Catheter balloon in urethra: The risk of intra-urethral Foley catheter balloon inflation in spinal cord-injured patients: Lessons learned from a retrospective case series

16.04.202128.07.2023 by alexxlab

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Designs – Indwelling Urinary Catheters

Catheters are semi-rigid but flexible tubes. They drain the bladder but block the urethra.

The challenge is to produce a catheter that matches as closely as possible to the normal physiological and mechanical characteristics of the voiding system.

This requires construction of a thin-walled, continuously lubricated, collapsible (conformable) catheter to protect the integrity of the urethra; a system to hold the catheter in place without a balloon; and a design to imitate the intermittent washing of the bladder with urine.

Catheter products have changed significantly in their composition, texture, and durability since the 1990s.

The catheter should have a smooth surface with two drainage eyes at the tip that allow for urine drainage.

Drainage eyes are placed either laterally or opposed. Opposing drainage eyes generally facilitate better drainage.

Catheter Tips

The most commonly used catheter is a straight-tipped catheter.

A Coudé-tipped catheter, or Tiemann catheter, is angled upward at the tip to assist in negotiating the upward bend in the male urethra.

This feature facilitates passage through the bladder neck in the presence of obstruction from a slightly enlarged prostate gland (e.g., in benign prostatic hyperplasia) or through a narrowed stricture in the urethra.

The Carson catheter is a slightly larger bulb to assist in negation of restrictions.

The Council catheter features a reinforced hole at the tip of the catheter.

A whistle-tipped catheter is open at the end and allows drainage of large amounts of debris (e.g., blood clots).

Catheter Size and Length

Each catheter is sized by the outer circumference and according to a metric scale known as the French (Fr) gauge (range is 6 to 18 Fr), in which each French unit equals 0.33 mm in diameter.

The golden rule is to use the smallest catheter size (termed bore), generally 14 to 16 Fr, that allows for adequate drainage.

The use of large-size catheters (e.g., 18 Fr or larger) is not recommended because catheters with larger diameters can cause more erosion of the bladder neck and urethral mucosa, can cause stricture formation, and do not allow adequate drainage of periurethral gland secretions, causing a buildup of secretions that may lead to irritation and infection. Also, large size catheters can cause pain and discomfort.

Balloon Size

A retention balloon prevents the catheter from being expelled. The preferred balloon size may be labeled either 5 mL or 10 mL, and both are instilled with 10 mL of sterile water for inflation per manufacturer’s instructions. Larger balloons (30 cc – 60 cc) are generally used to facilitate drainage or provide hemostasis when necessary, especially in the postoperative period. The balloon of the catheter usually sits at the base of the bladder, obstructing the internal urethral orifice.

A fully inflated balloon allows the catheter tip to be located symmetrically. If a 5 mL balloon is inflated with more than 10 mL of water, irritation may occur unilaterally on the bladder wall from increased pressure of the balloon.

The specified amount of inflation ensures a symmetrical shape and allows for the catheter to maintain position in the bladder while minimizing patient discomfort Underfilling or overfilling may interfere with the correct positioning of the catheter tip, which may lead to irritation and trauma of the bladder wall.

A balloon with a fill size greater than 10 mL, such as a 30 mL balloon, is not recommended because the 10 mL size keeps residual urine minimal, thus reducing the risk of infections and irritation.

The catheterized bladder is in a collapsed state as a result of constant urine drainage. However, a 30 mL balloon will allow persistence of a small pool of undrained urine, so the bladder emptying is not complete and the undrained urine can leak around the catheter (referred to as “catheter bypassing”)..

The use of a larger balloon size is mistakenly believed by many nurses to be a solution to catheter leakage or urine bypassing around the catheter. However, a large balloon increases the chance of contact between the balloon or catheter tip and the bladder wall, leading to bladder spasms that may cause urine to be forced out around the catheter.

A 30 mL balloon is used primarily to facilitate traction on the prostate gland to stop bleeding in men after prostate surgery or to stop bleeding in women after pelvic surgery.

Routine use of larger capacity balloons (30 mL) should be avoided for long-term use as they can lead to bladder neck and urethral erosion.

Several catheter materials have been found to lose water from the inflated balloon over time in the bladder with 100% silicone catheters losing as much as 50% of their volume within 3 weeks.

In men, the catheter should be passed initially to the bifurcation (the “Y” junction where the balloon arm and catheter meet) to ensure that the balloon will not be inflated in the urethra.

Catheter Materials

A wide range of catheter materials are available, and the material selected should be chosen by:

how long the catheter will remain in place,
comfort,
the presence of latex sensitivity,
ease of insertion and removal, and
ability to reduce the likelihood of complications such as urethral and bladder tissue damage, colonization of the catheter system by microorganisms, and encrustation

Note: Prior to insertion, all indwelling catheters should be visually inspected for any imperfections or surface deterioration.

1. Latex Catheter: The possibility of a latex allergy is an important consideration as many urinary catheters are constructed from latex or a related material.

There are reported increases in allergies and reactions in patients with long-term use of all urinary latex and rubber catheters. Patients who have asthma and other allergies are at increased risk for these allergies. Latex allergy can result in symptoms such as skin irritation, rashes, and blisters. Urethritis and urethral strictures can also result from latex allergies. Coatings such as silicone and polytetrafluoroethylene (PTFE) are used to coat latex catheters.

2. Hydrogel coating, which remains intact when used, has demonstrated the ability to reduce the high level of cytotoxicity associated with latex catheters. However, coated latex catheters do not protect against an allergic reaction to the underlying latex because the coating wears off.

Bonded hydrogel-coated latex catheters may be longer lasting than silicone catheters because their hydrogel coating prevents bacterial adherence and reduces mucosal friction. Hydrogels or polymers coat the catheter, absorbing water to produce a slippery outside surface. This results in the formation of a thin film of water on the contacting surface, thus improving its smoothness and lubricity. These properties might act as potential barriers to bacterial infection and reduce the adhesion of both gram-positive and gram-negative bacteria to catheters.

3. Silicone- and hydrogel-coated catheters usually last longer than PTFE-coated catheters. If the person is latex sensitive, silicone catheters should be used. Avoiding latex catheters may also decrease the incidence of encrustation. All-silicone (100%) catheters are biocompatible and are believed to have encrustation-resistant properties. Silicone catheters are thin-walled, rigid catheters with a larger diameter drainage lumen.

4. Antimicrobial-coating: A major problem with Foley catheters is that they have a tendency to contribute to urinary tract infections (UTI). This occurs because bacteria can travel up the catheters to the bladder where the urine can become infected. In an attempt to prevent bacterial colonization, catheters have been coated with silver alloy or nitrofurazone, a nitrofurantoin-like drug.

This has been helpful, but it has not completely solved this major problem. An additional problem is that Foley catheters tend to become coated over time with a biofilm that can obstruct the drainage. This increases the amount of stagnant urine left in the bladder, which further contributes to the problem of urinary tract infections. When a Foley catheter becomes clogged, it must be flushed or replaced.

Both nitrofurazone-coated and silver alloy-coated catheters seem to reduce the development of asymptomatic bacteriuria during short-term (< 30 days) use.
Despite their unit cost, there is a suggestion that these devices might be a cost-effective option if overall numbers of infections are significantly reduced through their use.

Antibiotic-coated catheters were found in a meta-analysis to prevent or delay bacteriuria in short-term catheterized, hospitalized patients. However, in 2012, nitrofurazone impregnated catheters were taken off the market.
Silver is an antiseptic that inhibits growth of gram-positive and gram-negative bacteria. Silver alloy-coated catheters are thought to cause less inflammation and have a bacteriostatic effect because they reduce microbacterial adherence and migration of bacteria to the bladder.
Because they prevent bacterial adherence, these catheters also minimize biofilm formation through their release of silver ions that prevent bacteria from settling on the surface.
There appear to be few adverse effects, and microbial resistance to the active agent is unlikely.

Catheter Drainage BagsDrainage bags and an anchor for the drainage tube are parts of the design of an indwelling urinary catheter system. These may include a: leg drainage bag, overnight drainage bag, and a spare leg strap or a device to secure the catheter tubing to the leg. Drainage bags that cannot be worn and concealed are commonly referred to as “nighttime or overnight bags,” or “large capacity bags,” or “bedside bags”. Drainage bags that can be worn and concealed are commonly referred to as “leg bags” or abdominal bags, commonly referred to as “belly bags.” Leg bags generally hold 300- 900 cc whereas an overnight bag can hold up to 2000cc. It is recommended that reusable drainage bag be replaced every 30 days.

The current design of urinary drainage bags prevents the introduction of bacteria into the closed indwelling urinary catheter system. There are anti-reflux bags, single use bags, closed urinary drainage systems, and bags with urine sampling ports. A leg bag cannot be characterized as closed because of the need to regularly open the leg bag for drainage and connect to an overnight drainage bag in most cases. To minimize opening of a catheter system, a leg bag can be attached to a larger bag for overnight drainage.

References:
1. Brosnahan J, A. Jull, et al. Types of urethral catheters for management of short-term voiding problems in hospitalized patients. Cochrane Database of Systematic Reviews, 2004, (1): CD004013.
2. Gray M. Does the construction material affect outcomes in long-term catheterization? JWOCN, 2006, 33: 116-121.
3. Lawrence EL. and IG. Turner. Materials for urinary catheters: A review of their history and development in the UK. Med Engineering Phys, 2005, 27: 443-453.
4. Leuck AM, Johnson JR, Hunt MA, Dhody K, Kazempour K, Ferrieri P, et al. Safety and efficacy of a novel silver-impregnated urinary catheter system for preventing catheter-associated bacteriuria: a pilot randomized clinical trial. Am J Infect Control. 2015;43:260-5. DOI: 10.1016/j.ajic.2014.11.021.
5. Newman D. The indwelling urinary catheter: Principles for best practice. JWOCN, 2007, 24: 655-661.
6. Pickard R, Lam T, MacLennan G, Starr K, Kilonzo M, McPherson G, et al. Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterisation in hospital: a multicentre randomised controlled trial. Lancet. 2012;380:1927-35. DOI: 10.1016/S0140-6736(12)61380-4.
7. Politano AD, Campbell KT, Rosenberger LH, Sawyer RG. Use of silver in the prevention and treatment of infections: silver review. Surg Infect (Larchmt). 2013;14:8-20. DOI: 10.1089/sur.2011.097.
8. Weissbart SJ, Kaschak CB, Newman DK. Urinary drainage bags. In: Newman DK, Rovner ES, Wein AJ, editors. Clinical Application of Urologic Catheters and Products. Switzerland: Springer International Publishing; 2018, 133-147.
9. Zugail AS, Pinar U, Irani J. Evaluation of pain and catheter-related bladder discomfort relative to balloon volumes of indwelling urinary catheters: A prospective study. Investig Clin Urol. 2019 Jan;60(1):35-39. doi: 10.4111/icu.2019.60.1.35. Epub 2018 Dec 6.

Urethral Dilation Balloon Catheter | Cook Medical

Urethral Dilation Balloon Catheter

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Specifications

Collapsed
Expanded

Order Number	Reference Part Number	MR Status	Fr	Length cm	Inflated Balloon Diameter mm	More Info
Open Tip
G17844	UDBS-070029-OW	N/A	7. 0	29	8.7	Expand »
Additional Specs Description – Balloon Length cm 18 Accepts Instrumentation inch .038
Coudé Tip
G17842	UDBS-090029	N/A	9. 0	29	8.7	Expand »
Additional Specs Description – Balloon Length cm 18 Accepts Instrumentation inch —

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Bladder catheterization | Dobromed

Quite often, in pathological processes in the human body, more often of a urological nature, it becomes necessary to drain the bladder, that is, to create an artificial outflow of urine from the bladder reservoir cavity. In modern medical practice, this process is carried out using a whole set of modified devices (catheters) made of various materials. Bladder catheterization is used for both diagnostic and therapeutic purposes.

What causes the need for catheterization MP

Indications for the drainage procedure are individual and depend on many reasons. Usually, these are patients with urological problems. The drainage system is necessary:

when examining the urethral tract for the presence of obstruction in patients who have lost the ability to perform independent micturition, which led to their long delay (more than 12 hours) and the development of an acute pain syndrome, which may be the result of dysfunction of the bladder innervation, a strong inflammatory the process in the urethra, the presence of calculi or tumor formations in the organs of the urinary system themselves and in the tissues adjacent to it;
for laboratory monitoring of urine for microflora – for greater reliability of the results, sterile urine is taken directly from the reservoir bladder cavity;
if necessary, a cystourethrographic examination – diagnostics with a contrast agent;
for washing the bladder cavity from stagnant urine, pus, or blood clots formed as a result of infectious and inflammatory processes, or surgical interventions;
indications for catheterization are patients who have undergone surgical interventions on the organs of the urinary system, which contributes to the processes of complete regeneration and recovery;
and finally, patients who are in a state of coma and who have lost the ability to independently mict;
the patient has infectious urethritis;
pathological disorders that prevent the flow of urine into the bladder cavity;
trauma to the bladder organ and urethral tract;
presence of blood in the urethra and scrotum;
signs of urinary reflux;
potential complications in the form of acute prostatitis or penile fracture;
a real risk of infection of the MP from the outside.

Bladder drainage methods

Depending on the condition of patients and the purpose of drainage, bladder catheterization in women and other patients of various ages can be one-time, performed periodically (intermittent catheterization) or installed for a permanent period. For each specific case, its own drainage system is selected.

if it is necessary to withdraw urine from the reservoir bladder cavity for diagnostic evaluation of the urinary tract condition and collection of urine for laboratory monitoring;
in pregnant women with urological problems, to stabilize the condition just before childbirth;
if necessary, medicinal irrigation of the MP reservoir tissues.

Disposable catheters are used for this purpose. The duration of the procedure does not exceed 2 minutes, and the minimal presence of a drainage tube in the body minimizes the risks of additional infection and the development of other complications.

The permanent catheterization procedure has been used since the middle of the last century for chronic urinary problems. The drain is left in the bladder reservoir for a long time. It is installed by the urethral route, or by means of a cystostomy (an incision in the pubic area of the abdomen). But, as studies show, prolonged drainage contributes to the formation of calculi (stones) in the urinary excretion system and increases the risk of malignant tumors in the bladder.

According to international studies and recommendations from the urological association, indwelling catheters should not be placed for more than 2 weeks.

The method of intermittent drainage has been widely used since the end of the 20th century to replace permanent drainage. The method is based on 4, 6 single catheterization during the day, which imitates the normal processes of urine excretion by single drainage. This technique represents the lowest risk of developing functional disorders in the kidneys, infectious and other disorders. It can be used for many months and years without causing any harm to health.

Types of urinary drainage systems

There are different types of bladder catheters, differing in material, size and modification, for women, men and children, soft (rubber), hard or rigid (metal) and semi-soft (synthetic), equipped with additional internal channels (from 1 to 3), for permanent and temporary drainage. Consider some of them used in medical practice:

Nelaton (Robinson) drainage system – the simplest version of a rubber or polymer catheter. Designed for intermittent drainage in uncomplicated cases. Made from polyvinyl. Under the influence of body temperature becomes soft. Equipped with two side openings and a closed rounded end. They are used for both men and women, they differ only in length – for women from 12 cm to 15, for men, up to 40 cm. Sizes are marked with different color coding. A special hydrophilic coating, when interacting with moisture, makes it slippery, which does not require additional lubrication, and minimizes the risk of additional infection;

Mercier (Timman) system – equipped with an elastic curved tip, two holes and one outlet channel. It is used in complex infectious and inflammatory processes against the background of adenomatous growths in the prostate, or stenosis of the urethral tract;
Nelaton system with Timman tip – has the characteristics of a basic system, but the curved tip of the above device helps to drain patients with a prostate;
catheter for long-term use of the Pezzera system. It has the form of a conventional rubber tube, equipped with two output channels and a retainer in the form of a thickening of the tube;

The

Foley drainage catheter is the most commonly used type of drainage in urology. It is an excellent option for long-term use. Equipped with a special balloon (filled with sterile liquid) holding the device inside the MP. Through this catheter, the bladder is washed, drugs are administered, or urine is removed into the urinal attached to the end of the tube;

two-channel with a common passage for the outflow of urine and washing the MP and the channel through which balloon liquid is introduced;
three-channel with an additional channel for the introduction of drugs, made of silicone-coated latex (cheap option), which eliminates the deposition of salts inside the catheter, or silver-coated silicone (expensive option), which inhibits bacterial replication and reduces the risk of infection;
two-channel with a coraco-curved tip of Timman, which is the most convenient option for catheterization against the background of the prostate and its hyperplasia;
with women’s and children’s versions (shorter in length and with a smaller diameter).

Drainage with rigid (metal) systems is rare today. In normal practice, catheterization with a soft catheter is used, which minimizes the risk of injury to the urethra.

In each case, the drainage system is selected by a doctor and installed by medical personnel. Self-drainage is fraught with serious consequences, additional infection and the development of dangerous complications, since the procedure requires special preparation and knowledge of certain rules of the installation algorithm.

Self-catheterization is performed only in emergency cases, when there is no way to call a doctor, or medical help is too late.

Preparation for drainage manipulation

The preparatory period for catheterization of patients consists of several stages, including:

preliminary examination by a doctor to clarify the absence of contraindications;
following a certain nutritious diet (excluding fried and spicy foods, alcohol and sweet drinks with gas) a couple of days before the procedure;
careful preparation of the patient by a specialist (treatment of the genitals with an antiseptic, familiarization with the technique of catheterization).

At the next stage, a special kit for catheterization is selected, including:

A set of sterile improvised materials necessary for the procedure – gauze, cotton swabs and napkins;
Disposable medical gloves;
Painkillers and sterile solutions to facilitate insertion of the catheter tube;
Sterile plastic tweezers and Janet syringe cone configuration;
Antiseptic solution and genital preparations;
Urine tray.

Peculiarities of bladder drainage in adults

Drainage of the bladder organ in men is associated with peculiarities of the anatomical configuration of the urethra (long and curved) and different structure of its sections – prostatic, membranous and cavernous, which makes it quite vulnerable and sensitive to various types of damage .The algorithm for performing bladder catheterization in men is determined by a certain, consistent technique for introducing a drainage device.

drainage can be administered to men in a standing or lying position. The classic method is lying on couches with legs bent at the knees;
the procedure begins with the treatment of the head of the penis with an antiseptic, instillation of sterile glycerin into the urethral fissure and treatment with it, the end of the catheter tube;
The urine collection vessel is placed between the patient’s legs. If a permanent system is installed, the patient is given recommendations for its care in parallel. Sometimes a patient who has undergone surgery is offered an operation to remove the stoma;
the next stage is the introduction of the system. With an antiseptic-treated tweezers, the doctor, at a distance of 6 centimeters from the edge, grabs the catheter tube and gradually immerses it into the urethra. To prevent uncontrolled micturition, the head of the penis is slightly squeezed.

reaching the cavity of the urinary reservoir with a catheter is marked by the release of urine;
after the release of urine, the tube of the system is attached to a syringe with sterile furatsilin, for subsequent rinsing of the bladder reservoir. If necessary, intravesical drug therapy is carried out in parallel;
after intravesical lavage, the system is removed from the urethral cavity and disinfected. To avoid complications, the removal of the system from the bubble is performed after the complete exit of the liquid or air from the balloon fixator;
the remains of drops, solution or urine are removed from the penis with a sterile napkin, and the patient is advised to lie down after the procedure for an hour.

types and characteristics – Articles

Urological catheters

Urological catheters – tubular medical devices. They are intended for the withdrawal of urine, washing, the introduction of medicinal solutions or surgical instruments into the bladder for manipulation procedures.

Indications for catheterization

Therapeutic indications	Diagnostic
Chronic or acute urinary retention. Helpless state of the patient, coma. Hematuria (admixture of blood in urine). Postoperative restoration of the function of the genitourinary system (rehabilitation).	Diuresis monitoring. ultrasound. Evaluation of the condition of the urethra, bladder. Urine collection for testing.

Key features

Urological catheters from modern materials have such characteristics as:

biocompatibility;
chemical inertness, stability;
hypoallergenic;
atraumatic.

Materials

Latex, silicone or PVC are modern materials used in the manufacture of urological tubes to remove urine from the bladder in case of obstructed outflow.

Duration of use

Latex products have the shortest period of use – no more than a week. Silicone – up to a month. Silver-plated catheters can be placed in the bladder for up to three months.

Types of catheters

The choice of product depends on the condition, age and sex of the patient, the expected period of use, the type of manipulation. Each brand has different lengths and sizes. Devices are produced in sterile packages.

Types:

soft or hard;
disposable, reusable;
intended for continuous catheterization of the bladder;
children’s, women’s, men’s.

Malekot catheter (Peztsera)

Purpose – long-term removal of urine from the bladder through a cystostomy. It is recommended for patients with acute urinary retention, with various types of damage to the urethra.

Cystostomy is a long-term tube inserted through the peritoneal cavity into the bladder. The outflow of urine occurs in a special urinal.

Nelaton catheter

Designed for repeated (up to 4-5 times a day) urine output in case of impaired natural urination. It is made of PVC, has thermoplasticity (becomes soft at body temperature), is equipped with an olive-shaped tip, which simplifies its introduction into the bladder cavity. Lubricated Nelaton tubes are prescribed for self-catheterization. Women’s and children’s are available in 20 cm, men’s – 40 and 45 cm.

Nelaton catheter with Tiemann tip

Special bend facilitates insertion of the tube. Used for short-term catheterization.

Tiemann Catheter (Mercier)

Used to remove urine from men. Used in the presence of benign prostatic hyperplasia.

Prostate hyperplasia, or adenoma, is a tumor of the glandular tissue of the prostate.

Foley catheter

Soft tube with a special balloon that allows the catheter to be fixed in the bladder. The design of the catheter with two or three holes (two- and three-way) allows not only to drain urine, but also to administer drugs, remove blood clots, wash the cavity of the bladder and urethra. The duration of catheterization is up to 7 days.

Catheterization algorithm

General rules for women, men and children:

Thorough toilet of the genitals. Parents or medical staff help children.
Lie on the couch with your back, spread your legs and bend them at the knees, put a vessel, an oilcloth under your buttocks. Toddlers, especially those who are restless, need the help of adults.

Algorithm for a medical worker

General rules for medical personnel:

Prepare a set of tools and materials. Sterile: catheters, tray, containers for collecting urine for analysis, medical gloves, tweezers, Janet syringe, diapers, oilcloth. Antiseptic, petroleum jelly or glycerin, furatsilina solution.
Lay the patient on the couch, put an oilcloth under the buttocks, then a vessel or tray for urine.
Put on sterile gloves and treat the patient’s external genitalia with antiseptic agents.
Carry out the necessary manipulations, if necessary, attach a urinal to the catheter.
Make an entry in the medical record about the procedure performed.

Male catheterization

Male urological catheter long, thin, curved. This characteristic is associated with the anatomical and physiological features of the urethra, its two S-shaped bends.

Algorithm:

Lay the patient on the couch, treat the external genitalia, wipe the head with a napkin with furatsilin.
Gently squeeze the head of the penis to open the opening of the urethra.
Insert the catheter by pulling the penis gently upwards.
Collect urine, carry out the necessary medical manipulations (washing, treatment, removal of blood clots).
Pull out the catheter, treat the glans penis with an antiseptic.

Procedure for a woman

Female urethra is shorter, straighter, wider. Therefore, catheters have these features, they are up to 20–30 cm long. In gynecology, the Foley tube is used to stimulate the uterus before childbirth.