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April 12 2023Common Catheter Problems for Jr Drs Urology Anatomy Refresher – Urinary Tract 1. Urinary Tract: 2. Kidney 3. Renal pelvis 4. Ureter 5. Bladder 6. Urethra 7. Adrenal gland 8. Renal artery & vein 9. Inferior Vena Cava 10. Abdominal Aorta 11. Common Iliac artery / vein 12. Liver 13. Sigmoid colon 14. Pelvis https://en.wikipedia.org/wiki/BladderQuestion 1 Mr Jones is a 54 year old male presenting to the emergency department with severe abdominal pain and urgency to pass urine. The pain is situated in the suprapubic region, with no radiation. He admits he has been unable to urine for 24 hours despite the sensation to void. He has a past medical history of hypertension, hypercholesterolaemia and depression. On examination: HR 110, RR 25, BP 120/89, T36.7. Tenderness in the suprapubic region with a palpable bladder. Which medication is most likely to be contributing to his presentation? A. Tamsulosin B. Ramipril C. Atorvastatin D. Amitriptyline E. AmlodipineQuestion 1 Mr Jones is a 54 year old male presenting to the emergency department with severe abdominal pain and urgency to pass urine. The pain is situated in the suprapubic region, with no radiation. He admits he has been unable to urine for 24 hours despite the sensation to void. He has a past medical history of hypertension, hypercholesterolaemia and depression. On examination: HR 110, RR 25, BP 120/89, T36.7. Tenderness in the suprapubic region with a palpable bladder. Which medication is most likely to be contributing to his presentation? A. Tamsulosin Amitriptyline is a tricyclic antidepressant (TCA – anticholinergic): B. Ramipril TCA blocks acetylcholine transmission C. Atorvastatin Acetylcholine neurotransmitter sends D. Amitriptyline signals to contract bladder and void (Parasympathetic NS) Bladder does not contract E. AmlodipineACUTE URINAR Y RETENTION Acute Urinary Retention = New onset of inability to pass urine Causes q Obstructive: § Benign Prostatic Hyperplasic, Prostate Cancer q Urinary Tract Infections q Acute Pain / Constipation q Medications: § Anticholinergics – antipsychotics, antidepressants (SSRIs, TCAs…) § Opioids § Anaesthetics / epidurals § Antispasmodics (oxybutynin…) q Neurological : § peripheral neuropathy, iatrogenic nerve damage, upper motor neurone disease ACUTE URINAR Y RETENTION Acute Urinary Retention = New onset of inability to pass urine Investigations Symptoms • Acute Pain - Suprapubic, severe, discomfort • Bladder Scan: • Inability to micturate - urge present • Measure of volume of urine retained post-void (normal <400mL) • >1L – possibility of high pressure chronic retention • Supra-pubic tenderness • Bloods: • Palpable bladder • Inflammatory markers: infection? • DRE – faecal impaction / Prostate enlargement • Renal function (U&Es): renal consequence? • Pyrexia / diaphoresis (infection?) • Ultrasound Urinary Tract • Visualise the urinary tract to look for signs ofronephrosis • Catheterised? à Clot retention? Haematuria? https://www.gponline.com/urinary-retention-red-flag-symptoms/genito-urinary-system/article/1016966 https://radiopaedia.org/articles/hydronephrosis?lang=gb ACUTE URINAR Y RETENTION - TREATMENT Start Tamsulosin: Alpha-blocker – relaxes contraction of bladder wall/prostate to allow urine flow (SEs: hypotension) Monitor for Output & Post-obstruction diuresis: !!! CATHETERISE !!! • Kidneys experience loss of the intra- Provides instant relief by draining urine directly from medullary concentration gradient the bladder from prolonged retention… Reverse any identified causes: • Worsens AKI as water exits blood Stop responsible medications quickly into the urine REMEMBER : Measure the volume / output after • Patients with output >200mL/h should inserting the catheter Treat active infections (UTIs): Urine MCS / urinalysis receive IV fluids to replace losses https://urologyaustin.com/general-urology/catheter-care-and-catheterization/ https://teachmesurgery.com/urology/presentations/chronic-urinary-retention/#Post-Obstructive_DiuresisQuestion 2 A 13 year old mal is brought into the emergency department by his parents with severe pain in his testes. This started suddenly after a game of football at school, but he experienced no trauma. On examination, his left testes is swollen, red and hot. It appears higher in position to the right and is very tender on palpation Given the most likely diagnosis, which of the following reflexes abnormalities is likely to be present? A. Present Babinski Reflex B. Absent Babinski Reflex C. Absent Cremasteric Reflex D. Present Cremasteric Reflex E. Present Morrow ReflexQuestion 2 A 13 year old mal is brought into the emergency department by his parents with severe pain in his testes. This started suddenly after a game of football at school, but he experienced no trauma. On examination, his left testes is swollen, red and hot. It appears higher in position to the right and is very tender on palpation Given the most likely diagnosis, which of the following reflexes abnormalities is likely to be present? A. Present Babinski Reflex – normal <2yo, ?UMN lesion B. Absent Babinski Reflex – normal >2yp C. Absent Cremasteric Reflex – Consistent with TESTICULAR TORSION D. Present Cremasteric Reflex - normal E. Present Moro – normal in infant (falling reflex) TESTICULAR TORSION - ANATOMY = Extension of abdominal peritoneum https://www.meddean.luc.edu/lumen/meded/grossanatomy/abd/inguinal/inguinal_fr.html https://teachmeanatomy.info/pelvis/the-male-reproductive-system/spermatic-cord/TESTICULAR TORSION Twisting of the spermatic cord* Clinical Presentation ** At the tunica vaginalis • Severe unilateral testicular pain • Not improved on elevating the testes (Prehn’s Sign - + in epididymo-orc)itis Constriction of vascular • Can be intermittent or constant supply to the testes • +/- Nausea & vomiting • Scrotal swelling / oedema / Erythema • High Riding testes ISCHAEMIA & NECROSIS • Loss of cremasteric reflex • Elevation of testes on touching medial thigh SURGICAL EMERGENCY Risk Factors • 12 – 25 year olds • Previous Torsion or Family History • Undescended testes • “bell-clapper deformity” (horizontal lying testes, increased mobility of tunica vaginalis) TESTICULAR TORSION Twisting of the spermatic cord Investigations 4 – 6 HOUR WINDOW • !! CLINICAL DIAGNOSIS !! DO NOT DELAY SURGICAL EXPLORATION Constriction of vascular • Ultrasound can be used to investigate in unclear cases: supply to the testes ISCHAEMIA & NECROSIS Doppler used to diagnose poor blood flow. • Rule out infection: • Bloods – inflammatory markers / U&Es • Urinalysis / MCS • Urethral swabs etc.. https://journals.sagepub.com/doi/full/10.1177/1557988320953003 TESTICULAR TORSION Twisting of the spermatic cord Management 4 – 6 HOUR WINDOW URGENT SURGICAL EXPLORATION Constriction of vascular supply to the testes Pre-operatively: Analgesia & anti-emetics Intra-operatively: ISCHAEMIA & NECROSIS • Cord untwisted à bilateral orchidopexy • Fixation of both testes to prevent further torsion 90-100% success rates performed within 6 hours Complications • Testicular infarction • Testicular atrophy - infertility • Chronic testicular pain 50% success rates performed after 12 hours https://journals.sagepub.com/doi/full/10.1177/1557988320953003 https://step2.medbullets.com/renal/120713/testicular-torsionQuestion 3 A 52 year old male presents to the emergency department after waking up with a very painful and unprovoked penile erection. He is not aware how long this has been going on for, but it has not gone away since he woke up 6 hours ago and is becoming increasingly painful. He has a background of hypertension, sickle cell anaemia and gout. Which of the following anatomical structures is responsible in the process of a penile erection? A. Corpus Callosum B. Corpus Luteum C. Corpus Cavernosum D. Corpus Spongiosum E. GlansQuestion 3 A 52 year old male presents to the emergency department after waking up with a very painful and unprovoked penile erection. He is not aware how long this has been going on for, but it has not gone away since he woke up 6 hours ago and is becoming increasingly painful. He has a background of hypertension, sickle cell anaemia and gout. Which of the following anatomical structures is responsible in the process of a penile erection? A. Corpus Callosum (white matter structure in the brain connecting hemispheres) B. Corpus Luteum (created following from follicle following release of oocyte during ovulation) C. Corpus Cavernosum – muscular erectile tissue of the penis that relax during (parasympathetic) stimulation, allowing blood to fill the area & cause enlargement D. Corpus Spongiosum – erectile tissue of the penis surrounding the urethra. Does not become enlarged during a penile erection. E. Glans – “head” of the penis PRIAPRISM Priapism: “An unwanted, prolonged, painful erection of the penis” • Not associated with sexual desire • > 4 hours Why an emergency? • Blood collects within the… Corpus cavernosa à venous stasis à ISCHAEMIA If untreated = impotence & fibrosis Low Flow / Ischaemic: High Flow / Non - Ischaemic: • Veno-occlusive • Blockage of venous drainage • Unregulated cavernous arterial inflow • Causes: iatrogenic, sickle cell • Rapid arterial entry & slow exit disease, haematological disorder• Causes: sexual stimulation, traumaPRIAPRISM - INVESTIGATIONS Priapism: “An unwanted, prolonged, painful erection of the penis” • Corporeal Blood Gas Ischaemic = Acidotic Bloods • FBC • CRP / ESR • Coagulation screen Causes: • U&Es & Bone profile • Sickle Cell Disease *most common • Anti-coagulants • Haemoglobin electrophoresis (+/- drug screen) • Anti-depressants • Recreational drugs (cocaine, cannabis) ? Spinal Injury • Erection medicatios (e.g. Sildenafil) • PR examination • Imaging (CT / MRI)PRIAPRISM - MANAGEMENT Priapism: “An unwanted, prolonged, painful erection of the penis” • Immediate = Corporeal Aspiration • Surgical Management – surgical shunt • Prognosis: 90% of cases with priapism lasting >24 hours do not regain the ability to have intercourse. • Management = Penile prosthesis insertionPARAPHIMOSIS Paraphimosis: ”inability to pull forward a retracted foreskin over the glans penis” The foreskin gets stuck! Tight restrictive band around The glans becomes If not treated… the foreskin that prevents its oedematous due to blocked Penile ischaemia & retraction over the glans risk of infection venous return Symptoms: • Progressive pain & swelling of the glans • Unable to retract the foreskin • May have had repeated admissions if not treated Management: • Reduced as soon as possible with analgesia (penile block) -- manual reduction -- dextrose-soaked gauze -- Dundee technique (puncture using needles & draining fluid) • Definitive Management – CircumcisionQuestion 4 A 26 year old female presents to her GP as she has felt “generally well” for past 2 days. She complains of lethargy, reduced appetite and 7/10 back pain on her right side, radiating to her groin. She has recently completed a 3 day course of trimethoprim for a UTI, which has relieved her dysuria & frequency symptoms. Observations: HR 123. BP 89/56. T39.1. SpO2 95% on RA. RR 16. Given her presentation, which of the following would you do next? A. Advise her to take paracetamol for her pain and go home to rest B. Prescribe a further course of oral antibiotics for her to take at home C. Advise patient to attend A&E if her symptoms continue D. Refer patient to A&E immediately for further investigationQuestion 4 A 26 year old female presents to her GP as she has felt “generally well” for past 2 days. She complains of lethargy, reduced appetite and 7/10 back pain on her right side, radiating to her groin. She has recently completed a 3 day course of trimethoprim for a UTI, which has relieved her dysuria & frequency symptoms. Observations: HR 123. BP 89/56. T39.1. SpO2 95% on RA. RR 16. Given her presentation, which of the following would you do next? A. Advise her to take paracetamol for her pain and go home to rest B. Prescribe a further course of oral antibiotics for her to take at home C. Advise patient to attend A&E if her symptoms continue D. Refer patient to A&E immediately for further investigation à HIGH NEWS. SEPSIS?ACUTE PYELONEPHRITIS Pyelonephritis: inflammation of the kidney parenchyma and the renal pelvis Bacterial infection of the kidney Neutrophils infiltrate the tubules and Via bacteraemia interstitium to cause suppurative inflammation Formation of small renal cortical abscesses occur and streaks of pus in the renal medulla. Via UTI Most common organisms: 80% Escherichia coli • Other…. Klebsiella, Proteus, Enterococcus • Commensal: Staphylococcus saprophyticus Via lymphatics ( retroperitoneal abscess) • Catheter-associated: Staphylococcus faecalis, Staphylococcus aureus Pseudomonas https://speciality.medicaldialogues.in/antimicrobials-for-acute-pyelonephritis-2018-nice-guidelinesACUTE PYELONEPHRITIS Investigations • Urinalysis / Urine MCS Fever • Bloods: • Inflammatory markers Unilateral Loin pain • Renal function • Imaging Nausea and Vomiting • Renal Ultrasound • CT KUB (non-contrast: if stone suspected) 24 – 48 hours Lower Urinary symptoms: o Dysuria Management • Resuscitation (ABCDE – Sepsis 6) o Urgency • IV Fluids o Frequency • Empirical antibiotics o HaematuriaCOMMON CA THETER ISSUES FOR FYs “Doctor, my patient’s catheter has stopped catheter isn’t draining?” working!”CATHETERS 1. Check there are no ‘external’ blockages: Is the catheter twisted, kinked, accidentally clamped? 2. Check for obvious ‘internal’ blockages?: Is there obvious sludge/debris blocking the tubing? Haematuria / clots? 3. Ask the nurses to perform a bladder scan: Helps differentiate blocked catheter vs low urine output. 4. Ask the nurses to flush the catheter: If resistance, could indicate blockage. Can also help dislodge & break blockages. But can also cause further blockages later on… 5. Change the catheter for larger lumen OR 3 Way Catheter3- WA Y CATHETERS • Wider bore then normal foley catheter • Indication: Haematuria, to allow continuous bladder irrigation • 3 Distal ports: 1. Balloon inflation (20mL vs 10mL) 2. Irrigation fluid port 3. Outflow for urineBYPASSING CATHETER • Could potentially be blocked (follow blocked catheter steps) “Doctor, my patient’s catheter is leaking / bypassing!” • Lumen of catheter is too small - consider inserting a wider bore catheter • If changing a catheter – consider prophylactic antibiotic cover! • Check balloon is fully inflated o Previous catheter-associated UTI o High risk of infection (immunocompro• If patient is wearing a leg bag, is this o Difficult insertion too far down the leg? o Those at risk of infective endocarditisCommon Catheter Problems for Jr Drs Urology