Clinical Notes
Removalof Obstructed FoleyCatheterFrom the Urethra LT COL MATTHEW M. RICE, MD, MC,* GREG MOGEL, BSt Thfs case Illustrates an approach to resolve a frustrating problem assoelated with Foley catheter balloon obstructlans. By Identifying Its position in the urethra, the balloon can be deflated with mlnlmal effort and limited urethra injury, using the suggested technique of transperineal needle Insertion. (Am J Emerg led 1991;9:72-73. Copyright 0 1991 by W.B. Saunders Company)
It has been estimated that at least 15% of the hospitalized patients in the United States have in place a Foley catheter.’ This figure can be expected to increase in the face of an aging population. The incidence of balloon catheters that fail to deflate is not known, although the problem is not uncommon.* A nondeflating catheter balloon is most frequently located in the bladder; however, the balloon may migrate and be found distal to the bladder (Figure 1). If this is the case, treatment options change. We report the case of a male patient with an obstructed Foley balloon located in the spongy urethra and discuss the approach to resolving such a problem. CASE REPORT A 90-year-old male nursing home resident was brought to the emergency department with a Foley catheter that could not be removed. On examination the patient was found to be in baseline demented and aphasic state with blood pressure, 120/80 mmHg; pulse rate, 76 beats/min; respirations, 16 breaths/mitt; and temperature 97.7”F. He was noted to have blood at the urethral meatus and a Foley catheter that was draining clear urine. Conventional attempts to empty the balloon were unsuccessful and the catheter resisted removal. The Foley was cut approximately 4 inches distal to the meatus, but the balloon failed to drain. It was then noted that the balloon, inflated with an estimated 5 ml of fluid, could be palpated in the base of the penis. The ventral surface of the penis was prepped, and a penile ring block was performed using 1% lidocaine. A 25-gauge spinal needle was inserted into the base of the penis ventrally, bursting the balloon (Figure 2). The remnants of the catheter were easily removed. A 20F catheter was subsequently placed without incidence.
From the *Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA; and the TUniversity of Pennsylvania, Philadelphia, PA. Manuscript received March 16, 1990; revision accepted May 30, 1990. Address reprint requests to Dr Rice: Program Director, Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA 98431. Key Words: Foley catheter, obstruction, urethra. Copyright 0 1991 by W.B. Saunders Company 0735-6757/91/0901-0020$5.00/0 72
DISCUSSION Migration of a Foley catheter can generally be prevented by proper inflation of the balloon with a minimum of 1Occ of sterile water. Migration may have caused the balloon obstruction but that cannot be proven. Location of the balloon raises potential for complications due primarily to the likelihood of urethral trauma and potential urethral disruption. Commonly, the balloon will be found in the bladder when it fails to deflate. Numerous approaches to achieve deflation have been suggested, but there is no generally agreed upon technique. Some methods once widely applied are no longer in common usage, most notably the technique of chemical rupture. The Kendall Company’s Curity Foley Catheter Tray (Boston, MA) insert suggests consulting two articles in the event of non-deflation.3*4 Both references primarily describe the chemical rupture method, a rubber solvent such as ether, acetone, or chloroform poured into the balloon. However, the associated trauma and irritation to the urothelium make this method highly undesirable. Over-inflation as a method of balloon rupture is not generally recommended, particularly because the balloon may be in the urethra.5 This leaves the most common techniques of deflation: threading a stylet through the balloon port and puncturing6 the balloon and percutaneous rupture of the balloon using a tine gauge needle. Various stylets have been suggested, most commonly
FIGURE 1. Catheter in proximal urethra.
RICE AND MOGEL n REMOVAL OF OBSTRUCTED FOLEY CATHETER
73
The approach can be suprapubic’ or transperineal” if the balloon is in the bladder. If the balloon has migrated into the urethra and is palpable in the penis, the percutaneous route is preferred because of simplicity and high success rate. Precautions must be observed. The remnants of the catheter should be fully examined after removal to ensure that no fragments have been retained to serve as a source of infection. A urologist should be involved because of the risk of a disrupted urethra. Should the replacement catheter be difficult or impossible to place, the urologist must be prepared to intervene before there is a complication from extravasation of urine. SUMMARY The nondeflating Foley catheter balloon is a problem that may present to the emergency department with increasing frequency. The possibility of migration into the urethra should be considered in any case of deflation failure. Percutaneous rupture of the balloon is recommended in such cases. REFERENCES
FIGURE 2.
Needle insertion into ventral base of penis.
guidewires from CVP line trays.’ Although this approach is quite safe, it is often unsuccessful8*9 because of the relatively tortuous path of the urethra. Further, the stylet often punctures only the wall of the catheter and not the balloon. The percutaneous rupture of catheter balloons has likewise been described in the literature.
1.Finke BG, Friedland G: Prevention and management of infection in the catheterized patient. Urol Clin N Am 1976;3:313 2. Package Insert. Kendall Co., Curity Foley Catheter Tray 3. Bodner H: Using the urinary catheter and other devices. Post Grad Med 1975;3:67-91 4. Lebowitz RL, Effman EL: Ether Cystitis. Urology 1976; X11:4-427 5. Stephens HW Jr: When the catheter won’t come out. Res Staff Phys 19?3;19:76 6. Browning GGP, Barr L, Horsburgh, AG: Management of obstructed balloon catheters. Br Med J 1964;269:69-91 7. Ellis GL: The stuck foley catheter. Ann Emerg Med 1967;16:471 (lett) 6. Ross WB, et al: Management of obstructed balloon catheters. Br Med J 1964;269:319 (lett) 9. Moscovich R: Suprapubic puncture for non-deflating urethral balloon catheters. J R Coll Surg Edinburgh 1964;29: 161-163 10. Pearman RO: Balloon catheter which will not deflate. J Urol 1960;64:438
Removalof Obstructed FoleyCatheterFrom the Urethra LT COL MATTHEW M. RICE, MD, MC,* GREG MOGEL, BSt Thfs case Illustrates an approach to resolve a frustrating problem assoelated with Foley catheter balloon obstructlans. By Identifying Its position in the urethra, the balloon can be deflated with mlnlmal effort and limited urethra injury, using the suggested technique of transperineal needle Insertion. (Am J Emerg led 1991;9:72-73. Copyright 0 1991 by W.B. Saunders Company)
It has been estimated that at least 15% of the hospitalized patients in the United States have in place a Foley catheter.’ This figure can be expected to increase in the face of an aging population. The incidence of balloon catheters that fail to deflate is not known, although the problem is not uncommon.* A nondeflating catheter balloon is most frequently located in the bladder; however, the balloon may migrate and be found distal to the bladder (Figure 1). If this is the case, treatment options change. We report the case of a male patient with an obstructed Foley balloon located in the spongy urethra and discuss the approach to resolving such a problem. CASE REPORT A 90-year-old male nursing home resident was brought to the emergency department with a Foley catheter that could not be removed. On examination the patient was found to be in baseline demented and aphasic state with blood pressure, 120/80 mmHg; pulse rate, 76 beats/min; respirations, 16 breaths/mitt; and temperature 97.7”F. He was noted to have blood at the urethral meatus and a Foley catheter that was draining clear urine. Conventional attempts to empty the balloon were unsuccessful and the catheter resisted removal. The Foley was cut approximately 4 inches distal to the meatus, but the balloon failed to drain. It was then noted that the balloon, inflated with an estimated 5 ml of fluid, could be palpated in the base of the penis. The ventral surface of the penis was prepped, and a penile ring block was performed using 1% lidocaine. A 25-gauge spinal needle was inserted into the base of the penis ventrally, bursting the balloon (Figure 2). The remnants of the catheter were easily removed. A 20F catheter was subsequently placed without incidence.
From the *Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA; and the TUniversity of Pennsylvania, Philadelphia, PA. Manuscript received March 16, 1990; revision accepted May 30, 1990. Address reprint requests to Dr Rice: Program Director, Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA 98431. Key Words: Foley catheter, obstruction, urethra. Copyright 0 1991 by W.B. Saunders Company 0735-6757/91/0901-0020$5.00/0 72
DISCUSSION Migration of a Foley catheter can generally be prevented by proper inflation of the balloon with a minimum of 1Occ of sterile water. Migration may have caused the balloon obstruction but that cannot be proven. Location of the balloon raises potential for complications due primarily to the likelihood of urethral trauma and potential urethral disruption. Commonly, the balloon will be found in the bladder when it fails to deflate. Numerous approaches to achieve deflation have been suggested, but there is no generally agreed upon technique. Some methods once widely applied are no longer in common usage, most notably the technique of chemical rupture. The Kendall Company’s Curity Foley Catheter Tray (Boston, MA) insert suggests consulting two articles in the event of non-deflation.3*4 Both references primarily describe the chemical rupture method, a rubber solvent such as ether, acetone, or chloroform poured into the balloon. However, the associated trauma and irritation to the urothelium make this method highly undesirable. Over-inflation as a method of balloon rupture is not generally recommended, particularly because the balloon may be in the urethra.5 This leaves the most common techniques of deflation: threading a stylet through the balloon port and puncturing6 the balloon and percutaneous rupture of the balloon using a tine gauge needle. Various stylets have been suggested, most commonly
FIGURE 1. Catheter in proximal urethra.
RICE AND MOGEL n REMOVAL OF OBSTRUCTED FOLEY CATHETER
73
The approach can be suprapubic’ or transperineal” if the balloon is in the bladder. If the balloon has migrated into the urethra and is palpable in the penis, the percutaneous route is preferred because of simplicity and high success rate. Precautions must be observed. The remnants of the catheter should be fully examined after removal to ensure that no fragments have been retained to serve as a source of infection. A urologist should be involved because of the risk of a disrupted urethra. Should the replacement catheter be difficult or impossible to place, the urologist must be prepared to intervene before there is a complication from extravasation of urine. SUMMARY The nondeflating Foley catheter balloon is a problem that may present to the emergency department with increasing frequency. The possibility of migration into the urethra should be considered in any case of deflation failure. Percutaneous rupture of the balloon is recommended in such cases. REFERENCES
FIGURE 2.
Needle insertion into ventral base of penis.
guidewires from CVP line trays.’ Although this approach is quite safe, it is often unsuccessful8*9 because of the relatively tortuous path of the urethra. Further, the stylet often punctures only the wall of the catheter and not the balloon. The percutaneous rupture of catheter balloons has likewise been described in the literature.
1.Finke BG, Friedland G: Prevention and management of infection in the catheterized patient. Urol Clin N Am 1976;3:313 2. Package Insert. Kendall Co., Curity Foley Catheter Tray 3. Bodner H: Using the urinary catheter and other devices. Post Grad Med 1975;3:67-91 4. Lebowitz RL, Effman EL: Ether Cystitis. Urology 1976; X11:4-427 5. Stephens HW Jr: When the catheter won’t come out. Res Staff Phys 19?3;19:76 6. Browning GGP, Barr L, Horsburgh, AG: Management of obstructed balloon catheters. Br Med J 1964;269:69-91 7. Ellis GL: The stuck foley catheter. Ann Emerg Med 1967;16:471 (lett) 6. Ross WB, et al: Management of obstructed balloon catheters. Br Med J 1964;269:319 (lett) 9. Moscovich R: Suprapubic puncture for non-deflating urethral balloon catheters. J R Coll Surg Edinburgh 1964;29: 161-163 10. Pearman RO: Balloon catheter which will not deflate. J Urol 1960;64:438
