A Problem with Plumbing

aka Unusual Urine 006

A 62 year-old male presents to the emergency department with a problem with his plumbing. Last week he had an indwelling catheter inserted for urinary retention. He was to have a trial of void today, but the Continence Nurse hasn’t been able to remove the indwelling catheter (IDC, aka Foley catheter). It seems that the balloon won’t deflate.

What are you going to do?


Questions

Q1. What is the first thing to do when confronted with this problem?

Answer and interpretation

Inspect all visible parts of the catheter to try to identify any likely sites of obstruction.

Usually the problem affects parts of the catheter inside the patient.

IDC-diagram
Note the syringe adaptor plug (20) that connects to the balloon inflation/ deflation channel. Also note the deflated balloon (18) just proximal to the drainage hole (26).
IDC-in-situ
Foley catheter in situ.

You’ve done that, but are none the wiser.


Q2. What will you do next?

Answer and interpretation

Sometimes IDCs cannot be removed because of ‘cuffing‘.

Cuffing usually occurs when the balloon is deflated rapidly, such that it deflates asymmetrically and doesn’t fully deflate. This means that it can snag at the bladder outlet when removal is attempted.

The first step should be to reinflate the balloon with 1 mL of saline, then slowly deflate it again. Make sure the balloon is in the bladder — not the urethra — before inflating!

This may overcome the ‘cuffing’ problem and facilitate removal.


You tried that. It didn’t work. Now what?


Q3. What are the most common causes of balloon deflation failure?

Answer and interpretation

Failure of balloon deflation prevents removal of the IDC. This is most commonly caused by:

  • debris in the inflation/deflation channel (crystals may form inside the balloon or the channel to which it is attached).
  • malfunction of the valve in the inflation/deflation channel.

Checking that the IDC balloon inflates and deflates correctly prior to insertion does not remove the risk of later problems.

If you have ultrasound available, confirm that the IDC balloon is inflated — in patients with prolonged catheterisation concretions may form around the catheter tip. Forceful removal may result in an inadvertent TURP!


Q4. What are your next steps in trying to remove the IDC?

Answer and interpretation

Attempt to disrupt the inflation/ deflation channel.

This can be done in a step-wise manner:

  • cut off the inflation port syringe adaptor plug. This will allow removal of the IDC if the syringe adaptor plug is the source of the problem. It is not usually effective. There may be a defect further down the channel, so cutting further along the IDC may remove the defect… but don’t cut too low — just on the patient’s side of a suspected obstruction — and clamp the catheter with forceps to prevent recoil into the urethra. You don’t want to lose the remaining part of the IDC somewhere inside!
  • attempt to aspirate fluid from the inflation/ deflation channel and collapse the balloon.
  • if the above have failed, insert a thin rigid wire (e.g. central line guidewire) into the channel. This may overcome the valve-flap defect. If not the wire may be used to puncture the balloon by advancing all the way along the inflation/ deflation channel.

Some suggest injecting contrast into the inflation/ deflation channel to determine the level of obstruction. Also, some suggest that cutting the catheter should be performed only as a last resort — in which case, you might prefer to attempt the methods described in Q4 prior to cutting the catheter.


You tried those steps too. Still no luck.


Q5. What is your next approach to removing the IDC?

Answer and interpretation

Attempt to puncture the balloon with a needle.

Needle puncture of the balloon can be attempted as follows:

  • over inflate the balloon (50-100 mL of saline)
  • apply gentle traction to stabilize the IDC balloon against the bladder neck.
  • Use a 25 Fr spinal needle (under local anesthesia) to attempt percutaneous balloon puncture. This may be performed blindly, but is best performed under ultrasound guidance.
  • An alternative approach in females is to gentle advance the needle up the urethra alongside the IDC to attempt balloon puncture (transurethral approach).

Transrectal and transvaginal approaches to balloon puncture are also options.

IDC balloon needle deflation
Indentation of catheter balloon just prior to deflation with a transcutaneous spinal needle. (Image from Lee et al, 2005)

Q6. What if you are still unsuccessful?

Answer and interpretation

It’s time to call a urologist!

If the previous methods are unsuccessful, it is best to seek advice from a urologist. Other balloon rupture techniques may be tried, but chances are the patient will require cystoscopy.


Q7. What other methods of IDC balloon rupture are there?

Answer and interpretation

There are at least two other methods:

  • balloon erosion by instilling a volatile or corrosive substance
  • overfilling the balloon with saline

These methods may lead to fragmentation of the IDC balloon, or in the latter case, painful bladder distention.

Instillation of volatile or corrosive  substances such as toluene, ether, acetone or mineral oil may achieve balloon rupture. One technique described in Roberts and Hedges is the installation of 10 mL of mineral oil down the inflation/ deflation channel and into the balloon. If success is not achieved after 10 minutes a further 10 mL may be administered.

Alternatively, the balloon may be ruptured by overfilling with saline. This may require as much as 200-300 mL of saline administered into the balloon. The bladder itself should be filled with 100 mL of saline first, to cushion the effects of balloon rupture.


Q8. What are the complications of balloon deflation techniques?

Answer and interpretation

Complications include:

  • injury to local structures, such as needle puncture of the rectum during attempted balloon perforation —
    rectal puncture is generally of negligible clinical significance.
  • balloon fragmentation
    this may lead to foreign body stone formation. The methods described in Q6 are at high risk of causing this complication. If fragmentation is suspected the patient should undergo cystoscopy.
  • chemical cystitis
    this is a complication of the instillation of erosive substances as described in Q6. If these methods are used (not recommended), the bladder should be copiously irrigated withe saline following replacement of the IDC.

The pros and cons of different methods are shown in this table from Lee et al, 2005:

balloon-deflation-table

Q9. What should be done following removal of the malfunctioning IDC?

Answer and interpretation

The IDC must be inspected for missing fragments.

If missing fragments are suspected the patient will require cystoscopy so that they may be found and removed. If there are no fragments missing, the IDC can be replaced as indicated.


References
  • Ultrasound Top 100 – Case 027 (Blood clot in the bladder with IDC in place)
  • Ultrasound Top 100 – Case 041 (Misplaced urinary catheter)
  • Ultrasound Top 100 – Case 042 (Urinary catheter balloon being inflated)
  • Lee WMM, Tsui KL, Kam CW. Trans-abdominal ultrasound-guided suprapubic puncture of a non-deflating Foley catheter balloon Hong Kong J Emerg Med. 2005;12:42-45 [fulltext]
  • Patterson R, Little B, Tolan J, Sweeney C. How to manage a urinary catheter balloon that will not deflate. Int Urol Nephrol. 2006;38(1):57-61. PMID: 16502053.

CLINICAL CASES

Unusual Urine

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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