Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Chapter 31. Straight Urethral Catheterization Download Section PDF Listen Mark Adler, MD + • Diagnostic evaluation.• Temporary relief of urinary retention. +++ Absolute + • Suspected urethral injury (eg, blood at meatus, laceration).• Unable to identify urethra (eg, labial adhesion).• Neutropenia. ++Table Graphic Jump Location | Download (.pdf) | Print• All equipment should be latex free. Allergy to latex is common, particularly in certain populations (such as patients with meningomyelocele.) + • Catheter.• Feeding tube (4–5F).• Urinary catheters (6F and up).• Sterile collection cup.• 10% povidone-iodine (or equivalent).• Castile soap.• Sterile gloves, drapes, and gauze.• Lidocaine (2%) anesthetic jelly or water-based lubricant.• Catheter sizing estimates:• Infant: 5F feeding tube or 6F catheter• Toddler: 6–8F catheter• Older child: 8F catheter• Adolescent: 8–10F catheters ++Table Graphic Jump Location | Download (.pdf) | Print• Always choose the smallest catheter that will work; a catheter that is too small might kink and one that is too large will cause unnecessary pain. + • Urethral trauma.• Hematuria.• Pain (common).• Psychological stress (common, as child is restrained for procedure).• Catheter mishaps (eg, knot forms in bladder) (very rare). + • Because spontaneous voiding may occur during skin preparation or as the procedure is initiated, have a sterile container available to collect the urine.• When labial adhesions are present, holding the child in a frog-leg position and rocking the hips back and forth may line up the opening in the adhered labia with the urethral opening.• Cotton gauze pads are useful to hold the penis or to apply traction to the labia once the skin has been prepared and is slippery.• Remember that many of the newer, non-latex gloves fit poorly, making holding a slippery skin surface nearly impossible; wear tightly fitting non-latex gloves when possible.• Although 1 study showed that pain was reduced by applying lidocaine topically and injecting anesthetic into the urethra, this does not represent typical use of lidocaine jelly in clinical practice. + • Keep the patient covered until ready to begin.• Good lighting is helpful. + • The child is placed supine.• The female patient is placed in the frog-leg position.• The male patient is placed with legs extended. + • Catheterization requires the passage of a tube through the urethra into the urinary bladder.• In girls, the urethra is a short tube that opens just rostral to the vaginal introitus and is often obscured in younger girls by vaginal tissue (Figure 31–1). + • A common problem with catheterization of young females results from confusion and erroneous passage of the catheter into the vagina (Figure 31–2). + • In boys, the urethra begins at the meatus and passes down through the penile shaft and into the urinary bladder after passing through the prostate gland (Figure 31–3). + • The prostate and the urethral valves cause some resistance to catheter passage.• Uncircumcised males have a foreskin that covers the glans completely; this structure must be retracted partially to clean the urethral meatus before catheterization (Figure 31–4). + • Occasionally, a tight phimosis prevents retraction and visualization of the meatus.• While it is possible to catheterize without visualization, the risk of obtaining a contaminated specimen increases.• Take care to evaluate the location of the urethra in young males since an undiagnosed hypospadias is a possibility, even if the child has been circumcised.• The urethra in hypospadias can be located anywhere along the caudal aspect of the phallus from the base to just slightly caudal to the normal meatus.• Significant hypospadias should not be catheterized without urologic evaluation. ++Figure 31–1.Graphic Jump LocationView Full Size||Download Slide (.ppt)Female genitourinary system. ++Figure 31–2.Graphic Jump LocationView Full Size||Download Slide (.ppt)Female perineum. ++Figure 31–3.Graphic Jump LocationView Full Size||Download Slide (.ppt)Male genitourinary system. ++Figure 31–4.Graphic Jump LocationView Full Size||Download Slide (.ppt)Foreskin reduction and catheter insertion. + • Observe sterile procedure.• Wear sterile gloves.• Use 1 hand to touch the patient if necessary, while keeping the hand with the catheter clean. +++ Male +++ Circumcised Boys + • The glans and the distal phallus are cleaned with a 10% povidone-iodine solution.• The penis is held gently retracted away from the body in the nondominant hand, with the penis held at about a 90-degree angle to the body.• The catheter is lubricated with a water-based jelly with or without lidocaine and passed directly through the meatus downward (not angled rostrally).• Some resistance may be felt at the prostate level, which can be overcome by using steady pressure.• Do not push and pull the catheter to get it to pass.• Once urine is visible in the catheter or collection cup, stop advancing the catheter.• Remove the catheter gently after the sample is obtained. +++ Uncircumcised Boys + • The procedure is the same as in circumcised boys, except that the foreskin is prepared first and then the foreskin is retracted just to the point that the meatus is visible. This area is then prepared as well.• The catheter is inserted in the same fashion as above.• The foreskin is then returned to the normal position. +++ Female + • The periurethral area and labia minora and majora are prepared with a 10% povidone-iodine solution.• The catheter is lubricated with a water-based jelly with or without lidocaine and is passed into the urethra and directed straight downward toward the bed or very slightly rostrally (Figure 31–5). + • In smaller children, vaginal tissue can obscure the urethral opening; this tissue can be moved with a cotton swab.• The first portion of the urine may be discarded; this is analogous to a mid-stream urine collection. This is only possible if the collection system is not a kit with the collection vial attached to the catheter.• Applying pressure of the suprapubic area (Credé maneuver) may force out additional urine.• Remember to remove residual povidone-iodine from the skin. ++Figure 31–5.Graphic Jump LocationView Full Size||Download Slide (.ppt)Catheter insertion in female. + • Urine obtained via catheter may be evaluated in a number of ways:• Urine dipstick tests (bedside) are a series of paper squares impregnated with chemical reagents that change color under specific conditions. Be aware that reading the strips beyond the recommended times on the container may lead to false-positive results.• Urinalysis (formal laboratory testing) is often a combination of the above tests and a microscope examination of the urine. The strict nature of the laboratory procedures yields a more accurate result, even for dipstick test.• Culture is commonly used to detect bacteria.• Urine can also be tested for virus (eg, cytomegalovirus) and fungi.• Polymerase chain reaction is done to test for Chlamydia trachomatis and Neisseria gonorrhoeae.• Urine human chorionic gonadotropin (hCG) is done to detect pregnancy.• Toxicology screen looks for drugs of abuse or specific substances.• Other (eg, urine electrolytes, organic acids). + • Pain.• Hematuria.• Dysuria with or without urinary retention.• Paraphimosis, resulting from failure to reduce the foreskin after the procedure.• Catheter knot (in infants, caused by advancing small catheters too far, allowing catheter to knot; may require cystoscopy or surgical removal). + • Dysuria and hematuria complications are transient.• Infants and toddlers who have dysuria and refuse to void can be placed in a warm bath, which promotes voiding.• Ongoing symptoms would be unusual and should prompt a new visit and evaluation, with consideration of other causes of the symptoms (eg, inadequate treatment of an infection). ++Dayan PS, Chamberlain JM, Boenning D, Adirim T, Schor JA, Klein BL. A comparison of the initial to the later stream urine in children catheterized to evaluate for a urinary tract infection. Pediatr Emerg Care. 2000;16:88–90. [PubMed: 10784208] ++Gerard LL, Cooper CS, Duethman KS, Gordley BM, Kleiber CM. Effectiveness of lidocaine lubricant for discomfort during pediatric urethral catheterization. J Urol. 2003;170(2 Pt 1):564–567. ++Levison J, Wojtulewicz J. Adventitious knot formation complicating catheterization of the infant bladder. J Paediatr Child Health. 2004;40:493–494. [PubMed: 15265197] + Chapter 32. Suprapubic Catheterization Download Section PDF Listen Mark Adler, MD + • Diagnostic evaluation of urine in an infant. +++ Absolute + • Neutropenia.• Thrombocytopenia and bleeding disorders.• Cellulitis and infection at puncture site.• Age greater than 2 years. +++ Relative + • Urogenital anomalies.• Recent urologic or lower abdominal surgery. ++Table Graphic Jump Location | Download (.pdf) | Print• All equipment should be latex free. Allergy to latex is common, particularly in certain populations (such as patients with meningomyelocele.) + • 22-gauge, 2–3-cm needle.• 3-mL or 5-mL syringe.• Sterile collection cup.• 10% povidone-iodine (or equivalent).• Sterile gloves, drapes, gauze.• Topical anesthetic or buffered 1% lidocaine solution, or both. + • Infection (rare).• Intestinal perforation (very rare).• Failure to obtain urine (success rates vary widely but less successful than catheterization).• Psychological stress (common, as child is restrained for procedure).• Pain (certain; can be limited somewhat with anesthesia).• Hematuria.• Microscopic is very common.• Macroscopic is uncommon. + • Appropriate patient restraint is critical to the success of the procedure.• More than 2 or 3 attempts do not add to success rates.• Ultrasonography has been reported to increase success rates in some studies.• Because spontaneous voiding may occur during skin preparation or as the procedure is initiated, have a sterile container available to collect the urine. + • Keep the patient covered until ready to begin.• Good lighting is helpful. + • The child is placed supine in the frog-leg position. + • The needle is passed through the abdominal wall just rostral to the pelvic rim in the midline.• The bladder in an infant is located in the abdomen, which allows for direct access to the bladder lumen with a needle. (The bladder in an older child and adult is located in the pelvis.)• Various methods to improve success have been cited and include the following:• Ensuring that time has passed since the last void.• Encouraging the child to drink.• Percussing the abdomen to ascertain bladder fullness.• Obtaining an ultrasonogram. This can be used to ensure bladder fullness or to guide needle insertion. + • Observe sterile procedure.• Wear sterile gloves.• Use 1 hand to touch the patient if necessary, while keeping the hand with the needle clean.• Strongly consider applying a topical anesthetic before starting the procedure.• Leaving the topical anesthetic on for a sufficient time period provides a reasonable degree of topical anesthesia.• Remove the topical anesthetic prior to skin preparation.• The practice of additional injection of lidocaine varies; the injection represents a separate needle stick and is associated with pain from lidocaine infiltration.• Apply 10% povidone-iodine solution to the skin surface of the abdomen 1–2 cm above the pubic symphysis.• Attach the syringe to the needle.• The provider should be positioned so that the dominant hand can insert the needle through the skin above the pubic symphysis and direct the needle caudad at about 20 degrees from perpendicular (Figure 32–1). + • A lesser angle may be used in very young infants whose bladder is more rostral.• The skin is penetrated and the needle is advanced into the bladder.• Slowly advance the needle while aspirating the syringe.• When urine appears, stop and fill the syringe, then withdraw the needle.• Clean the skin of residual povidone-iodine.• Apply a gauze bandage to the needle puncture site.• If no urine is obtained on the first attempt, change the angle of the needle slightly toward perpendicular and repeat (without coming out of the skin).• This may be done once or twice (at most). Additional attempts are unlikely to yield urine.• Consider waiting and repeating or obtaining urine by urethral catheterization. ++Figure 32–1.Graphic Jump LocationView Full Size||Download Slide (.ppt)Angle of needle entry (sagittal view). + • Urine obtained via suprapubic catheter is usually evaluated for infection.• Other urine tests that do not require sterile urine would likely be obtained via catheter and include the following:• Urine dipstick tests (bedside) are a series of paper squares impregnated with chemical reagents that change color under specific conditions. Be aware that reading the strips beyond the recommended times on the container may lead to false-positive results.• Urinalysis (formal laboratory testing) is often a combination of the above tests and a microscope examination of the urine.• Culture is commonly used to detect bacteria.• Urine can also be tested for virus (eg, cytomegalovirus) and fungi. + • Pain.• Hematuria.• Intestinal perforation (rarely results in complications or peritonitis).• Infection of abdominal wall. + • There are considerable differences of opinion over the role of suprapubic aspiration (SPA) in the evaluation of children with suspected urinary tract infection.• Advocates argue that SPA carries no risk of contamination when compared with urethral catheterization.• Advocates argue that SPA is the first-line test for infants with fever and suspected urinary tract infection so that the consequences of a false-positive urine culture (eg, unnecessary antibiotics, follow-up testing, overlooking another locus of infection) are avoided.• The argument against SPA includes the following:• Procedure is invasive and painful.• Success rates for obtaining urine are lower for SPA than for catheterization.• SPA usually requires a physician, whereas catheterization is more often done by nurses. + • Clear instructions on caring for the puncture site (ie, watching for redness, pain, and purulent discharge) as well as information about the symptoms of peritonitis should be given to the parents. ++Austin BJ, Bollard C, Gunn TR. Is urethral catheterization a successful alternative to suprapubic aspiration in neonates? J Paediatr Child Health. 1999;35:34–36. [PubMed: 10234632] ++Henretig FM, King C. Textbook of Pediatric Emergency Procedures. Baltimore, MD: Williams & Wilkins; 1996. ++Polnay L, Fraser AM, Lewis JM. Complication of suprapubic bladder aspiration. Arch Dis Child. 1975;50:80–81. [PubMed: 1124947] ++Tobiansky R, Evans N. A randomized controlled trial of two methods for collection of sterile urine in neonates. J Paediatr Child Health. 1998;34:460–462. [PubMed: 9767511] + Chapter 33. Paraphimosis Reduction Download Section PDF Listen Jennifer Trainor, MD + • Reduction of retracted, constricting foreskin. +++ Relative + • Recent penile surgery. + • Nonsterile gloves.• Ice packs.• 2 × 2 or 4 × 4 gauze.• Topical anesthetic or buffered 1% lidocaine solution, or both. + • Failure of reduction (success rates depend on duration of paraphimosis and degree of edema).• Psychological stress (common; child is restrained for procedure).• Pain (certain; can be limited somewhat with anesthesia).• Cold injury. + • Use gauze to grasp the foreskin.• If swelling is pronounced, try manual compression prior to reduction.• Timid attempts at reduction in an effort to reduce pain ultimately result in delayed reduction and increased overall pain.• If initial attempts are unsuccessful, urgent referral to a urologist is recommended. + • The child is placed supine.• Distract the child by having the parent or assistant lean over the examining table, placing his or her body between the child’s upper torso and the genital area. This also prevents the child from getting up and allows the parent or assistant to engage the child face to face.• Good lighting is helpful. + • The child is placed supine in the frog-leg position.• If the child is uncooperative, his legs and pelvis should also be restrained by an assistant. + • Figure 33–1A shows a normal penis with foreskin. + • Early paraphimosis (retracted foreskin) is illustrated in Figure 33–1B.• Late paraphimosis (retracted foreskin with significant edema) is shown in Figure 33–1C. ++Figure 33–1.Graphic Jump LocationView Full Size||Download Slide (.ppt)A: Normal penis and foreskin. B: Early paraphimosis. C: Late paraphimosis. + • Consider the use of a dorsal penile block in advance of the procedure, particularly when there is severe edema.• With gloved hands, grasp the retracted foreskin between the thumb and the index and middle fingers of each hand.• Using a gauze pad to grasp the foreskin improves traction.• Simultaneously pull the foreskin distally as you compress the glans with both thumbs (Figure 33–2). + • Apply constant and firm pressure.• When sufficient pressure is applied, the foreskin suddenly reduces, popping over the glans.• If the initial attempt is unsuccessful, consider manual decompression before subsequent attempts.• Place your hand around the distal foreskin and glans and apply constant circumferential pressure for approximately 5 minutes.• Then, attempt reduction again as described above.• Alternatively, you can apply an ice-water slurry (sealed in either a specimen collection bag or a tied-off glove) to the paraphimotic foreskin and glans.• You may apply the ice pack for up to 3 minutes at a time, taking care to monitor for cold or pressure injury.• There is a significant amount of discomfort associated with ice packs, so they may not be tolerated in the absence of a dorsal penile block, especially in young children. ++Figure 33–2.Graphic Jump LocationView Full Size||Download Slide (.ppt)Proper hand positioning for reduction. + • Pain.• Injury to the glans or shaft with overaggressive manipulation. + • If the simple technique described above in conjunction with decompression fails to reduce the foreskin, the child should be referred to a urologist promptly.• An unreduced paraphimosis can lead to skin ulceration and necrosis of the distal glans.• Surgical reduction techniques, such as needle puncture decompression, dorsal slit, or immediate circumcision, are beyond the scope of the general practitioner and should not be performed in the office setting. + • If there is any breakdown of the surface of the glans or the foreskin, either bacitracin or polymyxin plus bacitracin can be applied until healing is achieved.• The parents should be instructed to return when new redness or swelling appears or if the swelling fails to resolve within 24 hours.• Prevention should be stressed.• The foreskin should always be reduced promptly after retracting it for bathing in order to prevent recurrence.• Referral to a urologist for consideration of circumcision is strongly suggested, particularly in the older child. ++Henretig FM, King C. Textbook of Pediatric Emergency Procedures. Baltimore, MD: Williams & Wilkins; 1996.