Plumbing problems

Urethral and Suprapubic catheters (SPCs) and managing common issues

Urethral and Suprapubic catheters (SPCs) come with similar issues.

To avoid duplication, we focus on SPCs.

SPCs are surgically placed catheters which enable the drainage of urine from the bladder while bypassing the urethra.

Indications:

1. Urinary retention following urethral trauma

2. Patients indefinitely requiring a long term catheter mainly in neurological conditions such as MS/stroke/demyelinating conditions

3. Patient and carer preference

Insertion:

1. Traditionally a blind technique of SPC insertion was employed where a full and palpable bladder was assumed to displace the bowel away from the site of puncture.
   Luckily we don’t rely on tradition in the era of imaging!

2. Ultrasound or CT guided SPC insertion - the method of choice as it reduces the risk of bowel injury.

   
   

As a rule of thumb, once the first catheter is placed, it should not be changed unless done so by a urologist in the first 6 weeks. This allows the catheter tract to form and early removal risks a loss of the tract requiring salvage in hospital or clinic.

Patients may present with the following problems:

1. Blocked catheter

2. Expelled catheter

3. Blood in catheter

4. Difficulty re catheterising

5. Pain and bypassing

6. Formation of bladder stones secondary to the SPC which acts as a foreign body

Management of SPC problems:

1. Blocked catheter - Flush gently with 10-20ml. This will usually dislodge the debris and allow the catheter to drain. If the catheter has been in for a while and is due a change then replacement of the catheter with an aseptic non touch technique will resolve the problem.

2. Expelled catheter - Usually noted when a patient with a weak abdominal wall has a bout of coughing or severe bladder spasms, displacing the balloon and catheter. Needs to be replaced ASAP.

3. Blood in catheter - Assess for symptoms of a UTI. A urine dip from the catheter is a poor measure of infection as it will almost always be leukocyte and nitrite heavy with white cells detected. If the patient does not have features of an infection, it is worth referring the patient to a haematuria clinic for full assessment.

4. Difficulty re-catheterising may be due to poor technique/ lack of confidence in performing a catheter exchange or because the tract has stenosed or has been lost. In this case a guidewire may be a useful adjunct (if used correctly) to finding the tract and railroading a catheter over. If you have any difficulty, it is best to speak to the urology registrar for advise.

5. Pain and by passing is often due to bladder spasms - a simple anticholinergic will relieve this and mirabegron may be used at the lowest possible dose. Note that bypassing from the urethra can occur and as long as good volumes of urine are passing via the SPC, the patient can be reassured. This is likely due to low resistance at the urethra. Persistent bypassing can be assessed in the outpatient setting with appropriate cystometry.

Common nephrostomy issues

Nephrostomies are percutaneously inserted conduits facilitating the drainage of the renal pelvis.

As is the case with any external drain or tube, nephrostomies present with challenges and issues from time to time most of which can be managed the following day if sensible.

As a general rule, nephrostomy problems in a single functioning kidney should be assessed and managed urgently to preserve renal function and avoid developing an AKI or infection.

When dealing with nephrostomies, as with catheters; using incontinence sheets to keep the patient and linen dry is recommended and your nursing and HCA colleagues will be grateful.

Common problems with nephrostomies:

1. Blocked tube

2. Blood stained urine

3. Displaced nephrostomy

Blocked nephrostomy

Patients note that there is little to no urine output. Sometimes their carer would have noticed this at the time of emptying the bag or changing the bag.

If the patient is able to pass reasonable amounts of urine per urethra this is a reassuring first step as it implies urine is draining down the ureters at the very least.

1. Remove the nephrostomy bag gently by peeling away the sticky bits. Avoid tugging on the nephrostomy tube as it will cause pain and risk displacing the tube.

2. Once the bag has been removed, examine the port and tube as well as the skin surrounding the nephrostomy. The presence of heavy encrustation (chunky salt deposits) indicates that the lumen may very well be occluded by the same and may require a change if the following measures fail.

3. Also look for any obvious kinks in the tube. If you attempt to straighten the kink, please secure the proximal end to avoid tugging on the tube.

4. Draw 10-20mL of normal saline in a syringe. You may need a normal tipped syringe or luer-lock syringe (the screw on type) depending on the nephrostomy port so keep a spare handy.

5. Gently push the saline through the nephrostomy. Use as much pressure as you would when you flush a cannula. If this works, well done!

6. If pushing the saline through is futile, gently pull on the plunger and try pushing again, this may displace some of the debris within the tube. Do this a few times before moving on.

7. If the patient is tolerating the procedure, apply firmer pressure. Stop when there is discomfort.

8. Gently push the nephrostomy tube into the stoma slightly and try flushing again. This manipulation may help bypass a renal stone or detach it from the walls of the pelvis and into the pelvis proper allowing drainage.

9. Whether you succeeded or failed, place a fresh nephrostomy bag and revisit the patient in an hours time to check if the tube has started to drain.
   

If there is no urine coming out, book the patient for a nephrostomy exchange.

Escalate early if the patient has a single kidney or single functioning kidney.

Blood stained urine:

Blood stained urine immediately after a nephrostomy exchange or first time insertion can be expected and should resolve within the day.

Should a patient with a nephrostomy present with bloody urine and feeling unwell with elevated white cell counts and inflammatory markers, think about pyelonephritis.

Manage the patient on the lines of pyelonephritis with antibiotics.

Displaced nephrostomy

Delirium can be a confusing time for all involved and it is not unusual to receive a call regarding a patient who has pulled their nephrostomies out.

Assess the patient, start appropriate antibiotics and arrange for urgent nephrostomies in this instance.

Remember, infected and obstructed kidneys are a recipe for septic shock.