Patient has pulled out his Foley - management options?

[driedcaribou]

Hi there- just a quick question.

I've had several delirious patients on my wards pull out their Foley's.

I have had some senior residents tell me to re-catheterize right away, some tell me to wait, and some tell me to just call Uro and let them handle it.

The logic of replacing it immediately is to prevent hemostasis and the others tell me to wait to allow it to clot....

What is the best way to manage this scenario?

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[StickMe]

I would replace the foley immediately. Placing the foley allows for hemostasis rather than preventing it. I've seen people drip blood all over the place once that foley comes out. Once you place the foley in, the blood stops and the urine clears. Also, you need to keep the foley in long-term to allow the urethra to heal without scarring down. They'll probably need to follow up with a urologist if you didn't already consult one for the replacement.

 

[driedcaribou]

The patient wasn't mine but I followed his progress notes and because of the difficulty with reinsertion, uro didn't recommend replacing the Foley if he was still passing urine.

But he's still hematuric.

His team doesn't seem to really care about it as long as the primary operation he came in for is ok.

It's unfortunate.

 

[Pir8DeacDoc]

Of course he's still hematuric. He basically gave himself a TURP. A little blood in the urine is to be expected. As long as the urine is passing without a high PVR then he doesn't have any huge clots and all is fine.

 

[former military]

when I was a resident a fellow resident was sick of being called about a demented old man pulling his catheter and occasionally pulling it out.
he was so frustrated he tucked the real catheter between his legs and taped it to the back of his leg... he then taped 7-8 dummy foleys that the patient could reach and intermittently pull on to keep himself busy

 

[basupran]

when I was a resident a fellow resident was sick of being called about a demented old man pulling his catheter and occasionally pulling it out.
he was so frustrated he tucked the real catheter between his legs and taped it to the back of his leg... he then taped 7-8 dummy foleys that the patient could reach and intermittently pull on to keep himself busy

Interesting.... I will keep this in my memory bank for the future.

 

[bobbyseal]

Guys who auto-TURP themselves can be rather irritating. I usually replace the foley and put 30ml in the balloon. Rusch makes a nice hematuria 3 way catheter with a large eyehole at the end. I then irrigate the bladder out of any blood clot. Put the foley to traction to tamponade the bladder neck from bleeding for a day or so. If necessary, you can start some CBI.

After that, order up some Seroquel and restraints so the gorked out guy doesn't keep pulling on the catheter.

 

[kempke]

becides tape what would you sugest we do to prevent him from pulling the cath apart time annd time again?

 

[MattD]

Yeah as much as people complain about mean 'ole restraints, if a patient is delirious and injuring himself, on go the straps as far as I'm concerned.

 

[sponch]

If the guy is voiding on his own, I wouldn't put the catheter back. A little bleeding is expected and will stop with time. I've often found that other services have catheters in people without a clear indication. Sometimes it's for "hygiene" because the RNs complain about changing diapers, etc. If the guy can't pee, that's a different problem and he needs a catheter put back and a sh*tload of pink tape to secure it as well as restraints (pharmacologic and mechanical).

 

[cpants]

If the guy is voiding on his own, I wouldn't put the catheter back. A little bleeding is expected and will stop with time. I've often found that other services have catheters in people without a clear indication. Sometimes it's for "hygiene" because the RNs complain about changing diapers, etc. If the guy can't pee, that's a different problem and he needs a catheter put back and a sh*tload of pink tape to secure it as well as restraints (pharmacologic and mechanical).

If the foley wasn't indicated to begin with, as many are not, it does not necessarily need to be replaced. It may now be indicated if he is bleeding a lot, in retention, or there is suspicion of urethral injury. A urology consult is probably warranted in most cases, so that they are at least aware of the guy. If there is indication for a foley, a nice big threeway catheter should be placed and secured. The patient should be minimally put on 1 to 1 and in most cases put in restraints and medicated until his delirium or the foley indication resolves. There is NO excuse for a foley to be pulled out a second time, though I've seen this happen surprisingly frequently.

 

[sponch]

If the foley wasn't indicated to begin with, as many are not, it does not necessarily need to be replaced. It may now be indicated if he is bleeding a lot, in retention, or there is suspicion of urethral injury. A urology consult is probably warranted in most cases, so that they are at least aware of the guy. If there is indication for a foley, a nice big threeway catheter should be placed and secured. The patient should be minimally put on 1 to 1 and in most cases put in restraints and medicated until his delirium or the foley indication resolves. There is NO excuse for a foley to be pulled out a second time, though I've seen this happen surprisingly frequently.

I disagree with the urology consult thing. I don't want to hear about it until the primary team exhausts all the things they can do. I never understood the "heads up" consults. It's not like it takes a long time to evaluate and treat a patient and it certainly doesn't take a ton of preparation. I don't need any lead time. The only thing these consults do is take up time.

 

[cpants]

I disagree with the urology consult thing. I don't want to hear about it until the primary team exhausts all the things they can do. I never understood the "heads up" consults. It's not like it takes a long time to evaluate and treat a patient and it certainly doesn't take a ton of preparation. I don't need any lead time. The only thing these consults do is take up time.

Yeah, on second thought I agree with you. I didn't really mean a full consult, more a heads up call so the GU guys can assess the likely necessity of consult. Nothing worse than coming back in at 2am for a guy that's been in the ER since noon and is now in retention. I'd rather just do a preventative consult at 5 before I go home.

 

[felipe5]

becides tape what would you sugest we do to prevent him from pulling the cath apart time annd time again?

We often will wrap a large ace bandage around their leg to obscure the majority of the catheter. Works quite well

 

[sponch]

We often will wrap a large ace bandage around their leg to obscure the majority of the catheter. Works quite well

that's a nice trick. gotta remember that one.

 

[felipe5]

hey just out of curiosity whats your guys' approach to difficult foleys (ie typical stuff, not urethral trauma)? Basically we typically try coudes and if theres any questions or concerns we end up scoping and place a council over a wire +/- dilating. The reason I ask is that at our last local/regional AUA meeting (south central) I saw a talk (from colorado i think?) about a protocol that they had but I can't recall all of the details. Just curious what you all do

 

[sponch]

hey just out of curiosity whats your guys' approach to difficult foleys (ie typical stuff, not urethral trauma)? Basically we typically try coudes and if theres any questions or concerns we end up scoping and place a council over a wire +/- dilating. The reason I ask is that at our last local/regional AUA meeting (south central) I saw a talk (from colorado i think?) about a protocol that they had but I can't recall all of the details. Just curious what you all do

it is my firm belief that 90% of the so called "difficult" catheters can be solved with a good old fashioned 18-french coude tip catheter. the rest are urethral strictures, bladder neck contractures, or large prostates that have been too traumatized and have false passages that prevent a catheter from going to the right place. those need either a scope or an sp tube.

in our busiest call year, i only had to use the scope to get a catheter in a handful of times. now, when i am called to place a "difficult" catheter, i insist that the person asking for the consult try it themselves. they usually give some b.s. line about how they haven't done one since medical school or how the nurses do it all the time and if the nurse has trouble, they're definitely going to have trouble.

my response is: "the first thing i'm going to do when i get there is to put in an 18 french coude tip with a lot more force than the nurses typically use and that works 9 out of 10 times. so please just try it and i will gladly help you if that fails."

i also point them to a video on how to put a catheter in from NEJM. there's really no excuse for trying. http://www.nejm.org/doi/full/10.1056/NEJMvcm054648

if i get a particularly stubborn medicino, i resort to saying "look, you're a doctor, you guys can float a swan into someone's right heart. in fact, you guys love doing that and can't wait to practice on some poor soul in the medical ICU. are you telling me you can't stick a tube in some dude's penis with a little more force than a nurse?"

 

[felipe5]

Agreed the 18 and 20 Fr coude are should be the first thing tried IMHO---The protocol that was describedI think by someone from Colorado at the south central aua section involved placement of a wire blindly (or was it a feeding tube?) then a catheter---definitely different. Our tough foleys (bncs, strictures) seem to come in droves However. at my institution most of the resistance comes from nursing staff...I swear the foreign sounding coude (and don't get me started on spt's) is tantamount to a swan or a massive chest tube or something---maybe if it was called a "jolly" or "safe tip" catheter maybe it wouldn't instill the sense of fear it does round here.

Hey just curious what do u all use for punch spt tubes? We had these tiny little pig tails that would enevitably clog or fall out but we recently got a slick choui (?) punch kit with some fascial dilators that seem pretty nice. Word

 

[sponch]

Agreed the 18 and 20 Fr coude are should be the first thing tried IMHO---The protocol that was describedI think by someone from Colorado at the south central aua section involved placement of a wire blindly (or was it a feeding tube?) then a catheter---definitely different. Our tough foleys (bncs, strictures) seem to come in droves However. at my institution most of the resistance comes from nursing staff...I swear the foreign sounding coude (and don't get me started on spt's) is tantamount to a swan or a massive chest tube or something---maybe if it was called a "jolly" or "safe tip" catheter maybe it wouldn't instill the sense of fear it does round here.

Hey just curious what do u all use for punch spt tubes? We had these tiny little pig tails that would enevitably clog or fall out but we recently got a slick choui (?) punch kit with some fascial dilators that seem pretty nice. Word

We all use the Rusch AC851 SupraFoley SP Introducer 16Fr. http://www.myrusch.com/frontend/bin/start.htm.

It's basically a metal obturator fitted through a peel away sheath. I incise the skin and fascia with an 11 blade. Use a long needle and syringe to aspirate back until I find the bladder and get an idea of what trajectory to go. Then, I push the obturator in the same direction. You can feel it pop through the fascia into the space of Retzius. Once you penetrate the bladder wall, urine starts to flow out between the obturator and the sheath. That's how you know you're in. Then you remove the obturator and quickly put a 16F Foley down the sheath and deploy the balloon. If you're too slow, you'll get a geyser of urine in your face. The sheath can then be peeled away (like those tunneled central catheter introducer sheaths. A couple of silks to secure the tube and you're done. A hell of a lot faster than getting the scope cart, light box, wires, etc. With this you don't have to use a wire, you don't have to dilate. Just stab the darn thing in like a laparoscopic trocar and you can write a quick note and go back to sleep.

 

[tms]

We all use the Rusch AC851 SupraFoley SP Introducer 16Fr. http://www.myrusch.com/frontend/bin/start.htm.

It's basically a metal obturator fitted through a peel away sheath. I incise the skin and fascia with an 11 blade. Use a long needle and syringe to aspirate back until I find the bladder and get an idea of what trajectory to go. Then, I push the obturator in the same direction. You can feel it pop through the fascia into the space of Retzius. Once you penetrate the bladder wall, urine starts to flow out between the obturator and the sheath. That's how you know you're in. Then you remove the obturator and quickly put a 16F Foley down the sheath and deploy the balloon. If you're too slow, you'll get a geyser of urine in your face. The sheath can then be peeled away (like those tunneled central catheter introducer sheaths. A couple of silks to secure the tube and you're done. A hell of a lot faster than getting the scope cart, light box, wires, etc. With this you don't have to use a wire, you don't have to dilate. Just stab the darn thing in like a laparoscopic trocar and you can write a quick note and go back to sleep.

One thing to remember when placing a punch, advance the catheter a little more after you get urine back. That's the head fake. You'll secure the the catheter to the skin, the bladder will decompress, and the poor malencot will be pulled back out of the bladder. I always visualize placement with ultrasound. It can be difficult to see the catheter, but usually, the needle tip can be seen. You can visualize the tip in the bladder, then advance the catheter off of the needle. The problem with some of the smaller diameter punch SP kits (10 and 12 FR) is that if long term management is needed, you may need to dilate the tract in the clinic with Amplatz dilators. Let me tell you, patients hate this.

 

[tms]

it is my firm belief that 90% of the so called "difficult" catheters can be solved with a good old fashioned 18-french coude tip catheter. the rest are urethral strictures, bladder neck contractures, or large prostates that have been too traumatized and have false passages that prevent a catheter from going to the right place. those need either a scope or an sp tube.

in our busiest call year, i only had to use the scope to get a catheter in a handful of times. now, when i am called to place a "difficult" catheter, i insist that the person asking for the consult try it themselves. they usually give some b.s. line about how they haven't done one since medical school or how the nurses do it all the time and if the nurse has trouble, they're definitely going to have trouble.

my response is: "the first thing i'm going to do when i get there is to put in an 18 french coude tip with a lot more force than the nurses typically use and that works 9 out of 10 times. so please just try it and i will gladly help you if that fails."

i also point them to a video on how to put a catheter in from NEJM. there's really no excuse for trying. http://www.nejm.org/doi/full/10.1056/NEJMvcm054648

if i get a particularly stubborn medicino, i resort to saying "look, you're a doctor, you guys can float a swan into someone's right heart. in fact, you guys love doing that and can't wait to practice on some poor soul in the medical ICU. are you telling me you can't stick a tube in some dude's penis with a little more force than a nurse?"

Werd! sponch, I'd take call with you anytime bud.

The 18 FR coude is the Go-To catheter if you can't place a standard 16 FR out-of-the-box catheter. If I get the usual "nurse can't place a catheter" consult where it's obvious the resident hasn't even evaluated the patient of if they've tried themselves with a standard catheter, I have the resident meet me at the bedside. If nothing else, it gives my the opportunity to educate and potentially avert this the next time. I know... way too optomistic. Anyway, I usually dilate the urethra by injecting the syringe of lube directly into the meatus. Then viola, the 16 FR passes magically. If this doesn't work, I have a syringe of viscous lidocaine. Inject per urethra for more dilation and some "local anesthesia." I try the 18 FR coude. I always have a catheter tip syringe and saline to verify placement as the lube can temporarily occlude the catheter and I don't want to come back if the lube liquifies and there still is no urine output. You can always verify placement at the bedside by distending the bladder at bedside with saline and palpate the bladder or visualizing with ultrasound if you don't get urine return.

If these measures don't work and I can palpate the bladder, I do ultrasound-guided SP punch and follow-up with a RUG cystogram.

I would love to scope in catheters +/- dilation, but the logistics of taking the patient to the OR are usually difficult to overcome and we've had some flexible scopes damaged or lost in the transport to and fro the bedside.

 

[cpants]

My algorithm is (move on to next step if it doesn't work):

1. 18Fr coude (prostate trouble) or 12-14Fr silastic (stricture hx) with tons of lube
2. Attempt to pass a glide wire blindly -- if successful put a pollack over it and confirm placement, then replace wire and place a council tip(dilate first if necessary)
3. Flexible scope, wire, +/- dilation, council tip
4. SPT -- prefer the Seldinger technique kits to punch
5. OR
6. CMO

Bonus tip: If moving beyond step 1 some dilaudid/ativan are good ideas

Sponch: You would really put an SPT before scoping? Ouch.

 

[StritchMD2011]

My algorithm is (move on to next step if it doesn't work):

1. 18Fr coude (prostate trouble) or 12-14Fr silastic (stricture hx) with tons of lube
2. Attempt to pass a glide wire blindly -- if successful put a pollack over it and confirm placement, then replace wire and place a council tip(dilate first if necessary)
3. Flexible scope, wire, +/- dilation, council tip
4. SPT -- prefer the Seldinger technique kits to punch
5. OR
6. CMO

Bonus tip: If moving beyond step 1 some dilaudid/ativan are good ideas

Sponch: You would really put an SPT before scoping? Ouch.

This is my exact algorithm too. 18 coude is the best catheter ever made as far as I'm concerned.

 

[nemo183]

when I was a resident a fellow resident was sick of being called about a demented old man pulling his catheter and occasionally pulling it out.
he was so frustrated he tucked the real catheter between his legs and taped it to the back of his leg... he then taped 7-8 dummy foleys that the patient could reach and intermittently pull on to keep himself busy

HELP! I'm wondering if this might work for a patient with Tourette Syndrome who has a compulsion to yank at it, causing trauma and infection. The only other option is x4 in/out daily. difficult to arrange in the community, hardly ideal, but not impossible. He is now in considerable pain because of the trauma and has constant infections

Does anyone have any other creative ideas that might help what is becoming a serious problem?

 

[cpants]

HELP! I'm wondering if this might work for a patient with Tourette Syndrome who has a compulsion to yank at it, causing trauma and infection. The only other option is x4 in/out daily. difficult to arrange in the community, hardly ideal, but not impossible. He is now in considerable pain because of the trauma and has constant infections

Does anyone have any other creative ideas that might help what is becoming a serious problem?

I doubt decoys are going to work on a lucid patient with Tourette's who has a compulsion to pull on it. Sounds like a guy who cannot be managed with a Foley. Why does he need it? Retention? Could he be TURP-ed? Otherwise, I think intermittent cath is the safest option. Is there a reason he can't learn to cath himself?

 

[nemo183]

I doubt decoys are going to work on a lucid patient with Tourette's who has a compulsion to pull on it. Sounds like a guy who cannot be managed with a Foley. Why does he need it? Retention? Could he be TURP-ed? Otherwise, I think intermittent cath is the safest option. Is there a reason he can't learn to cath himself?

Thanks for that. He's not able do it himself because of the T/S. Sorry, should have made it clear that the T/S has caused spinal mythopathy and he's now a wheelchair user. He's 29 and that seems an unsatisfactory solution for him. I'm wondering if there's any mileage in Sacral Neuromodulation?

 

[DoctwoB]

Thanks for that. He's not able do it himself because of the T/S. Sorry, should have made it clear that the T/S has caused spinal mythopathy and he's now a wheelchair user. He's 29 and that seems an unsatisfactory solution for him. I'm wondering if there's any mileage in Sacral Neuromodulation?

Sacral neuromodulation is a treatment for refractory overactive bladder and urge incontinence. It does not treat urinary retention, whether it's from underachiever bladder or outlet obstruction. He sounds like someone who needs urodynamics to assess if he has any degree of outlet obstruction that
would benefit from surgery, but unlikely given his age. Better option may be to better treat Tourette's as best as possible and get a SPT. Also since when does Tourette's cause myelopathy?

 

[armybound]

InterStim is used for nonobstructive urinary retention. I agree with urodynamics.

 

[nemo183]

Sacral neuromodulation is a treatment for refractory overactive bladder and urge incontinence. It does not treat urinary retention, whether it's from underachiever bladder or outlet obstruction. He sounds like someone who needs urodynamics to assess if he has any degree of outlet obstruction that
would benefit from surgery, but unlikely given his age. Better option may be to better treat Tourette's as best as possible and get a SPT. Also since when does Tourette's cause myelopathy?

The spinal myelopathy was thought to be caused by the severity of his neck tics. (paper written up in Neurology) The DBS was fitted to try and reduce them, with but with limited success. He now has a rechargeable battery, which is an improvement on constant replacement every 3-4 years. (the settings are wacked up to 11, so big current drain.) I'm liking a heavily bound and wrapped SPT as the way forward. Current issue is the ghastly state of the trauma injuries, grim.

 

[nemo183]

InterStim is used for nonobstructive urinary retention. I agree with urodynamics.

Cheers, thanks for that.

 

[anonperson]

...

 

[anonperson]

The spinal myelopathy was thought to be caused by the severity of his neck tics. (paper written up in Neurology) The DBS was fitted to try and reduce them, with but with limited success. He now has a rechargeable battery, which is an improvement on constant replacement every 3-4 years. (the settings are wacked up to 11, so big current drain.) I'm liking a heavily bound and wrapped SPT as the way forward. Current issue is the ghastly state of the trauma injuries, grim.

Should see a urologist who specializes in neurogenic bladder. Usually are at academic medical centers.
At minimum will need cystoscopy, video urodynamics (will evaluate the upper tracts-make sure they aren't getting killed by a high pressure system, check for sphincter dyssnergia, compliance issues etc).

Depending on those test results will guide management: can be meds, botox, catheters, urinary diversion/augments etc.

 

[nemo183]

Should see a urologist who specializes in neurogenic bladder. Usually are at academic medical centers.
At minimum will need cystoscopy, video urodynamics (will evaluate the upper tracts-make sure they aren't getting killed by a high pressure system, check for sphincter dyssnergia, compliance issues etc).

Depending on those test results will guide management: can be meds, botox, catheters, urinary diversion/augments etc.

Thanks. That's exactly where he is now. The urge to keep pulling and doing more damage led to a cycle of damage resulting in the DBS failing, requiring emergency surgery to fix. After this, they'll be a damage assessment. The indwelling will have to stay and the patient sedated until then. Currently looking at supra pubic contained within strapping/binding/pouch purposely made.

 

[cpants]

Agree with urodynamics to determine the reason for retention and ensure a safe reservoir. If he has nonobstructive retention, sacral neuromodulation is an option. SPT sounds like a terrible idea. I would only consider it if his urethra is too strictured down to reliably catheterize. Otherwise it is a matter of time until he rips that out and you are back in the same situation. No urologist is going to sign up for someone who is going to rip out their SPT on a regular basis.

IMO, assuming he is obstructed, the best options are:
1) intermittent catheterization -- by nurses at his SNF if he can't do it himself. I'm assuming a guy this debilitated is institutionalized?
2) TURP/sphincterotomy to make him incontinent. Then use a condom catheter to keep him dry. He can rip that off all he wants.