UROLOGIC ILLOGIC

I remember, when I joined this institution nine years ago, I had lightening enthusiasm and believed in changing the way the world works (you must appreciate that all young people have dreams and should be allowed to have them). I then met the then Hospital administrator and said we should never use Simple rubber Catheters even for temporary bladder drainage.

My opinion was based on the fact that these ghastly catheters are made of India rubber, which is raw, untreated and can cause severe and florid tissue reaction to the urethral mucosa even in the short term. They should be replaced by Plastic (PVC) catheters for routine purposes. They are inexpensive, properly sterilised and of course caused minimum tissue reaction.

My opinion was naturally respected and it was agreed that everyone in the Hospital should use The order was passed for execution. But to my dismay, the prepared catheter boxes continued to hold Simple Rubber Catheters. I started a regular practice of throwing ALL these catheters into the dustbin every time I used a box. Despite this, they kept appearing again and again. I spoke to the administrator and the Matron on several occasions, but to no avail. I have lost the count as how many times I have done this. But today if you open a catheter box, you will still see half a dozen simple rubber catheters in the box.

I often wonder how the routines and conventions get set in a hospital practice. Some protocols are followed like rituals. Some get standardised after a period. But some are followed from generations. What is more amazing is the effort required to change such fixed protocols. They can be frustratingly hopeless. A sister in a ward, for instance, believes that only sweepers will touch the urine bags for emptying and it is well neigh impossible to make her believe otherwise. Use of Simple Rubber catheters is only one such example. Looking further ahead you may find many such rituals which are followed into practice through generations but are proven illogical in the modern practice of Medicine.

1. Bladder Training: The practice of bladder training has intrigued me over many years. While weaning the patient off the catheter, the commonest instruction is “Clamp the catheter and release every four hours”.

Clamping the catheter only distends the bladder for a set time. The only information it can possibly give is about the sensation of fullness. It gives no other information and certainly tells us nothing about the return of

motor power. In the modern era of Urodynamics clamping the catheter is totally useless and serves no purpose in bladder training. Besides it carries a serious risk of systemic sepsis in the paraplegics in whom this practice is more rampant. The knowledge of Urodynamics tells us clearly that bladder fullness, urge to void are totally sensory phenomena and that the return of sensory perception do not give any information on the motor activity of the bladder, unless they are evaluated by objective tests such as Urodynamics. 2. Flush those stones out : The commonest and the most popular concept of treating ureteral calculi is to “flush” them with high fluid intake and Diuretics. Some clinicians would go to the extent of instituting intravenous fluids and diuretics together. This practice should be deprecated for more than one reason. The total load of fluid from the body is normally handled by both the functioning kidneys simultaneously. A kidney that is obstructed by a stone usually has a suppressed filtration. The majority of fluid load therefore is taken up by the unaffected kidney, which will excrete most of the fluid. The calculus will remain where it is. If the stone is impassable, then such a practice theoretically will virtually bring on a colic and make the matters worse. The sensible thing to do in such situation is to keep a normal fluid intake and prevent dehydration. Intravenous supplementation of fluid is indicated in the rare event of severe vomitting with a threat of dehydration.

3. Catheter Myths: One of the commonest practices hard to eradicate is

the use of Rubber catheters. They must be totally abandoned for the reasons mentioned above. Besides, in a busy Hospital practice, a more sensible solution is to use an indwelling Foley type of catheter. The reason is simple. In the majority of cases of acute urinary retention, the cause of retention is not obvious and would need further evaluation. It would be sensible to buy some time till the appropriate investigations are performed to define the cause. Simple Rubber catheters still find useful place as tourniquets and as suction catheters, where they can be rightfully used (although better substitutes are now available in both places).

4. Managing Incontinence: Use of catheters should be discouraged

prior to patient evaluation for Incontinence. The bedside clinical evaluation of any incontinence involves physical examination, nursing observations, dry intervals and residual volume estimation. Presence of catheter will preclude all these tests and clearly interfere with the evaluation. A proper diagnosis of incontinence should therefore dictate the appropriate therapy. Indwelling Catheters are then

required only in cases of refractory incontinence in the female patients.

5. Catheter Leakage: Another common problem encountered in the wards is “urine leaking out by the side of the catheter”. This is often described as Catheter leak. One is often tempted to pass a larger catheter to stop such a leak. A logical explanation for this phenomenon is bladder spasms. The commonest causes are Catheter blockage, trigonal irritation and infection. Blockage must be excluded by gentle irrigation. Trigonal irritation can be minimised by using a good quality catheter and by inflating the Foley balloon by the minimal amount of water( 5 to 10 mls only). Sepsis should be appropriately treated. Spasms refractory to these measures are controlled effectively (but temporarily) with oral anticholinergics such as Oxybutynin and Propantheline in large doses. Passing a larger catheter is not only illogical but can be hazardous since it will not control the leak and in females it may further dilate the urethra, making future management difficult.

6. Slow Decompression: It is commonly advised in a case of chronic urinary retention to pass a catheter and use slow and controlled drainage (often referred to as slow decompression). The rationale is that if such bladders are decompressed rapidly, then bleeding can occur from the bladder and from the Kidneys. There are now enough studies to show that such a procedure does not prevent the bleeding if it is to occur. Such haematuria is usually self-limiting and does not produce any significant complications.

7. Condom Drainage: Condoms are often used external urinary collection devices in males. There are proper custom made devices like Conveen Sheath, Uri drop and Gold Seal, which come in different sizes, fit the penis well and are inexpensive. Condoms are poor substitutes for this purpose, since they kink very often and can cause obstruction without the notice of the nursing staff.

Illogic practices are certainly more ubiquitous. Urology is one field where these practices are carried from generations. Better substitutes are now available with the advances in knowledge but more after some rational thinking.

That is the easy part. The difficult part is how to eradicate these customs from Institutions. If one can achieve it easily, he can mould the world. We can then boast to practise the modern Medicine in the real sense.