Problems with straight cath on a male pt

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Hi,

I'm relatively new to nursing and am doing home care on a 17yo male patient with a developmental disability. He needs a straight cath every 3-4 hours (size 10F). Most of the time I have no problem with the procedure but sometimes the flow shuts off suddenly after about 50 mL. I know if it's been 4 hours since his last cath, his diaper is dry and he's not dehydrated he should have at least 120mL so I can't figure out why it would just stop or what to do about it. I always hold the cath in place so know it doesn't slip out and I do make sure that I don't insert it too far because doing so could cause the hole to be above the level of urine. It seems as though he's 'clamping down' to cut off the flow, but I'm not sure if this is even possible. I try to apply pressure to the bladder (there's an order to do this) but it doesn't help. Also, sometimes when I cath him at night there's only a very slow trickle and despite applying pressure it takes 30-45 minutes to drain out 200 mL of urine. Because of his developmental disability (his mental age is about 5), he isn't able to communicate with me regarding whether or not he's clamping down on purpose and he doesn't understand when I ask him to relax. Another oddity is that every time I cath him he gets an erection as the cath is going in... i would think that a cath insertion isn't something to get aroused over... Does anyone have any ideas as to what is going on here?

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" most of the time i have no problem with the procedure but sometimes the flow shuts off suddenly after about 50 ml. i know if it's been 4 hours since his last cath, his diaper is dry and he's not dehydrated he should have at least 120ml so i can't figure out why it would just stop or what to do about it. i always hold the cath in place so know it doesn't slip out .."

...good move...

".. and i do make sure that i don't insert it too far because doing so could cause the hole to be above the level of urine.

huh? his bladder isn't full of air, so there is no "above the level of the urine," because there's no air/fluid level. so this is making me think that perhaps it should be a little further in, because the opening in the catheter might not be fully into the bladder proper, but up against the bladder neck.

"it seems as though he's 'clamping down' to cut off the flow, but i'm not sure if this is even possible. "

it actually is; i've seen this. it's also possible that bearing down would occlude the opening on the catheter with bladder wall or bladder neck.

"i try to apply pressure to the bladder (there's an order to do this) but it doesn't help. also, sometimes when i cath him at night there's only a very slow trickle and despite applying pressure it takes 30-45 minutes to drain out 200 ml of urine."

if the opening of the catheter is up against tissue, this would happen.

"because of his developmental disability (his mental age is about 5), he isn't able to communicate with me regarding whether or not he's clamping down on purpose and he doesn't understand when i ask him to relax. another oddity is that every time i cath him he gets an erection as the cath is going in... i would think that a cath insertion isn't something to get aroused over... does anyone have any ideas as to what is going on here?"

erections can occur with stimuli of all kinds, and clearly he doesn't have the mental capacity to understand the sexual kind. adolescent males have surging hormones and can have erections over nothing; they can be surprised with one popping up in the middle of a discussion of quadratic equations in math class, after an unexpected tightness in the trousers when shifting positions, for any kind of penile stimulation, or for nothing at all. this might well be what you're seeing.

you can try the old trick of putting his hands in warm water or wrapping them in warm washcloths to help him relax; you can get a prescription to use lidocaine jelly instead of plain lube, too. but i'd try inserting it one extra centimeter or two or so (gently, don't jam it against resistance) first and see if that makes any difference.

also, if he's been getting cathed with 10f pedi caths forever, perhaps he's grown enough by now that 12f might be better. ask.

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Specializes in Adult ICU.

Sometimes when I cath a pt and stop getting return it is due to the positioning of the pt on their back. I don't know if you have it but I would raise the bed and tilt it down to allow more urine to flow out but I doubt you have a adjustable bed.

Other reason I have found is that there is kink, bent or some type of obstruction in the actually cath like a piece of sediment or mucus logged in it. Also not being in all the way as the longer you hold it your hand may get tired and the cath may slip out. A lot of times the pt just doesn't have as much urine as you were expecting to get.

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why push up farther if its coming out and then stopping???? How much does he weigh???? because urine should really be figured out by body weight not by ml/hour...maybe that's all he needs to make if he is very thin, and if he is not drinking or replacing fluids that may be all that is there.....

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Specializes in ICU, Telemetry.

It was an old man, not a young one, but I had a patient that I could only get his urine to flow if he turned on his side. I'm sure in my case the pt had some BPH, but it's an idea...I also think maybe like some of the other's said, he's simply outgrown peds supplies and is ready for adult?

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Specializes in MR/DD.

Try changing his position, I usually have better luck if I raise the head of the bed or place the patient on his/her side.

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why push up farther if its coming out and then stopping???? How much does he weigh???? because urine should really be figured out by body weight not by ml/hour...maybe that's all he needs to make if he is very thin, and if he is not drinking or replacing fluids that may be all that is there.....

Exactly. The 30ml/hour is based on the same formula as pediatric urine output expectations for an average sized person UP TO the adult formula (minimum is half of the pediatric formula) depending on age . So knowing his weight will be helpful in knowing the true minimum you should be getting. So a range is then broken down into the average....

http://www.easycalculation.com/medical/Pediatric_urine_output.php

Are there any contraindications in additional fluids? Concentrated urine irritates the bladder; it can also cause spasms, which could be made worse by the introduction of the catheter. That, along with positioning may be a factor :confused:

The erection can cut off the urine flow with a tube in the urethra, especially if it's a fairly flimsy catheter; if it's a firmer sort, I'd try the positioning tips already mentioned.

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Specializes in Acute Care, Rehab, Palliative.

Have you tried a bigger catheter size? A 12 or even a 14 may give better results, and like others have suggested, a different position.

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Huh? His bladder isn't full of air, so there is no "above the level of the urine," because there's no air/fluid level. So this is making me think that perhaps it should be a little further in, because the opening in the catheter might not be fully into the bladder proper, but up against the bladder neck.

That's interesting... it makes sense, but I was taught that a straight cath should only be inserted far enough for urine to start flowing. It really does seem as though he's bearing down because as it's flowing it suddenly stops and I know the cath hasn't moved. But, a straight cath is so rigid, it's hard to imagine anyone being able to pinch it off completely in this way. If you've seen it, I'll believe it. Now I just have to figure out how to get him to stop doing it :p

His mother insists that he be cathed while sitting on the toilet (which I don't like at all for sanitary reasons) because she thinks it will help train him to pee on his own. So, the position shouldn't be the problem. I'm not sure exactly what he weighs (over 100 lbs), but when the urine flows normally I tend to get 120-200 mL and it's clear yellow so he's not dehydrated (no other signs of dehydration either).

I'll try to convince his mother to ask for a bigger cath.

Thanks for the replies!

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Huh? His bladder isn't full of air, so there is no "above the level of the urine," because there's no air/fluid level. So this is making me think that perhaps it should be a little further in, because the opening in the catheter might not be fully into the bladder proper, but up against the bladder neck.

That's interesting... it makes sense, but I was taught that a straight cath should only be inserted far enough for urine to start flowing. It really does seem as though he's bearing down because as it's flowing it suddenly stops and I know the cath hasn't moved. But, a straight cath is so rigid, it's hard to imagine anyone being able to pinch it off completely in this way. If you've seen it, I'll believe it. Now I just have to figure out how to get him to stop doing it :p

His mother insists that he be cathed while sitting on the toilet (which I don't like at all for sanitary reasons) because she thinks it will help train him to pee on his own. So, the position shouldn't be the problem. I'm not sure exactly what he weighs (over 100 lbs), but when the urine flows normally I tend to get 120-200 mL and it's clear yellow so he's not dehydrated (no other signs of dehydration either).

I'll try to convince his mother to ask for a bigger cath.

Thanks for the replies!

:smackingf He's 17, and mom is still thinking potty training is gonna happen? (poor lady) I'd tell mom that to get the urine out, he needs to be positioned in a way that can't be done on the pot (though people who self-cath do that- but that is their option....not sure I'd do that with sterile equipment ). If it's a more rigid cath, the erection isn't doing it - ime.

Good luck :)

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