Diane Newman: Welcome. I'm Diane Newman. I'm an adult nurse practitioner and adjunct professor of urology and surgery, research investigator senior at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia.

For the next few minutes, I'm going to review with you the importance of a catheter tip, especially in those individuals where we have difficulty with inserting an intermittent catheter for intermittent catheterization.

I thought I'd start with a case study. Here's Mr. D, a 68-year-old patient who's been performing intermittent catheterization for the past three years. He does it four times a day and have been managing very well using a straight tipped catheter. However, in the past three months, he's finding it progressively harder to pass the catheter as he hits resistance. And what happens is then he's forcing the catheter through, which is not something we want the patient to do. On some days, he needs to use two to three catheters at each attempt before he successfully gets into the bladder.

So now it's uncomfortable he's seeing some bleeding because he's irritating that urethra, and it's very, very uncomfortable, and sometimes it can even be painful. So he's, in your office, requesting an indwelling catheter. We do not want to convert this patient to an indwelling catheter because we all know there's so many more complications associated when that catheter would stay in place.

I thought I'd go back and give a little bit of a historical background around the use of catheters or tubes that go into the bladder to drain. As we all know, they're integral to our urologic practices, but the word catheter comes from the Greek and it means to thrust into or to send down. In ancient China, they used onion stalks, and then you see things such as gold, silver or something hard to get through the urethra. Even before Christ, so BC, they started with this S-shaped silver tube that actually found buried in a volcano.

Then in the 800s, a Persian physician describes a catheter with side holes. So then you start to see that we now have a concept of a tip with openings so that you can actually drain the urine out through these side holes or eyelets we call them. Then in 11th century they became a little more flexible, moldable, and then Benjamin Franklin actually created a silver wire helical tube rubbed with tallow. Actually, I think it was for his brother who had stones. In the 1850s, smooth flexible catheters came in place. And then after World War II, we have the whole concept of sterile IC and then Lapides' clean intermittent catheterization research.

But what happens with catheterization, and I've been doing this for many, many years, is we do sometimes run into difficulties. And what can happen is that it can be a difficult... Catheterization can be really very common in urology, and it's defined as the inability of the nurse, physician or urologist to pass a catheter before using say some type of catheterization. Difficult means you have to have multiple attempts. So what this short little lecture is about is the fact that maybe the tip can help in these situations because for the patient, multiple attempts can cause anxiety, stress, of course that you can traumatize the urethra, and can be very painful, and it can actually cause a significant amount of bleeding in certain cases.

We wanted to make sure though, prior to catheterizing and deciding which tip to use, is that do a history on the patient. Have they had a prostatectomy in the past, maybe have a bladder neck contracture? Do they have strictures? Have they had pelvic trauma or radiation to the area which can really make catheterization difficult? Have they had a history in the past? Have they been catheterized? What was that like? And then do they have any types of sexually transmitted infections which may have caused a urethral stricture, which is very common in men who catheterize.

So causes in men is just listed here on this slide, but we also have issues with difficult catheterization in women. We understand in men, it's a longer urethra, we have the prostate. So yes, with enlarge of the prostate, we may have a difficulty getting through that area of the urethra, but also in women can occur. Women who have post-menopausal have atrophy in the area. That tissue is thin, a very friable, may not be able to pass a catheter. Someone's morbidly obese. Are you able to identify the meatus to insert the catheter? And of course, prolapse, where the prolapse actually hides that urinary meatus.

It's important with men with their prostate issue, especially the aging male, is that we understand that that prostate can be large. There's a non-malignant growth of the prostate. Again, it's only in men. And we see progressive disease after the age of 40 when that prostate enlarges and starts squeezing that urethra. And I actually have a picture here to show you of an enlarging prostate. So you can see how those three lobes of the prostate gland surround the urethra. And over time as it enlarges, the prostate grows as we see with BPH, or with prostate cancer, that can also happen, you see that it's actually... I always say it's like cutting off a garden hose to my patients. It's squeezing your urethra, and it sometimes makes it almost impossible to catheterize a male patient or for that patient themselves to catheterize. And this is something that we have to think about as clinicians and as well as teaching patients about this.

Strictures can occur. This is, again, inflammation of the urethra. Strictures can lead to fibrosis and scarring of the tissue, of the lining of the urethra. Again, more common in men and boys than we do see in women. It occurs after procedures of the urethra bladder, and also, we see it occur after say any radiation, brachytherapy in men who are undergoing treatment for prostate cancer. It can also be congenital problems in children. But this is a major complication we see long term in a patient who is performing intermittent catheterization long term.

Again, rare in women, more common in men, much in younger men. Under the age of 65, it's probably obstructive LUTS. And then these are some of the other causes that we see with strictures.

And this again just shows you a picture. On the left is an x-ray where you see a bulbar urethral stricture. And then on the right, these are the areas where stricture can occur. The other thing you remember is it's important to ask the patient where is that resistance? Where can't you pass it? Is it the beginning, the end, or the middle of the catheterization? Because strictures can occur up near the meatus.

Also, we still have men who are not circumcised. And what you have is phimosis where that glans is really swelled and over the meatus because throughout their life they may have not been retracting that foreskin. And we have buried penis in older male, so that can make it really difficult to catheterize.

So let's talk a little bit more what can we do, especially thinking about the tip of the catheter. Well, us clinicians, we're not taught. I know in nursing school, we're not taught how to complete difficult catheterization. I'm not sure a lot of residents, even in urology, are taught, although they do encounter difficult catheterizations. There's very little in literature. I did find some references, which is at the end of this lecture, but there's very little information about catheter tips.

And what I try to do is give you kind of a timeframe of the differences and tips that go back to the 1800s. So you can see with that coudé tip, which is a curved tip, was actually invented by a French urologist. It's called a Tiemann catheter. Then we get into Goodyear coming out with that red rubber rigid catheter. Then the coudé, Nelaton is also another name that we call coudé tip. We then went to hydrophilic coudé tips. We do have straight tips also. And then what you've seen in around 2012 is some concentration on these eyelets. How should they be constructed? And you see the term polished eyelets was coined at that time. And again, I just show you some pictures here of some of the different tips and their names that will be at the end of an intermittent catheter.

This is one of the references I found. It was a survey done by a British nurse in UK. It was around 189 clinicians. You see that hospital nurses, community nurses, and they asked them when they would use a coudé tip. And they found that the main reason was that the nurse tried a straight tip and it didn't work or she had difficulty catheterizing so she went to a coudé tip. Second reason included those with BPH, bladder neck obstruction, stricture. 20% had never used a curved tip catheter, and 50% of those 20% work in community settings. So if we discharge that patient and they be managing the community, we have nurses here in this UK study who've never understood that there's different tips, sizes, and designs. And actually when they did learn about coudé and use it, they found it was much more comfortable for the patient.

So let's talk about that curved tip catheter. It tends to be firmer, and it's curved with a slight angle, and that assists with navigating the urethra. There's some that have a more pointed curve tip and some have an olive tip, which is like a little bead on the end, which is a slightly more rounded tip on the end. And some people think that's easier to navigate the urethra, especially the male urethra with that little kind of curved olive tip at the end.

I think this slide is important because it talks about how do you insert that curve? And first of all, the curve is about 45 degrees angle, and it's very important that the patient positions their penis for insertion of this or else you can traumatize that urethra. You always want that curve going up to... I always say to the head of the patient. And the thing is that, so they have to try to strengthen out their urethra by pulling up their penis. This is important teaching moment with that patient when you first teach that male patient. Women, if we use a curved tip, we don't have to worry about because it's a much shorter urethra and length, but in male, it's very important that that curve is angled to go into the patient at the proper angle.

Now the eyelets, what are they? Well, they're sometimes called eyes, drainage, openings, eyelets. There's usually two. They can be placed on one side or opposite sides of the catheter, and they're usually found around the tip of the catheter. And basically, this is just some examples of eyelets, and here's some more. The size can differ, okay? So larger eyelets allow urine to drain faster. Smaller or fewer eyelets will cause the urine to drain slower. I mean, I think that makes sense. And the shape can be a little bit different here. And I just show you some examples of those eyelets on these catheters here. But they have to be constructed properly or they can cause some irritation to that urethra and some trauma as you catheterize.

So here's showing some pictures of polished or punched eyelets. They call them punched because how they make them, and you can see that they're much smoother. And what they do, they polish them or they ultrasonically smooth them out. So there's less abrasion as you pass that catheter through the urethra. And this is also, I think, important when you're thinking about choosing a catheter. And the one in the middle there you can see is a cure medical catheter with the polished eyelets.

So in summary, there's been some type of tube or catheter for centuries to drain the bladder and whether it been a gold rod or whatever, we've had them around for a long time because we've had urinary problems with urinary retention for a long time. Technological advances in catheters have really evolved and we have so many to choose from. Long-term catheter use though, those in-patients who are doing intermittent catheterization long term can traumatize the urethra and it can make catheterization very difficult for them, and they can end up like that case study I started this lecture with as far as (a) I don't want to do this anymore. And as clinicians, we can really make a difference. So you want to understand the benefit of a catheter tip and polished, smooth eyelets may decrease urethral trauma with repeated catheterizations. Thank you very much for listening.