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Urethral catheterization and more so difficult urethral catheterization (DUC) is one of the most common urological procedures and emergencies handled by urology trainees and urologists in general. Usually, multiple attempts would have been made by other caregivers before the urological team gets involved and additional techniques may then be required.
Common causes of DUC in the presence of a normal urethra include a tight external sphincter in an anxious patient or poor technique, while common pathologies that can result in DUC in our environment will include incomplete urethral strictures, benign prostatic enlargement, prostate cancer, bladder neck contracture, radiotherapy-induced stricture, and false passages among others.[1]
Several approaches to DUC have been described in literature to include but not limited to the following:
The use of catheter introducers is another alternative, however, these are rigid and could result in significant urethral trauma and multiple false passages, especially in the hands of the inexperienced.[3] All the other techniques described are not commonly utilized as equipment and accessories are not readily accessible. Recently, hydrophilic guidewires have become accessible in our practice, and this paper, we are reporting different ways we have found the guide wire extremely useful using innovative technique in improving our urological practice and we present different DUC scenarios with which we have used the guidewire and instances where S dilator supplementation was also required.
Following a failed (usually multiple) urethral catheterization attempt, alternatives may include the use of stiffer catheters or use of different sizes of the catheter or Coude-tipped catheter which are quite expensive and not readily available. It is customary to use smaller-sized catheters if the arrest of the catheter passage is noticed within the penile or bulbar urethra in a DUC, usually a size 14Fr or 12Fr. However, if the arrest is closer to the bladder neck, we would attempt using bigger-sized catheters usually Size 18 Fr or 20 Fr as these are stiffer and more likely to overcome prostatic resistance.
Our technique involves the use of a hydrophilic (Terumo) guide wire (0.035,' 0.89 mm width) [Figure 1]. We start by instilling 10'20 ml of local anesthetic lubricant into the urethra and allowing 3'5 min for the anesthetic to take effect. The hydrophilic guidewire is lubricated with sterile water and then inserted into the urethra and advanced until about 40 cm or more of its length has been introduced. With this, it can be safely assumed that the guide wire is within the urinary bladder. This is unlikely to cause any urethral trauma due to its soft flexible tip. If the guidewire cannot pass through due to complete obstruction, it will recoil out of the meatus, especially with the length of wire which has been advanced through the urethra meatus thus giving enough length for it to double back and reemerge through the meatus. The catheter is then railroaded over the guidewire past the point of resistance into the bladder. The catheter can be railroaded in one of the several ways:
In the elective setting where the urethroscope is utilized, the guide wire is passed under direct vision making it easier to negotiate the stricture segment. Then, serial dilation is done with well lubricated S-urethral dilators from 8 Fr to 20 Fr [Figure 2] over the guide wire into the bladder with confirmation by egress of urine. The desired catheter is then introduced over the guidewire by any of the techniques described above but our favored approach is use of the puncture technique using 18 G or 16 G cannula for straight tipped catheters as the requirements are readily assessable to us. Alternatively, the guide wire can be placed beyond the stricture segment as described under direct vision, and using a cold knife internal urethrotomy at 12 o'clock position of the urethra can be done for short segment incomplete stricture.
Below are pictures of the basic equipment used for the techniques described including the Hydrophilic guide wire (Terumo [Figure 1] and Zip [Figure 3]) and urethral S dilators with different sizes graduated from 8 Fr to 20 Fr for dilatation and stretching of urethral stricture.
Urethral catheterization is a routine medical procedure that facilitates direct drainage of the urinary bladder.[4] Patients of all ages may require urethral catheterization but much more so from middle-aged to elderly group or chronically ill are more likely to require an indwelling catheter. Acute/chronic urinary retention and other conditions of the genitourinary tract often lead to difficult catheterization and it is not uncommon in our environment to have patients who have a DUC.
This difficulty is usually in males for obvious reasons to include; long length of the urethra, enlarged prostate glands, and other potentially obstructive conditions peculiar in males. Multiple failed attempts at catheterization usually result in injury to the urothelium, which is only 3'4 layers thick[3] and this is quite common with nonspecialist teams with the consequence of increased pain and stress for the patient, potential urethral stricture requiring surgical reconstruction, and problematic subsequent catheterization. It also can lead to a significant increase in health-care cost due to added days of hospitalization, increased interventions, and increased complexity of follow-up evaluation.[3] Urology consultation for catheter placement often occurs when there is no organic pathology but instead when improper catheter placement has caused urethral injury in patients with normal problematic anatomy.[5]
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The approach to DUC where a catheter is needed for urinary retention or to monitor urine output should start with a thorough history and physical examination.[1] History should focus on preexisting lower urinary symptoms especially voiding and storage symptoms, predisposing factors for urethral strictures including previous urethritis, urethral injury from fall astride or pelvic trauma as well as instrumentation. Clinical information to suggest prostate or bladder malignancy should also be ascertained. Furthermore, information on past urologic surgeries including transurethral resection of the prostate, prostatectomy (simple/radical), previous difficult attempt at catheterization all in a bid to identify the etiology. Historical information pertaining to the previous attempts by other nonspecialists is of utmost importance, i.e. the distance at which obstruction was felt (<16 cm indicates possible urethral stricture, and >16 cm may indicate prostatic obstruction, incorrect technique, or bladder neck contracture), whether the Foley balloon was inflated before egress of urine (alerting the possibility of false passage from urethral trauma) or the types and sizes of catheters used, as well as how many attempts have been made previously[1] (the higher the number of previous failed attempts may indicate a more difficult catheterization).
A focused genitourinary examination may reveal obvious causes for the difficult catheterization to include penoscrotal edema, phimosis, meatal stenosis urethral stricture from induration along the urethra, enlarged prostate or malignant prostate features suggesting benign prostatic hyperplasia, or prostate cancer from the digital rectal examination.
Suprapubic catheterization may be needed after failed attempts at urethral catheterization or if there is pelvic or urethral trauma.[3] Suprapubic catheterization is one of the common procedures done in our own environment for urinary retention and failed attempts at catheterization by urology specialists. Hamza et al.[2] in Ahmadu Bello University Teaching Hospital in their recent retrospective study have reported that urinary retention was the most common urological emergency noted over a 6-year period, 352 out of 681 urological emergencies and 41.9% of the patients proceeded to have suprapubic catheter (SPC) following failed urethral catheterization. Several different approaches have been described by literature to achieve transurethral catheterization for patients with DUC; however, many of the basic requirements to achieve this are not readily available to us or expensive to procure. These will include flexible cystoscopes, ureteroscopes, guide wires or glide wires, filiform and followers, councilman catheters, Coude-tipped catheters, Tiemann-tipped catheters, and urethral S dilators among others. Suprapubic catheterization remains one of the most common emergency urological procedures in our environment and this was also reported in the study by Hamza et al.[2] For this reason, there appears to be overutilization of suprapubic catheterization in our setting, especially with patients presenting to the emergency department with urinary retention. Despite a shift from open suprapubic catheterization to percutaneous suprapubic catheterization with/without image guidance, our patients are still averse and not readily willing for the procedure and usually desire catheter placement per urethra and in cases of hematuria and bladder cancer suspected then an SPC may be contraindicated.[3] Additional costs also arise from the use of percutaneous SPC kits and ultrasonography. Recently, some of these high-profile tools have been made available to us especially the Terumo guidewire and urethral-S-dilators courtesy of our surgical exchange programs enabling us access to them. In this review, we have described our common utilization of these tools with very good outcome particularly with regards to its blind passage of the guide wire when there is suspicion of arrest from the prostatic origin and use of cystoscopy to guide the insertion, especially in strictures and contracture of the bladder neck. Of note is our transition from rigid metallic bougienage to use of the S Urethral dilators whose hydrophilic properties and its combination with guide wire use has a high success rate with less likelihood of creating false passages. It is less traumatic with a lower risk of significant hematuria thereby reducing requirements for blood transfusion and length of hospital stay. There is therefore an overall reduction in the cost of care and economic burden to the patients. It has become a viable option in patients with single-segment incomplete urethral strictures, especially in elderly unfit patients who may not be able to withstand prolonged reconstructive surgery like urethroplasty.
This review highlights our expanding utilization of recently available tools in the management of DUC and we can say their availability has created newer options now available to us in the management of our patients with DUC. We have tried to highlight the different ways we have found the guidewires useful and the techniques we used to achieve a successful outcome. We hope that this description can be encouraged in the urological specialty centers around the country especially for year 1 urological trainees being mostly the first responders to patients with DUC, especially in the acute emergency.
Furthermore, we would like to emphasize the right technique to the passage of urethral catheter firstly in females, the primary difficulty commonly encountered in catheter placement is identifying and cannulating the urethral meatus, which can be retracted or stenotic in patients with atrophic vaginitis or obscured by obesity, vaginal prolapse or scarring, and induration related to previous surgery or radiation therapy.[6] Proper positioning and retraction give the best chance for direct visualization and cannulation of the urethral meatus. This can be achieved by putting female patients in a supine frog-leg position with the head of the bed slightly lower than the feet. It may also be necessary to recruit assistance to retract a large abdominal or suprapubic pannus and provide focused lighting.
Similarly, identifying and cannulating the urethral meatus may be difficult in men in the setting of penile edema, buried penis, phimosis, and meatal stenosis. The male patient is usually lying supine and the penis is prepped using an aseptic technique, we advocate liberal use of lubricating jelly with lidocaine (10'20 ml) and giving sometime to work (10'15 min) before attempting to pass the catheter. It is also safer in males to advance the catheter to the connection point and allow egress of urine before inflating the catheter balloon and assessing for pain or discomfort while inflating the balloon. Following these basic steps described may reduce the incidence of DUC.
Finally, the cost of obtaining the guidewire ($490'$720 for a pack of 5) depending on the size and material used to make the wire and cost of S-dilators ($483.39) can be reduced if we have a large number of centers utilizing this basic equipment for their patients routinely and also improving, in the long run, it is their availability.
Conventionally, the patients who had successful catheterization with guidewire from this study would have proceeded to having SPC. Stocking the emergency department with hydrophilic guidewires reduces emergency SPC insertions and usually results in a successful urethral catheterization at the bedside. This technique is under local anesthesia and is well tolerated by the patient. It can be done blindly and poses less risk of iatrogenic urethral trauma. It is also useful in the management of urethral strictures when used in conjunction with the urethral S-dilators. We hereby recommend the utilization of this basic urological equipment for their long-term economical and cost-effective benefits.
Nil.
There are no conflicts of interest.
We would like to thank you to Prof. Tijani, Dr. Ojewola, Dr. Ogunjimi (Honorary consultant Urologists at LUTH) for allowing patients under their care to be added to the study. Thank you to Dr. Animashaun and Dr. Onyeze (now consultant urologist) and Dr. Oladimeji for having carried out some of the procedures in conjunction with the author.
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