Author: LT Sean D. Murnan, MD (EM Resident Physician, Naval Medical Center Portsmouth) // Edited by: Jennifer Robertson, MD, MSEd and Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital)

Urinary catheters are commonly utilized devices in the emergency department (ED). In addition, complications from these devices are also commonly seen and treated in the ED. This is not a guide on how to place a suprapubic catheter in a patient presenting to the ED. Rather, this is a review of the suprapubic catheter itself and how to manage mechanical problems and its uncommon, but potentially serious, complications.

Four Types of Urinary Catheterization

Indwelling urethral catheters – most commonly used in the inpatient or hospital setting for short term drainage of the bladder (Management of patients with chronic urinary obstruction) External catheters (i.e., condom catheters) Intermittent catheters – the catheter is removed immediately after bladder decompression. Suprapubic catheters The most invasive of the catheter types– requires surgical placement through the abdominal wall and into the bladder. In non-emergent situations, these are usually placed by a urologist via a percutaneous or open surgical technique.

I rarely ever see suprapubic catheters. What are the reasons a patient would have one?

Suprapubic catheters are beneficial because they prevent urethral trauma and stricture formation seen with long term indwelling catheters. They allow patients to attempt normal voiding without the need for re-catheterization of the urethra and they also interfere less with sexual activity.

A Cochrane review looking at 42 trials, 25 of which compared indwelling urethral catheters and suprapubic catheterization showed decreased incidence of asymptomatic bacteruria and decreased pain in the suprapubic catheter group. 1

Indications for suprapubic catheter placement 2 Urethral or pelvic surgery Urethral or pelvic trauma Chronic urinary obstruction secondary to prostatic obstruction Inability to insert a urethral catheter secondary to obstruction Wheelchair bound patient with lack of perineal or urethral sensation in which there is concern for pressure ulcers or urethral injury related to tension or sitting on the catheter tubing.



Take Home Point

-Your patient with the suprapubic catheter likely has significant comorbidities that need to be recognized and incorporated into your differential, even if the complaint is solely catheter dysfunction

Now that we have covered some of the different types of urinary catheters and have discussed indications for placing a suprapubic catheter, let’s look at some of the potential problems that we need to be aware of in patients with these catheters. They range from the malfunction of the catheter itself to some of the occult and obvious intra-abdominal complications of suprapubic catheter placement.

The suprapubic catheter is a significantly more invasive device than the standard indwelling Foley catheter. Thus, intra-abdominal complications can occur. The emergency clinician should be aware of and suspicious for the following complications in any patient with a suprapubic catheter who presents to the ED:

Small bowel obstruction (SBO): This is an uncommon complication of suprapubic catheter placement, but is a distinct possibility considering placement is through the abdominal wall. Patients with a SBO as a result of initial catheter placement typically will present to the ED days to even weeks after initial placement. Key points of the history and physical examination include recent catheter placement, increasing abdominal pain and tenderness, and possible peritoneal signs. Look for an obstructive picture with worsening distension, abdominal pain, nausea, vomiting and obstipation. SBO can also be a phenomenon of suprapubic catheter displacement following routine catheter changes.3,4 Use bedside ultrasound to verify that the catheter balloon is in the bladder.

Bowel perforation: This can occur at the time of initial placement or long after. There have been case reports of occult bowel perforation presenting three years after suprapubic catheter placement.5 In the immediate post operative period, this complication is more associated with closed (abdominal puncture) techniques because there is not direct visualization of the path to bladder6. This can also be a post-operative complication that is associated with routine catheter changes.7

Take Home Points

Bowel perforation and small bowel obstruction are complications of suprapubic catheter placement and exchange . 8

are complications of suprapubic catheter . Patients with closed or blind placement of suprapubic catheters, or previous abdominal or pelvic surgery are at higher risk.

are at higher risk. Presentation can be immediately post-op or years down the road.

May present without findings of an acute abdomen .

. Small bowel obstruction or bowel perforation should cross your mind in any patient with a SPC.

Use bedside ultrasound to verify balloon is in the bladder. If unsure or you have clinical concern – image these patients.

Mechanical Complications of Suprapubic Catheters

Common complications of suprapubic catheters, similar to Foley catheters, include infections, bladder spasms, obstruction, catheter encrustations, and retained catheters.10

A 74 year-old male with a history of chronic urinary retention secondary to severe BPH requiring placement of a suprapubic catheter 1 year ago, presents to your emergency department with a chief complaint, “My catheter is stuck.” He has attempted multiple times to deflate the balloon and pull the catheter, but it was extremely painful and he decided to come to the ED for help. The patient has normal vital signs and urine is still draining freely from the catheter into the collecting bag.

Catheter retention (i.e., inability to change out the catheter) is a fairly common problem. However, it can be daunting or perplexing in the setting of a busy emergency department shift.

Can be caused by “balloon cuffing” where the catheter balloon deflates successfully, but cannot be removed.

Often related to failed deflation of the balloon or incomplete deflation of the balloon.

Presents with an inability to aspirate fluid from the inflation channel Failed deflation is typically related to a damaged inflation valve from external clamping, kinking, crushing of the inflation channel, OR from obstruction caused by crystallization of fluid in the inflation channel.



Balloon Cuffing: this occurs when water is successfully aspirated from the inflation channel resulting in deflation of the balloon, BUT the catheter still cannot successfully be removed.11,12,13 More common with silicone vs latex catheters.13

More common in suprapubic catheters vs urethral catheters. 13

Balloon deflates, but the rigid silicone balloon cuff that forms during deflation can function as a hook.

Causes of balloon cuffing: Rapid aspiration of water from the balloon – balloon does not return to original shape Over inflation of the balloon – creates stretch and damages balloon shape

Managing suspected balloon cuffing: After full balloon aspiration, re-instill 0.5-1mL of water back into the catheter balloon. This helps to smooth out the retaining ridge that caused the hook-like balloon cuff.



Failed Balloon Deflation: The balloon will not deflate because of a problem with the inflation channel or valve. To fix this problem, the following supplies are needed: A guidewire from a central line kit

The 22-gauge central line from the above mentioned kit

A couple of packets of sterile surgical lubricant

A pair of scissors

Steps to Success : 10,13 Take the valve out of the equation. Use scissors to cut the inflation channel proximal to the inflation valve. If balloon does not spontaneously drain, there is likely obstruction of the channel unrelated to the valve. Use sterile, water-based lubricant to lubricate the guidewire and advance the j-shaped side of the guidewire into the inflation channel in an attempt to break up obstructions without puncturing the balloon. If successful, fluid should drain along the wire. If not successful, thread the 22-gauge central line catheter over the wire and remove the wire once the catheter tip is in the balloon.

:

At this point, you have probably spent a solid amount of time trying to troubleshoot the retained catheter, but without success. Time to move on to plan B . At this time, consultation with a urologist is recommended. Retrospective chart reviews of failed balloon deflation reported that 31% of cases of failed balloon deflation required extra-luminal balloon rupture. 14 23% improved with passive aspiration of the balloon 31% improved with cutting the catheter 15% improved with a wire passed through the balloon port 31% required extra-luminal balloon puncture

. At this time, is recommended.

Plan B: The balloon needs to be removed. However, here are some do NOT tips regarding balloon removal: Do NOT attempt over-inflation of the balloon with the goal of rupture. This can lead to intra-vesicular debris that can cause downstream obstruction and direct damage to the bladder and urethra. 15 In in-vitro studies, there was a 100% rate of free fragment formation from balloon over distension and rupture. 13 Do NOT attempt to puncture the balloon by blindly guiding a sharp object through the inflation channel. This can cause balloon fragmentation, direct bladder injury, and in many cases, is unsuccessful. Also, the balloon may fail to deflate even after puncture. 16 Do NOT instill chemicals in an attempt to dissolve, and thus, rupture the balloon. This has been described in the past with the use of ether, chloroform, acetone, and mineral oil. This has also associated with intra-vesicular debris. In addition, chemical cystitis, bladder contractures, hematuria, bladder rupture, and death can occur. 10



Plan B: Extra-luminal balloon puncture Urology will likely perform this procedure Trans-abdominal, perineal, and rectal ultrasound- guided percutaneous approaches to catheter balloon drainage have been described. However, these are operator dependent and carry significant risks including bowel perforation, bladder damage, and unintentional balloon rupture with fragment formation. 13,14 A novel approach : an angiocath is attached to a syringe and passed into the fistula in parallel to the tract of the suprapubic catheter. The catheter is advanced over the needle tip to protect the bladder from injury. When resistance is met, the needle is advanced, the balloon is penetrated, and the contents of the balloon are aspirated into the syringe. 15



Catheter Encrustation and Concretions17

Can present with catheter retention and/or urinary retention due to catheter obstruction

May also cause failed balloon deflation

The main cause of encrustation is infection by urease producing organisms (i.e., Proteus mirabilis) Colonization of the catheter with formation of biofilm Bacterial urease generates ammonia from urea => alkalinization of the urine => calcium and magnesium phosphate crystal formation and deposition.

Encrustations can break away from the catheter, forming a focus for stone formation and infection

When to suspect this: Catheter is unable to be removed even after successful aspiration of the balloon There is catheter retention in the setting of urinary retention

What to do about it: Urology consultation, will need cystoscopy and possibly second suprapubic catheter placement



Take Home Points: Suprapubic Catheter Retention

Successful balloon aspiration with inability to remove the catheter can mean two things Suspect balloon cuffing => this is an easy fix There could be concretions or encrustation

Failed balloon deflation is best managed in the ED with a step-wise approach Conservative measures should first be considered. These include cutting the balloon inflation channel or passing a guidewire or a central venous catheter. These are likely to relieve the obstruction and drain the balloon. When conservative measures fail, it is best to consult urology for extra-luminal drainage of the balloon unless you are familiar with the procedure.

Do NOT attempt to rupture the balloon by over-inflation or chemical instillation. You can cause significantly more harm than good via fragmentation, bladder injury, and/or chemical cystitis.

References / Further Reading

Kidd, E. A., Stewart, F., Kassis, N. C., Hom, E., & Omar, M. I. (2015). Urethral (indwelling or intermittent) or suprapubic routes for short-term catheterisation in hospitalised adults. The Cochrane Database of Systematic Reviews, (12), CD004203. http://doi.org/10.1002/14651858.CD004203.pub3 Hunter, K. F., Bharmal, A., & Moore, K. N. (2013). Long-term bladder drainage: Suprapubic catheter versus other methods: a scoping review. Neurourology and Urodynamics, 32(7), 944–51. http://doi.org/10.1002/nau.22356 Huang, J. G., Brough, S. J., Jensen, R. S., & Monsour, M. J. (2010). Suprapubic catheter displacement: a forgotten phenomenon. Emergency Medicine Australasia : EMA, 22(3), 249–51. http://doi.org/10.1111/j.1742-6723.2010.01293.x Goldblum, D., & Brugger, J. J. (1999). Bowel obstruction caused by dislocation of a suprapubic catheter. Surgical Endoscopy, 13(3), 283–4. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10064766 Gallagher, K. M., Good, D. W., Brush, J. P., Al-hasso, A., & Stewart, G. D. (2013). Small bowel injury after suprapubic catheter insertion presenting 3 years after initial insertion. BMJ Case Reports, 2013, 1–4. http://doi.org/10.1136/bcr-2013-201436 Harrison, S. C. W., Lawrence, W. T., Morley, R., Pearce, I., & Taylor, J. (2011). British Association of Urological Surgeons’ suprapubic catheter practice guidelines. BJU International, 107(1), 77–85. http://doi.org/10.1111/j.1464-410X.2010.09762.x Bonasso, P. C., Lucke-Wold, B., & Khan, U. (2016). Small Bowel Obstruction Due to Suprapubic Catheter Placement. Urology Case Reports, 7, 72–3. http://doi.org/10.1016/j.eucr.2016.04.015 Ahluwalia, R. S., Johal, N., Kouriefs, C., Kooiman, G., Montgomery, B. S. I., & Plail, R. O. (2006). The surgical risk of suprapubic catheter insertion and long-term sequelae. Annals of the Royal College of Surgeons of England, 88(2), 210–213. http://doi.org/10.1308/003588406X95101 Khan, S. A., Landes, F., Paola, A. S., & Ferrarotto, L. (1991). Emergency management of the nondeflating Foley catheter balloon. The American Journal of Emergency Medicine, 9(3), 260–3. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/2018599 Shapiro, A. J., Soderdahl, D. W., Stack, R. S., & North, J. H. (n.d.). Managing the nondeflating urethral catheter. The Journal of the American Board of Family Practice / American Board of Family Practice, 13(2), 116–9. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10764193 Li, Y., Margot, N., Chen, X., Hartmann, U., Kristensen, L. E., Klaassen, P. D., … Hartmann, U. (2014). Letter to the Editor Letter to the Editor. Neuro-Oncology, 35(11), 1–7. http://doi.org/10.1055/s-0035-1548759 Gonzalgo, M. L., & Walsh, P. C. (2003). Balloon cuffing and management of the entrapped Foley catheter. Urology, 61(4), 825–827. http://doi.org/10.1016/S0090-4295(02)02506-2 Patterson, R., Little, B., Tolan, J., & Sweeney, C. (2006). How to Manage a Urinary Catheter Balloon that will not Deflate. International Urology and Nephrology, 38(1), 57–61. http://doi.org/10.1007/s11255-005-2945-7 Hollingsworth, M., Quiroz, F., & Guralnick, M. L. (2004). The management of retained Foley catheters. The Canadian Journal of Urology, 11(1), 2163–6. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15003159 Huseyin, T. S., & Moalypour, S. M. (2002). A solution to the non-deflating balloon of a suprapubic catheter. Emergency Medicine Journal : EMJ, 19(4), 354. http://doi.org/10.1136/emj.19.4.354 Daneshmand, S., Youssefzadeh, D., & Skinner, E. C. (2002). Review of techniques to remove a Foley catheter when the balloon does not deflate. Urology, 59(1), 127–129. http://doi.org/10.1016/S0090-4295(01)01483-2 Ho, C. C. K., Khandasamy, Y., Singam, P., Goh, E. H., & Zainuddin, Z. M. (2010). Encrusted and incarcerated urinary bladder catheter: What are the options? Libyan Journal of Medicine, 5(1), 3–5. http://doi.org/10.3402/ljm.v5i0.5686

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