 This is evidenced by the success of our experienced PAs in urology, who can insert a 16 Fr bent-tip catheter on first attempt 68.8% of the time.7,8,11 Verbal reassurance to the patient, along with asking the patient to “blow out a candle” as the catheter tip traverses the external sphincter, are two tricks of the trade. Lower urinary tract pathology that will necessitate use of our simple technique includes phimosis, anasarca, meatal stenosis, urethral strictures and false passages, bladder neck contracture from prior surgeries or urethral manipulations, bulky benign prostatic hyperplasia, or prostate cancer.12 Ostensibly, all our PAs are trained and certified to perform these more challenging procedures, regardless of the urethral barriers.
Several methods have been described in the medical literature and on YouTube channels to tackle difficult indwelling urinary catheter insertions.7-18 These include use of a vaginal speculum to visualize the glans penis in a patient with anasarca, perineal pressure, rubber or metal ureteral dilators; use of flexible or rigid cystoscopes and ureteroscopes in combination with guidewires; open-ended ureteral catheters; catheter punch devices; or slitting or cutting the tip of the urethral catheter to accommodate the guidewire.7-12,14 We have found the last technique to be detrimental to the contour of the catheter tip, impeding the eventual smooth passage of the catheter, and damaging to the anchoring balloon.
A review of the literature revealed that our method was first described by Blitz in 1995.13 He used the technique after performing cystoscopy on patients who were difficult to catheterize. He also found the maneuver useful for exchanging previously difficult-to-place urethral catheters. Variations of the procedure were subsequently referenced by others.7-18 Blitz also concurred that a hydrophilic guidewire is superior to a standard guidewire for the successful execution of the maneuver (telephone communication with Barry F. Blitz, MD, April 6, 2018). The difference between our technique and the rest is our reliance on our PAs, and on equipment readily available on the medical or surgical units and physician offices, without having to depend on any expensive tools or surgical expertise. This enables the individual PA to independently tackle the difficult situation with minimal training, assistance, and supervision. Equally important, it also lets the PA insert any catheter of choice to manage the patient's urologic requirement.
We do not have patient demographic details due to the retrospective nature of our data analysis. Another shortfall is our inability to perform a controlled comparison of the outcomes, before and after the institution of our technique. A cursory examination of our technique also may lead to the conclusion that the maneuver is similar to other previously published procedures. Nonetheless, we can highlight the fact that the technique can be performed on any patient, without any complications, regardless of cause of the urethral impediment. A more close-up inspection of the data also reveals that almost a third of the patients consulted (238/764 = 31.2%) would have required a trip to the OR if not for the application of our maneuver. The main strength of our simple technique showcases the capability of our PAs to make use of available simple tools to insert any type of indwelling urinary catheter, regardless of patient characteristics.
Considering the large number of consultations for difficult urethral catheter placement and the rarity of available literature on the topic, this issue truly is underappreciated. When problems arise, they create significant financial consequences to the hospital, and at times disastrous complications to the patient and legal implications for providers. We believe that our simple technique lets PAs and NPs in hospital and office settings manage this vexing problem after a short period of training, with all the catheter options and inexpensive tools available at every medical facility.
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Keywords:Copyright © 2019 American Academy of Physician Assistants
physician assistant; indwelling urinary catheter; guidewire; urethral stricture; difficult placement; urology