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Bladder drainage and urinary protective methods
Introduction
Patients who undergo surgery for urinary incontinence or pelvic organ prolapse may require catheterization postoperatively because of voiding difficulty. Patients with neurogenic bladder, dysfunctional voiding, or intractable incontinence may require intermittent or indwelling catheterization for long-term management. Three catheterization methods—transurethral, suprapubic, and intermittent self-catheterization (ISC)—can be used. Surgeons may also recommend voiding trials for their patients postoperatively. Failure to void with voiding trials usually requires catheterization for a period of days to weeks.
Incontinent patients may use protective products to aid with urine loss. These appliances may be helpful when medical or surgical management is not entirely successful, or when treatment is not an option or is more objectionable to the patient than continued incontinence. This chapter will discuss indwelling catheterization, voiding trials, and various protective products.
Bladder drainage
Obstetricians and gynecologists often encounter the need for bladder drainage in patients after surgery and obstetric deliveries. Urinary retention is common after anesthesia and surgery, with a reported incidence of as high as 70%. General anesthesia can cause bladder atony by relaxing smooth muscle cells and by interfering with autonomic detrusor regulation. Intrathecal anesthetics interfere with the micturition reflex by blocking the afferent nerve supply to the bladder. Local anesthesia does not interfere with voiding function. Surgery for stress incontinence or pelvic organ prolapse also increases this risk by increasing urethral resistance to flow, which places the patient at risk for postoperative retention requiring temporary or prolonged bladder drainage. The risk of this retention after midurethral, vaginal, and retropubic procedures ranges from 3% to 25% and may be up to 47% for pubovaginal sling procedures. Adequate postoperative bladder drainage is important because overdistension is not only uncomfortable, but may lead to infection, as well as difficulty in resuming normal voiding. If overdistension or retention persists, patients may experience secondary myogenic damage attributable to changes in bladder architecture and function.
Transurethral catheterization
The first self-retaining transurethral catheter was described in 1937 by Frederic Foley. A saline-inflated intravesical balloon holds the catheter in place. The transurethral catheter is commonly used after many gynecologic procedures. In a prospective cohort study by that evaluated urinary retention after laparoscopic and vaginal surgery, 21% of the study population developed urinary retention, with the risk of retention greater in vaginal hysterectomy versus laparoscopic hysterectomy. In another study, conducted by , it was found that urinary retention was increased in patients who underwent high-grade cystocele repairs, levator plication, and Kelly plication.
Transurethral catheters may be used for short periods of time and are made of silicone/silastic or latex. Catheters are measured using the Charriere or French scale, where 0.33 mm equals 1 French. The rule of placing a catheter is to use the smallest catheter that will still allow for unobstructed drainage. In female patients, the usual size of transurethral catheter used during and after procedures is 14- to 16-French.
The major difficulty with use of transurethral drainage is the potential for infection. Urinary tract infections account for about 40% of hospital-acquired (nosocomial) infections, and about 80% of urinary tract infections occurring in hospitals are associated with urinary catheters. Pelvic surgery is frequently complicated by urinary tract infection. The risk of infection after incontinence surgery is approximately 33% to 47%. Some 45% of women who undergo obliterative procedures for prolapse develop urinary tract infection within 3 months of surgery. Factors that are associated with development of a urinary tract infection after surgery for prolapse and/or stress urinary incontinence include postoperative catheterization because of inability to void, longer operative times, history of recurrent urinary tract infection, and concomitant procedures. Bacterial colonization of a closed system is unavoidable, with a rate of 5% to 10% per day. The bacteria within the catheter system form an ever-changing biofilm that colonizes the catheter tubing and bag. Once these biofilms have developed, it is impossible to eradicate the organism from the urinary system, and the biofilms will persist until the catheter is removed. It is not recommended to treat asymptomatic bacteriuria in the presence of an indwelling catheter. Urinary tract infections will be eliminated in one third of patients who have their Foley catheter removed.
Medicare rules that took effect in October of 2008 deny reimbursement for treatment of inpatient catheter-associated urinary tract infections (CAUTIs) and any associated complications. Box 39.1 lists the Centers for Disease Control and Prevention guidelines for prevention of CAUTI.
Box 39.1
(From Gould CV, Umscheid CA, Agarwal RK, et al. Guideline for prevention of catheter-associated urinary tract infections. Infect Control Hosp Epidemiol . 2010;31:319.)
United States Centers for Disease Control and Prevention Guidelines for Placing Catheters in Patients
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