The principles and practice of modern surgery

by Roswell Park

Catheters, as such, are intended for the withdrawal of urine from the urinary bladder, or for the introduction and withdrawal of cleansing fluids. They are made of metal, glass, gum, and silk, or other similar material, in various sizes, while some are specially formed or bent in order to pass more easily over the obstruction offered by a median prostatic enlargement. Various forms are sold in the surgical depots, from which the purchaser may make a choice. Next to the simple tubular forms the elbowed or Coudé catheters are of the greatest value.

Catheters should be sterilized before use. Those used occasionally should be cleaned after use and dried, while those in daily use may be kept in an antiseptic solution after cleansing. The cleansing of a catheter should include not only attention to the exterior, but also removal from its bore of all clots, debris, etc. Some pressure behind the fluid used for this purpose is advisable. A clean metal or glass catheter may be sterilized in a flame just before use. All flexible catheters should be boiled just prior to their insertion, or they should be taken out of an air-tight receptacle in which they have been kept in contact with some antiseptic, or in an antiseptic vapor. For the latter purpose paraform offers an excellent material, as there is given off from it formaldehyde vapor, which is a powerful bactericide. It comes in crystals and in tablets. Rubber catheters should be boiled in a 5 to 10 per cent. solution of ammonium sulphate.

The urethra should also be cleansed, especially the meatus, in either sex. Cases of cystitis may be directly traced to infection introduced by a catheter, the result being the same whether the germs be not removed from the instrument or are carried in by it from the anterior urethra. This is particularly true in paralytics who have no power of expelling the urine, and in prostatics who need regular catheterization.

The technique of using the metal catheter in the male is the same as that of introducing a sound. A lubricant is necessary for the easy introduction of the instrument, and a sterilized ointment or oil will serve the purpose. Olive oil, mixed with iodoform, as often used, is not sterile. The hands of the operator should also be clean, and no part of a clean instrument should be allowed to come into contact with any portion of the patient’s surface. On this account the parts exposed should be covered with sterile towels.

The catheter being intended to afford relief with the least amount of discomfort, a smaller instrument may be used than would be inserted were it meant for the dilatation of a stricture. Occasionally, and in a sensitive patient or hyperesthetic urethra, a little cocaine solution may be used to advantage, especially if force or pressure need be made in order to overcome spasm of the cut-off muscle. The metal instrument is too rigid in some cases, while the gum catheter is too flexible. Under these circumstances, the silk instrument may be used.

If the tip of the instrument be kept close to the floor of the urethra it will rarely catch in any fossa or lacuna, particularly if the size has been correctly chosen. When apparent obstruction occurs at the triangular ligament the instrument should be withdrawn a little, tilted differently, or lifted a little so that it is made to hug the roof of the urethra rather than to press upon its floor. By a little manipulation of the end of the instrument any obstruction at the neck of the bladder may also be overcome. A sudden depression of the outer end as the catheter reaches this part, or a little pressure by the finger of the disengaged hand in the perineum, will give much help. It is well, occasionally, to introduce one finger into the rectum in order that by it the instrument may be better guided along its course. Only in cases where there has been previous disease or where unsuccessful attempts have already been made to pass an instrument will much real difficulty be found; that is, only in those already suffering from stricture, or from enlarged prostate with the difficulties which it affords, will one have to resort to manipulation requiring more than ordinary dexterity. In some of these cases even the expert is likely to meet with difficulty, rarely with absolute disappointment. Should it be impossible to empty a distended bladder with a catheter suprapubic puncture with the aspirator needle should be made.

When difficulty is experienced it is enhanced by spasm of the deep muscles, as a reflex from the soreness produced by repeated efforts and by hemorrhage.

Hemorrhage from this source is rarely of serious character and quickly ceases. In certain instances where it is aggravated much can be accomplished by leaving the catheter in situ for a few hours, or even for two or three days.

False passages will occur sometimes in spite of at least ordinary care, and are always serious in their nature. Extravasation of urine may result, with more or less disastrous consequences, or speedy septic infection may quickly terminate the life of the individual. They are to be avoided, as far as possible, by the use of instruments of large rather than of small size, with blunt tips, and by delicacy of manipulation. For this purpose it is well to avoid the use of catheters which require a wire stylet for the maintenance of their proper curve, lest during manipulation the point of the wire may work injury. The various accidents due to or connected with catheterization will be dealt with in their proper places in connection with the surgery of the urethra and bladder.

There are certain constitutional complications, however, which deserve mention. One of these is known as urethral fever, which comes on usually with a chill, followed by more or less rise in temperature, and with general disturbance of the system. It is to be regarded as a manifestation of septic intoxication, the hope being that the disturbance may not go beyond this degree. In cases that have once suffered from this intoxication precautions should be doubled. The deep urethra should be irrigated before and after the withdrawal of the urine, the patient should be kept in bed, and urotropin and quinine may be administered before and after the discharge of urine. Much may be done in the prevention of this as of other unpleasant occurrences, such as pain, excitement, suppression of urine, syncope, etc., by the previous use of cocaine and by due regard for gentleness. Should a septic process be set up in the deep urethra it may lead to sapremia of urethral origin, and to septicemia and pyemia. Septic complications accompanied by any local indications, such as swelling, should make the surgeon watchful for the time when an incision must be made for relief of tension or escape of pus.