URINARY RETENTION and CYSTOSTOMY | MRKH

URINARY RETENTION and CYSTOSTOMY

Acute retention of urine is an indication for emergency drainage of the bladder. If the bladder cannot be drained through the urethra, it requires suprapubic drainage.

Treatment of chronic retention is not urgent. Arrange to refer patients with chronic urinary retention for further management.

MALE URETHRAL ANATOMY

Urethra: 20cm long from bladder neck to the external meatus.

-Prostatic urethra

-Membranous urethra

-Penile urethra

Emergency drainage

Emergency drainage of the bladder in acute retention may be undertaken by:

 Urethral catheterization  Suprapubic puncture  Suprapubic cystostomy.

Urethral catheterization or bladder puncture is usually adequate, but cystostomy may become necessary for the removal of a bladder stone or foreign body, or for more prolonged drainage, for example after rupture of the posterior urethra or if there is a urethral stricture with complications.

If a catheter’s balloon fails to deflate, inject 3 ml of ether into the tube leading to the balloon. This will rupture the balloon. Cut it off and remove it. Prior to removing the catheter, irrigate the bladder with 30 ml of saline.

I- URETHRAL CATHETERIZATION IN THE MALE PATIENT

Technique

1-Reassure the patient that catheterization is atraumatic and usually uncomfortable rather than painful. Explain the procedure.

2- Wash the area with soap and water, retracting the prepuce to clean the furrow between it and the glans. Put on sterile gloves and, with sterile swabs, apply a bland antiseptic to the skin of the genitalia. Isolate the penis with a perforated sterile towel. Lubricate the catheter with generous amounts of water soluble gel.

3-Check the integrity of the Foley catheter balloon and then lubricate the catheter with sterile liquid paraffin (mineral oil). If you are right-handed, stand to the patient’s right, hold the penis vertically and slightly stretched with the left hand, and introduce the Foley catheter gently with the other hand (Figure 9.1).

At 12–15 cm, the catheter may stick at the junction of the penile and bulbous urethra, in which case angle it down to allow it to enter the posterior urethra. A few centimeters further, there may be resistance caused by the external bladder sphincter, which can be overcome by a gentle pressure applied to the catheter for 20–30 seconds. Urine escaping through the catheter confirms entry into the bladder.

Advance the catheter 5 to 10 cm before inflating the balloon. This prevents the balloon inflating in the prostatic urethra.

4-If the catheter fails to pass the bulbous urethra and the membranous urethra, try a semi-rigid coudé catheter. 5-Pass a coudé catheter in three stages. With one hand, hold the penis stretched and, with the other hand, hold the catheter parallel to the fold of the groin. Introduce the catheter into the urethra and bring the penis to the midline against the patient’s abdomen as the “beak” of the catheter approaches the posterior urethra. Finally, position the penis horizontally between the patient’s legs as the catheter passes up the posterior urethra over the lip of the bladder neck. At this point, urine should flow from the catheter.

If you fail to pass a catheter, proceed to filiforms and followers (Figure 9.2) or use a Foley catheter with a guide. If these procedures are unsuccessful, abandon them in favour of suprapubic puncture. Forcing the catheter or a metal bougie can create a false passage, causing urethral bleeding and intolerable pain, and increasing the risk of infection.

Fixation of the catheter

1-If you are using a Foley catheter, inflate the balloon with 10 –15 ml of sterile water or clean urine (Figure 9.2). Partially withdraw the catheter until its balloon abuts on the bladder neck.

2-If the catheter has no balloon, knot a ligature around the catheter just beyond the external meatus and carry the ends along the body of the penis, securing them with a spiral of strapping brought forward over the glans and the knot (Figures 9.3, 9.4, 9.5).

Aftercare 

 If the catheterization was traumatic, administer an antibiotic with a gram negative spectrum for 3 days 

 Always decompress a chronically distended bladder slowly 

 Connect the catheter through a closed system to a sterile container (Figure 9.6) 

 Strap the penis and catheter laterally to the abdominal wall; this will avoid a bend in the catheter at the penoscrotal angle and help to prevent compression ulceration 

 Change the catheter if it becomes blocked or infected, or as otherwise indicated. Ensure a generous fluid intake to prevent calculus formation in recumbent patients, who frequently have urinary infections, especially in tropical countries.