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Urethral Reaction to Foreign Objects
Vol. 106, August
THE JOURNAL OF UROLOGY
Copyright © 1971 by The Williams & Wilkins Co.
Printed in U.S.A.
URETHRAL REACTION TO FOREIGN OBJECTS M. RAY PAINTER,* A. A. BORSKI,t GILBERTO S. TREVINO
AND
W. E. CLARK, JR.
From the Fitzsimons General Hospital, Denver, Colorado
We are all aware of the complications associated with indwelling catheters. Generally we have accepted the associated pain and urethral discharge as necessary. Bacteriuria has been the most widely discussed complication1- 3 while some attention has been given to urethral strictures developing as the result of an indwelling catheter.4
In 1 year we diagnosed 6 strictures in patients who did not have urethral injury but had required an indwelling catheter. The caliber of the stricture was lOF or less. The number of urethras that have strictured to larger than lOF after indwelling catheters is undetermined. Keitzer has indicated that this number might be significant. 5 METHOD AND MATERIALS
As soon as it became available we began using the silicone rubber Malecot catheter in the treatment of urethral strictures. We found that urethral reaction and discharge were markedly decreased and almost completely absent in some cases. According to the literature, almost all patients with indwelling catheters have bacteriuria within 1 to 2 weeks. There is some evidence that bacteriuria can be delayed by strict catheter care. 6- 11 Accepted for publication September 1, 1970. Read at annual meeting of American Urological Association, Philadelphia, Pennsylvania, May 1014, 1970. * Current address: 2323 North 7th Street, Grand Junction, Colorado 81501. t Current address: Department of Urology, Walter Reed Hospital, Washington, D. C. 20012. 1 Kass, E. H.: Asymptomatic infections of the urinary tract. Trans. Ass. Amer. Physicians, 69: 56, 1956. 2 Beeson, P. B.: The case against the catheter. Amer. J. Med., 24: 1, 1958. 3 Levin, J.: The incidence and prevention of infection after urethral catheterization. Ann. Intern. Med., 60: 914, 1964. 4 Hardy, A. G.: Complications of the indwelling urethral catheter. Paraplegia, 6: 5, 1968. 5 Keitzer, W. A., Abreu, A., Navarro, I., Bernreuter, E. and Allen J. S.: Urethral strictures: prevention with plastic indwelling catheters. J. Urol., 99: 187, 1968. 6 Chamberlain, G., Dulake, C. and Kidd, E.: Indwelling urinary catheterization. Brit. J. Urol., 40: 315, 1968.
We routinely obtain urine cultures on patients with indwelling catheters twice weekly. In a retrospective review of that series of urethral strictures, we found that some patients had no bacteriuria after an internal urethrotomy and 6 weeks of silastic indwelling catheters. Of the 12 patients who had negative cultures at the time of operation, 6 remained negative. Two of these 6 patients did not have a complete set of cultures but they had negative cultures at 2 and 3 weeks. The other 4 patients had numerous negative cultures throughout the 6-week period. The average time of onset of infection in the remaining 6 patients was 2} 2 weeks. All patients had routine catheter care consisting of meatal cleansing, daily lubrication of the catheter at the meatus, closed urinary drainage and irrigation twice daily. They were treated for 1 week with a broad-spectrum antibiotic and maintained on mandelamine. Silastic Malecot catheters were a definite improvement but were stiff and difficult to keep indwelling. When Foley catheters made of a more non-reactive material were marketed, we decided to determine which catheter caused the least reaction. Four catheters were evaluated-Bard's latex rubber and teflon coated, Cutter's plastic resicath and Dow Corning's silicone coated catheters. The differences in reactions to these 4 catheters were less marked than expected. Ninety-four patients were closely observed for urethral pain and discharge. They were evaluated according to the amount of exudate daily: 0-no exudate, 1-some exudate on catheter daily, 2-exudate in morning only, 3-exudate during 7 Desautels, R. E.: Aseptic management of catheter drainage. New Engl. J. Med., 263: 189, 1960. 8 Duckman, S., Attardi, M. V., Dubner, M. S. and Ventura, B.: Effect of chemoprophylaxis and chemotherapy on bacilluria with indwelling catheter. New York J. Med., 69: 965, 1969. 9 Gladstone, J. L. and Robinson, C. G:·: Prevention of bacteriuria resulting from mdwelhng catheters. J. Urol., 99: 458, 1968. 10 Lind an, R.: The prevention of ascending, catheter-induced infections of the urinary tract. J. Chronic Dis., 22: 321, 1969. 11 Uehling, D. T.: Prevention of catheter bacteriuria. Wisconsin Med. J., 68: 206, 1969.
227
228
PAINTER AND ASSOCIATES
TABLE
1. Amount of urethral discharge during time
of indwelling catheter 3
0
Latex Plastic Teflon Silastic (Silicone Malecot)
TABLE
4 2 4 8 (10)
(3)
I 7
10 5 I 4 (1)
8 9 (4)
4
7 3 2
2. Cystoscopic evaluation of urethras after indwelling catheter Mild
Latex Plastic Teflon Silastic (Silicone Malecot)
Moderate
Marked
4
8
3
2
3
6 5 9 (1)
2
5 (4)
3. Gross evaluation of urethra and bladder reactions in dogs after 3 to 7 days with indwelling catheters
TABLE
Mild
Moderate
Marked
Urethra Plastic Latex Teflon Silastic
3 2
Plastic Latex Teflon Silastic
1 2
2 3
2
Bladder 4 2 2
day (1 pad or less), 4-exudate requiring more than 1 pad daily. Coated catheters caused a lesser degree of discharge than the latex rubber catheter (table 1). Cystoscopically, the amount of urethral reaction was classified as mild-injected with only 1 or 2 hemorrhagic areas, moderate-numerous hemorrhagic areas and marked-entire urethra hemorrhagic (table 2). Most urethras looked moderately to markedly injected after 72 hours regardless of type of catheter. After 6 weeks to 3 months of an indwelling catheter, this injection had decreased and the hemorrhagic areas were few. However, the urethra was lined with concentric rings of scarring which is apparent when the urethra is distended. Generally, the teflon and silastic catheters caused the least amount of reaction and latex rubber catheters caused the most prominent reactions.
In an experiment, the urethras of 18 dogs were examined grossly and microscopically after varying periods of catheterization. Most urethras were examined after 3 to 7 days of indwelling catheters. Three catheters were left indwelling for 2 weeks. The urethras of these 3 dogs became infected with severe bladder and urethral reactions. A severe infection and reaction developed in another dog after 1 week. The remaining 14 urethras and bladders were evaluated grossly and graded by degree of reaction as mild, moderate or marked (table 3). There was no significant difference in gross appearance; however microscopically the difference was quite marked. The teflon and silastic coated catheters showed a reaction of only 1 to 2 cell layers thick in the mucosa with little cellular reaction behind this and in some places the mucosa looked normal (fig. 1, A). The plastic catheter showed some destruction of the mucosa with a cellular reaction consisting mainly of lymphocytes (fig. 1, B). The latex catheter showed cellular reaction with predominant cells being polymorphonuclear leukocytes (fig. 2, A). We do not know the significance of the difference in the foreign object reaction to the latter 2 catheters and are not qualified to comment on whether this is a bio-electric phenomenon or a leeching process. However, the reaction can cause thrombosis in the submucosal area which could lead to ischemic necrosis and scarring of the urethra (fig. 2, B). DISCUSSION
Urethral reaction to foreign objects is dependent on many variables such as individual patient response, length of time catheter is indwelling, type of catheter and absence or presence of secondary infection. Our material does not conclusively indicate which of the 4 catheters is the one of choice. Our series is small and when broken down according to these variables, nothing can be proved scientifically. However, several interesting facets of this problem are clearly brought into focus. Cystoscopically all urethras show reaction after 2 to 3 days of indwelling catheter. This reaction is superficial and does not clearly indicate the degree of a submucosal reaction. We believe that this submucosal reaction is important in breaking down body defense mechanisms to infection as well as causing scarring of the urethra after the catheter has been removed.
URETHRAL REACTION TO FOREIGN OBJECTS
229
230
PAINTER AND ASSOCIATES
SUMMARY
The degree of reaction of urethras to foreign objects is significant and is dependent on individual patient response, length of time catheter is indwelling, type of catheter and absence or presence of secondary infection. This reaction plays an important role in the presence or ab-
sence of bacteriuria with an indwelling catheter and the development of scarring and stricturing in the urethra after the catheter has been removed. These conclusions are based on 94 patients with indwelling catheters, 59 cystoscopic examinations and 18 dog urethras examined grossly and microscopically after use of 4 types of indwelling catheters.
THE JOURNAL OF UROLOGY
Copyright © 1971 by The Williams & Wilkins Co.
Printed in U.S.A.
URETHRAL REACTION TO FOREIGN OBJECTS M. RAY PAINTER,* A. A. BORSKI,t GILBERTO S. TREVINO
AND
W. E. CLARK, JR.
From the Fitzsimons General Hospital, Denver, Colorado
We are all aware of the complications associated with indwelling catheters. Generally we have accepted the associated pain and urethral discharge as necessary. Bacteriuria has been the most widely discussed complication1- 3 while some attention has been given to urethral strictures developing as the result of an indwelling catheter.4
In 1 year we diagnosed 6 strictures in patients who did not have urethral injury but had required an indwelling catheter. The caliber of the stricture was lOF or less. The number of urethras that have strictured to larger than lOF after indwelling catheters is undetermined. Keitzer has indicated that this number might be significant. 5 METHOD AND MATERIALS
As soon as it became available we began using the silicone rubber Malecot catheter in the treatment of urethral strictures. We found that urethral reaction and discharge were markedly decreased and almost completely absent in some cases. According to the literature, almost all patients with indwelling catheters have bacteriuria within 1 to 2 weeks. There is some evidence that bacteriuria can be delayed by strict catheter care. 6- 11 Accepted for publication September 1, 1970. Read at annual meeting of American Urological Association, Philadelphia, Pennsylvania, May 1014, 1970. * Current address: 2323 North 7th Street, Grand Junction, Colorado 81501. t Current address: Department of Urology, Walter Reed Hospital, Washington, D. C. 20012. 1 Kass, E. H.: Asymptomatic infections of the urinary tract. Trans. Ass. Amer. Physicians, 69: 56, 1956. 2 Beeson, P. B.: The case against the catheter. Amer. J. Med., 24: 1, 1958. 3 Levin, J.: The incidence and prevention of infection after urethral catheterization. Ann. Intern. Med., 60: 914, 1964. 4 Hardy, A. G.: Complications of the indwelling urethral catheter. Paraplegia, 6: 5, 1968. 5 Keitzer, W. A., Abreu, A., Navarro, I., Bernreuter, E. and Allen J. S.: Urethral strictures: prevention with plastic indwelling catheters. J. Urol., 99: 187, 1968. 6 Chamberlain, G., Dulake, C. and Kidd, E.: Indwelling urinary catheterization. Brit. J. Urol., 40: 315, 1968.
We routinely obtain urine cultures on patients with indwelling catheters twice weekly. In a retrospective review of that series of urethral strictures, we found that some patients had no bacteriuria after an internal urethrotomy and 6 weeks of silastic indwelling catheters. Of the 12 patients who had negative cultures at the time of operation, 6 remained negative. Two of these 6 patients did not have a complete set of cultures but they had negative cultures at 2 and 3 weeks. The other 4 patients had numerous negative cultures throughout the 6-week period. The average time of onset of infection in the remaining 6 patients was 2} 2 weeks. All patients had routine catheter care consisting of meatal cleansing, daily lubrication of the catheter at the meatus, closed urinary drainage and irrigation twice daily. They were treated for 1 week with a broad-spectrum antibiotic and maintained on mandelamine. Silastic Malecot catheters were a definite improvement but were stiff and difficult to keep indwelling. When Foley catheters made of a more non-reactive material were marketed, we decided to determine which catheter caused the least reaction. Four catheters were evaluated-Bard's latex rubber and teflon coated, Cutter's plastic resicath and Dow Corning's silicone coated catheters. The differences in reactions to these 4 catheters were less marked than expected. Ninety-four patients were closely observed for urethral pain and discharge. They were evaluated according to the amount of exudate daily: 0-no exudate, 1-some exudate on catheter daily, 2-exudate in morning only, 3-exudate during 7 Desautels, R. E.: Aseptic management of catheter drainage. New Engl. J. Med., 263: 189, 1960. 8 Duckman, S., Attardi, M. V., Dubner, M. S. and Ventura, B.: Effect of chemoprophylaxis and chemotherapy on bacilluria with indwelling catheter. New York J. Med., 69: 965, 1969. 9 Gladstone, J. L. and Robinson, C. G:·: Prevention of bacteriuria resulting from mdwelhng catheters. J. Urol., 99: 458, 1968. 10 Lind an, R.: The prevention of ascending, catheter-induced infections of the urinary tract. J. Chronic Dis., 22: 321, 1969. 11 Uehling, D. T.: Prevention of catheter bacteriuria. Wisconsin Med. J., 68: 206, 1969.
227
228
PAINTER AND ASSOCIATES
TABLE
1. Amount of urethral discharge during time
of indwelling catheter 3
0
Latex Plastic Teflon Silastic (Silicone Malecot)
TABLE
4 2 4 8 (10)
(3)
I 7
10 5 I 4 (1)
8 9 (4)
4
7 3 2
2. Cystoscopic evaluation of urethras after indwelling catheter Mild
Latex Plastic Teflon Silastic (Silicone Malecot)
Moderate
Marked
4
8
3
2
3
6 5 9 (1)
2
5 (4)
3. Gross evaluation of urethra and bladder reactions in dogs after 3 to 7 days with indwelling catheters
TABLE
Mild
Moderate
Marked
Urethra Plastic Latex Teflon Silastic
3 2
Plastic Latex Teflon Silastic
1 2
2 3
2
Bladder 4 2 2
day (1 pad or less), 4-exudate requiring more than 1 pad daily. Coated catheters caused a lesser degree of discharge than the latex rubber catheter (table 1). Cystoscopically, the amount of urethral reaction was classified as mild-injected with only 1 or 2 hemorrhagic areas, moderate-numerous hemorrhagic areas and marked-entire urethra hemorrhagic (table 2). Most urethras looked moderately to markedly injected after 72 hours regardless of type of catheter. After 6 weeks to 3 months of an indwelling catheter, this injection had decreased and the hemorrhagic areas were few. However, the urethra was lined with concentric rings of scarring which is apparent when the urethra is distended. Generally, the teflon and silastic catheters caused the least amount of reaction and latex rubber catheters caused the most prominent reactions.
In an experiment, the urethras of 18 dogs were examined grossly and microscopically after varying periods of catheterization. Most urethras were examined after 3 to 7 days of indwelling catheters. Three catheters were left indwelling for 2 weeks. The urethras of these 3 dogs became infected with severe bladder and urethral reactions. A severe infection and reaction developed in another dog after 1 week. The remaining 14 urethras and bladders were evaluated grossly and graded by degree of reaction as mild, moderate or marked (table 3). There was no significant difference in gross appearance; however microscopically the difference was quite marked. The teflon and silastic coated catheters showed a reaction of only 1 to 2 cell layers thick in the mucosa with little cellular reaction behind this and in some places the mucosa looked normal (fig. 1, A). The plastic catheter showed some destruction of the mucosa with a cellular reaction consisting mainly of lymphocytes (fig. 1, B). The latex catheter showed cellular reaction with predominant cells being polymorphonuclear leukocytes (fig. 2, A). We do not know the significance of the difference in the foreign object reaction to the latter 2 catheters and are not qualified to comment on whether this is a bio-electric phenomenon or a leeching process. However, the reaction can cause thrombosis in the submucosal area which could lead to ischemic necrosis and scarring of the urethra (fig. 2, B). DISCUSSION
Urethral reaction to foreign objects is dependent on many variables such as individual patient response, length of time catheter is indwelling, type of catheter and absence or presence of secondary infection. Our material does not conclusively indicate which of the 4 catheters is the one of choice. Our series is small and when broken down according to these variables, nothing can be proved scientifically. However, several interesting facets of this problem are clearly brought into focus. Cystoscopically all urethras show reaction after 2 to 3 days of indwelling catheter. This reaction is superficial and does not clearly indicate the degree of a submucosal reaction. We believe that this submucosal reaction is important in breaking down body defense mechanisms to infection as well as causing scarring of the urethra after the catheter has been removed.
URETHRAL REACTION TO FOREIGN OBJECTS
229
230
PAINTER AND ASSOCIATES
SUMMARY
The degree of reaction of urethras to foreign objects is significant and is dependent on individual patient response, length of time catheter is indwelling, type of catheter and absence or presence of secondary infection. This reaction plays an important role in the presence or ab-
sence of bacteriuria with an indwelling catheter and the development of scarring and stricturing in the urethra after the catheter has been removed. These conclusions are based on 94 patients with indwelling catheters, 59 cystoscopic examinations and 18 dog urethras examined grossly and microscopically after use of 4 types of indwelling catheters.