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Review of techniques to remove a Foley catheter when the balloon does not deflate
SURGEON’S WORKSHOP
REVIEW OF TECHNIQUES TO REMOVE A FOLEY CATHETER WHEN THE BALLOON DOES NOT DEFLATE SIAMAK DANESHMAND, DAVID YOUSSEFZADEH,
AND
EILA C. SKINNER
ABSTRACT Failure of a Foley balloon to deflate may be caused by a faulty valve mechanism, blockage of the inflation channel, or, rarely, crystallization of the fluid within the balloon. We discuss the approach to successful management and present a stepwise algorithm to remove the catheter safely and expeditiously. UROLOGY 59: 127–129, 2002. © 2002, Elsevier Science Inc.
I
t is estimated that 15% to 20% of patients have a Foley catheter at some point during their hospital stay.1 A rare complication of Foley catheter use is the retention of the catheter because of balloon deflation failure. Urologists are usually consulted after multiple unsuccessful attempts to manipulate and deflate the balloon. Various techniques and maneuvers to address this complication have been described throughout published reports, including overinflation of the balloon, injection of ether or chloroform through the inflation channel,2 and bursting or deflating the balloon using a ureteral catheter stylet or other similar wires.2–5 Other methods, such as bursting the balloon with a needle through the suprapubic route with or without ultrasound guidance, have also been documented.6 –9 In women, direct puncture of the balloon using the urethral or transvaginal route has been reported.10,11 More elaborate methods described include the use of cystoscopy with endourologic instruments to burst and remove the catheter under direct vision.12,13 The goal of successful management is threefold: to remove the catheter intact, to minimize patient discomfort, and to be as efficient as possible. The failure of the balloon to deflate may be caused by a number of factors, including a faulty valve mechanism, blockage of the inflation channel From the Department of Urology, University of Southern California, Keck School of Medicine, Los Angeles, California Reprint requests: Siamak Daneshmand, M.D., Department of Urology, Los Angeles County, University of Southern California Medical Center, 1200 North State Street, Suite 5900, Los Angeles, CA 90033 Submitted: June 6, 2001, accepted (with revisions): September 4, 2001 © 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
by debris, or crystallization of the fluid within the balloon. The latter problem is rarely encountered and usually occurs when the balloon is filled with saline rather than water and has been retained for a long time. Balloons should not be overinflated until rupture to prevent leaving loose fragments in the bladder. In an experimental ex vivo study by Gulmez et al.,14 balloons were inflated to the point of rupture and the volume and free-fragment formation was measured. Balloons ruptured after an average of 158 mL, and 83% of the ruptured catheters left significant free fragments behind.14 Injection of ether through the balloon port also causes rupture of the balloon within a few seconds.14 Ether is no longer available at most hospitals, and this maneuver should be discouraged, because it can cause significant bladder irritation. TECHNIQUE Ordinarily, the first step should be to cut the side arm of the catheter, thereby removing the valve mechanism. This often results in the extrusion of the fluid in the balloon and identifies the valve as the culprit. This is a maneuver that can be attempted by the primary care physician with the urologist’s advice. If this technique fails, the problem typically lies distally at the junction of the inflation channel and the balloon. The urologist at this point should be prepared for the following steps to simplify the efforts at removing the catheter. Several investigators have described the use of the sharp end of a ureteral stent stylet. With the aid of lubrication, the wire can be advanced to the balloon through the inflation port.2–5 If debris is blocking the port, this simple method can lead to 0090-4295/02/$22.00 PII S0090-4295(01)01483-2 127
FIGURE 1. Ultrasound scan of bladder showing the Foley balloon and spinal needle (arrow) about to puncture it.
rapid deflation of the balloon. However, if the balloon remains inflated, an attempt can be made to burst the balloon with the sharp end of the wire. This latter technique is often not very successful. In the study by Gulmez et al.,14 the wire successfully burst the balloon in only 2 of 50 catheters and completely deflated the balloons in 6. Many balloons were punctured with the stylet; however, they did not deflate completely even after 24 hours.14 If the above attempts fail, one must resort to direct puncture of the balloon using a needle. Various approaches have been described, including the use of endoscopy to aid in the manipulation and removal of the catheter.12,13 However, this would require adequate anesthesia, as well as operating room access. Some investigators have also advocated the use of fluoroscopy to aid in suprapubic puncture of the balloon.8,15 The transrectal route has also been used by using a finger or ultrasound probe as a guide. This may result in transmitting fecal flora to the bladder, leading to cystitis. Also, it is not always possible to palpate the balloon by way of the rectum, and transrectal ultrasonography may not be readily available. Perineal puncture of the balloon is another possibility, although it requires that the balloon be palpable at the level of the membranous urethra. In the female patient, the catheter can be placed on slight traction to allow the balloon to sit at the bladder neck, after which a needle can be passed alongside the catheter through the urethra until the balloon is encountered. If this proves difficult, the transvaginal route may be used.10,11 In the male patient, we have found that the su128
FIGURE 2. Algorithm for removal of retained Foley catheter.
prapubic approach to balloon puncture is the easiest, safest, and most efficient method to release the catheter. Portable ultrasonography, which is readily available in most hospitals, is used to locate the balloon within the bladder. The bladder may be empty and not clearly visible, because the catheter generally continues to drain most of the urine. The bladder can be filled with saline through the catheter until clear visualization is obtained with ultrasonography. The catheter is then plugged and the suprapubic area cleansed, as in the preparation of suprapubic tube placement. Subcutaneous lidocaine (1% to 2% without epinephrine) may be used for analgesia. A 22-gauge spinal needle is advanced percutaneously into the bladder using ultrasonography as a guide, and the balloon is burst under direct monitor view (Fig. 1). The catheter is removed and examined for any missing pieces. In the study by Gulmez et al.,14 none of 50 catheters that were burst using direct puncture left any residual fragment. If any suspicion that fragments have been left in the bladder is present, cystoscopy should be performed. It is prudent to use antibiotics if extensive manipulation was carried out before catheter removal. Figure 2 shows the algorithm for the steps described. UROLOGY 59 (1), 2002
COMMENT A retained Foley catheter can present a challenging and sometimes frustrating situation. Patients are often uncomfortable, and every attempt should be made to alleviate the associated anxiety. By following the outlined algorithm, the urologist can efficiently and expeditiously solve this problem. REFERENCES 1. Williams JC, Doebler RW, and Curtis MR: Deflation techniques for faulty Foley catheter balloons: presentation of a cystoscopic technique. Tech Urol 2: 174 –177, 1996. 2. Chin PL, Singh RK, and Athey G: Removal of retained urinary catheters. Br J Urol 56: 185–187, 1984. 3. Sood SC, and Sahota H: Removing obstructed balloon catheter. BMJ 4: 735, 1972. 4. Browning GP, Barr L, and Horsburgh AG: Management of obstructed balloon catheters. BMJ 289: 89 –91, 1984. 5. Hessl JM: Removal of Foley catheter when balloon does not deflate (letter). Urology 22: 219, 1983. 6. Houghton PWJ, and Foster ME: Management of obstructed balloon catheters (letter). BMJ 289: 319, 1984.
UROLOGY 59 (1), 2002
7. Moisey CU, and Williams LA: Self retained balloon catheters—a safe method for removal. Br J Urol 52: 67, 1980. 8. Moffat LEF, Teo C, and Dawson I: Ultrasound in the management of undeflatable Foley catheter balloon. Urology 26: 79, 1985. 9. Chrisp JM, and Nacey JN: Foley catheter puncture and the risk of free fragment formation. Br J Urol 66: 500 –502, 1990. 10. Kleeman FJ: Technique for removal of Foley catheter when balloon does not deflate. Urology 21: 416, 1983. 11. Simson JNL: Management of obstructed balloon catheters (letter). BMJ 289: 319, 1984. 12. O’Flynn KJ, Thomas DG, and Hardy A: Harpoon device for removal of obstructed balloon catheters. Br J Urol 69: 217– 218, 1992. 13. Saxena A, Khanna S, and Vohra BK: Endoscopic management of undeflatable Foley catheter balloon. Br J Urol 69: 217–218, 1992. 14. Gulmez I, Ekmekcioglu O, and Karacagil M: A comparison of various methods to burst Foley catheter balloons and the risk of free-fragment formation. Br J Urol 77: 716 –718, 1996. 15. Rees M, and Joseph AEA: Ultrasound guided suprapubic puncture—a new simple way of releasing a blocked Foley balloon. Br J Urol 53: 196, 1981.
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REVIEW OF TECHNIQUES TO REMOVE A FOLEY CATHETER WHEN THE BALLOON DOES NOT DEFLATE SIAMAK DANESHMAND, DAVID YOUSSEFZADEH,
AND
EILA C. SKINNER
ABSTRACT Failure of a Foley balloon to deflate may be caused by a faulty valve mechanism, blockage of the inflation channel, or, rarely, crystallization of the fluid within the balloon. We discuss the approach to successful management and present a stepwise algorithm to remove the catheter safely and expeditiously. UROLOGY 59: 127–129, 2002. © 2002, Elsevier Science Inc.
I
t is estimated that 15% to 20% of patients have a Foley catheter at some point during their hospital stay.1 A rare complication of Foley catheter use is the retention of the catheter because of balloon deflation failure. Urologists are usually consulted after multiple unsuccessful attempts to manipulate and deflate the balloon. Various techniques and maneuvers to address this complication have been described throughout published reports, including overinflation of the balloon, injection of ether or chloroform through the inflation channel,2 and bursting or deflating the balloon using a ureteral catheter stylet or other similar wires.2–5 Other methods, such as bursting the balloon with a needle through the suprapubic route with or without ultrasound guidance, have also been documented.6 –9 In women, direct puncture of the balloon using the urethral or transvaginal route has been reported.10,11 More elaborate methods described include the use of cystoscopy with endourologic instruments to burst and remove the catheter under direct vision.12,13 The goal of successful management is threefold: to remove the catheter intact, to minimize patient discomfort, and to be as efficient as possible. The failure of the balloon to deflate may be caused by a number of factors, including a faulty valve mechanism, blockage of the inflation channel From the Department of Urology, University of Southern California, Keck School of Medicine, Los Angeles, California Reprint requests: Siamak Daneshmand, M.D., Department of Urology, Los Angeles County, University of Southern California Medical Center, 1200 North State Street, Suite 5900, Los Angeles, CA 90033 Submitted: June 6, 2001, accepted (with revisions): September 4, 2001 © 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
by debris, or crystallization of the fluid within the balloon. The latter problem is rarely encountered and usually occurs when the balloon is filled with saline rather than water and has been retained for a long time. Balloons should not be overinflated until rupture to prevent leaving loose fragments in the bladder. In an experimental ex vivo study by Gulmez et al.,14 balloons were inflated to the point of rupture and the volume and free-fragment formation was measured. Balloons ruptured after an average of 158 mL, and 83% of the ruptured catheters left significant free fragments behind.14 Injection of ether through the balloon port also causes rupture of the balloon within a few seconds.14 Ether is no longer available at most hospitals, and this maneuver should be discouraged, because it can cause significant bladder irritation. TECHNIQUE Ordinarily, the first step should be to cut the side arm of the catheter, thereby removing the valve mechanism. This often results in the extrusion of the fluid in the balloon and identifies the valve as the culprit. This is a maneuver that can be attempted by the primary care physician with the urologist’s advice. If this technique fails, the problem typically lies distally at the junction of the inflation channel and the balloon. The urologist at this point should be prepared for the following steps to simplify the efforts at removing the catheter. Several investigators have described the use of the sharp end of a ureteral stent stylet. With the aid of lubrication, the wire can be advanced to the balloon through the inflation port.2–5 If debris is blocking the port, this simple method can lead to 0090-4295/02/$22.00 PII S0090-4295(01)01483-2 127
FIGURE 1. Ultrasound scan of bladder showing the Foley balloon and spinal needle (arrow) about to puncture it.
rapid deflation of the balloon. However, if the balloon remains inflated, an attempt can be made to burst the balloon with the sharp end of the wire. This latter technique is often not very successful. In the study by Gulmez et al.,14 the wire successfully burst the balloon in only 2 of 50 catheters and completely deflated the balloons in 6. Many balloons were punctured with the stylet; however, they did not deflate completely even after 24 hours.14 If the above attempts fail, one must resort to direct puncture of the balloon using a needle. Various approaches have been described, including the use of endoscopy to aid in the manipulation and removal of the catheter.12,13 However, this would require adequate anesthesia, as well as operating room access. Some investigators have also advocated the use of fluoroscopy to aid in suprapubic puncture of the balloon.8,15 The transrectal route has also been used by using a finger or ultrasound probe as a guide. This may result in transmitting fecal flora to the bladder, leading to cystitis. Also, it is not always possible to palpate the balloon by way of the rectum, and transrectal ultrasonography may not be readily available. Perineal puncture of the balloon is another possibility, although it requires that the balloon be palpable at the level of the membranous urethra. In the female patient, the catheter can be placed on slight traction to allow the balloon to sit at the bladder neck, after which a needle can be passed alongside the catheter through the urethra until the balloon is encountered. If this proves difficult, the transvaginal route may be used.10,11 In the male patient, we have found that the su128
FIGURE 2. Algorithm for removal of retained Foley catheter.
prapubic approach to balloon puncture is the easiest, safest, and most efficient method to release the catheter. Portable ultrasonography, which is readily available in most hospitals, is used to locate the balloon within the bladder. The bladder may be empty and not clearly visible, because the catheter generally continues to drain most of the urine. The bladder can be filled with saline through the catheter until clear visualization is obtained with ultrasonography. The catheter is then plugged and the suprapubic area cleansed, as in the preparation of suprapubic tube placement. Subcutaneous lidocaine (1% to 2% without epinephrine) may be used for analgesia. A 22-gauge spinal needle is advanced percutaneously into the bladder using ultrasonography as a guide, and the balloon is burst under direct monitor view (Fig. 1). The catheter is removed and examined for any missing pieces. In the study by Gulmez et al.,14 none of 50 catheters that were burst using direct puncture left any residual fragment. If any suspicion that fragments have been left in the bladder is present, cystoscopy should be performed. It is prudent to use antibiotics if extensive manipulation was carried out before catheter removal. Figure 2 shows the algorithm for the steps described. UROLOGY 59 (1), 2002
COMMENT A retained Foley catheter can present a challenging and sometimes frustrating situation. Patients are often uncomfortable, and every attempt should be made to alleviate the associated anxiety. By following the outlined algorithm, the urologist can efficiently and expeditiously solve this problem. REFERENCES 1. Williams JC, Doebler RW, and Curtis MR: Deflation techniques for faulty Foley catheter balloons: presentation of a cystoscopic technique. Tech Urol 2: 174 –177, 1996. 2. Chin PL, Singh RK, and Athey G: Removal of retained urinary catheters. Br J Urol 56: 185–187, 1984. 3. Sood SC, and Sahota H: Removing obstructed balloon catheter. BMJ 4: 735, 1972. 4. Browning GP, Barr L, and Horsburgh AG: Management of obstructed balloon catheters. BMJ 289: 89 –91, 1984. 5. Hessl JM: Removal of Foley catheter when balloon does not deflate (letter). Urology 22: 219, 1983. 6. Houghton PWJ, and Foster ME: Management of obstructed balloon catheters (letter). BMJ 289: 319, 1984.
UROLOGY 59 (1), 2002
7. Moisey CU, and Williams LA: Self retained balloon catheters—a safe method for removal. Br J Urol 52: 67, 1980. 8. Moffat LEF, Teo C, and Dawson I: Ultrasound in the management of undeflatable Foley catheter balloon. Urology 26: 79, 1985. 9. Chrisp JM, and Nacey JN: Foley catheter puncture and the risk of free fragment formation. Br J Urol 66: 500 –502, 1990. 10. Kleeman FJ: Technique for removal of Foley catheter when balloon does not deflate. Urology 21: 416, 1983. 11. Simson JNL: Management of obstructed balloon catheters (letter). BMJ 289: 319, 1984. 12. O’Flynn KJ, Thomas DG, and Hardy A: Harpoon device for removal of obstructed balloon catheters. Br J Urol 69: 217– 218, 1992. 13. Saxena A, Khanna S, and Vohra BK: Endoscopic management of undeflatable Foley catheter balloon. Br J Urol 69: 217–218, 1992. 14. Gulmez I, Ekmekcioglu O, and Karacagil M: A comparison of various methods to burst Foley catheter balloons and the risk of free-fragment formation. Br J Urol 77: 716 –718, 1996. 15. Rees M, and Joseph AEA: Ultrasound guided suprapubic puncture—a new simple way of releasing a blocked Foley balloon. Br J Urol 53: 196, 1981.
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