The Importance of Proper CIC Technique

Case 1: A 41-year old man with difficulty with his intermittent catheterization

A 41-year old man was in the emergency room last night. Apparently, there was some difficulty with his intermittent catheterization, in a chronic care facility, that resulted in trauma and some gross bleeding from his urethra. The ER physicians were able to get a 14-French Foley in place without any difficulty when they contacted urology. They reported that the catheter was draining clear urine, and the patient was looking very well. He was discharged to a care facility. The patient's nurse/caregiver called today reporting some bleeding around the catheter indicating that they were concerned about this they were somewhat concerned.
On examination, the catheter is intact and patent draining clear yellow urine. There is no significant scrotal or penile hematoma. There is a small amount of pericatheter blood but there is no active bleeding.

We removed his Foley and did a cystopanendoscopy with a flexible cystoscope. There are 2 linear fresh lacerations in the pendulous urethra. There are 2 older well-healed false passages one on the left hand side of the verumontanum and the other just distal to the external sphincter. The 2 most recent linear lacerations are at least 2 cm in width and in length. They are on either side of each other in the pendulous urethra. They are granulating. The tissue is not bleeding, and it looks they are about ready to heal.

Comments and Lessons from This Case:  In this patient, switching him over to a Coude tip catheter is recommended with instructions for the care providers to keep the tip of the catheter upwards toward the patient's umbilicus and thus avoid the pendulous urethra or the 2 injury sites. In addition, the patient's penis must be placed on stretch when catheterized. Otherwise, one runs the risk of running into the folded-on-itself urethra. That is what happened here. In patients who must rely on others for CIC attention to detail is helpful in avoiding trauma to the urethra. The penis should be placed on stretch, to facilitate passage of the catheter into the posterior urethra and to avoid trauma to the pendulous urethra. The catheter should be well lubricated and in some cases a hydrophilic catheter, or a coude tip catheter should be used. This is relevant in patients with a reflex contraction of the external sphincter associated with catheter contact with that structure. In these cases when the sphincter contracts, the person catheterizing should wait several seconds to let the sphincter relax before proceeding. A hydrophilic catheter or a coude catheter may help in these cases. If gentle catheterization still results a in urethra trauma, and there is persistent difficulty with catheterization, botulinium toxin injection into the external sphincter can provide prolonged relief.

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