Urologic illogic today pune

1. UROLOGIC ILLOGIC
I remember, when I joined this institution nine years ago, I had
lightening enthusiasm and believed in changing the way the world works
(you must appreciate that all young people have dreams and should be
allowed to have them). I then met the then Hospital administrator and
said we should never use Simple rubber Catheters even for temporary
bladder drainage.
My opinion was based on the fact that these ghastly catheters are made
of India rubber, which is raw, untreated and can cause severe and florid
tissue reaction to the urethral mucosa even in the short term. They
should be replaced by Plastic (PVC) catheters for routine purposes. They
are inexpensive, properly sterilised and of course caused minimum
tissue reaction.
My opinion was naturally respected and it was agreed that everyone in
the Hospital should use The order was passed for execution. But to my
dismay, the prepared catheter boxes continued to hold Simple Rubber
Catheters. I started a regular practice of throwing ALL these catheters
into the dustbin every time I used a box. Despite this, they kept
appearing again and again. I spoke to the administrator and the Matron
on several occasions, but to no avail. I have lost the count as how many
times I have done this. But today if you open a catheter box, you will still
see half a dozen simple rubber catheters in the box.
I often wonder how the routines and conventions get set in a hospital
practice. Some protocols are followed like rituals. Some get standardised
after a period. But some are followed from generations. What is more
amazing is the effort required to change such fixed protocols. They can
be frustratingly hopeless. A sister in a ward, for instance, believes that
only sweepers will touch the urine bags for emptying and it is well neigh
impossible to make her believe otherwise. Use of Simple Rubber
catheters is only one such example. Looking further ahead you may find
many such rituals which are followed into practice through generations
but are proven illogical in the modern practice of Medicine.
1. Bladder Training: The practice of bladder training has intrigued me
over many years. While weaning the patient off the catheter, the
commonest instruction is “Clamp the catheter and release every four
hours”.
Clamping the catheter only distends the bladder for a set time. The only
information it can possibly give is about the sensation of fullness. It gives
no other information and certainly tells us nothing about the return of

2. motor power. In the modern era of Urodynamics clamping the catheter is
totally useless and serves no purpose in bladder training. Besides it
carries a serious risk of systemic sepsis in the paraplegics in whom this
practice is more rampant. The knowledge of Urodynamics tells us clearly
that bladder fullness, urge to void are totally sensory phenomena and
that the return of sensory perception do not give any information on the
motor activity of the bladder, unless they are evaluated by objective tests
such as Urodynamics.
2. Flush those stones out : The commonest and the most popular
concept of treating ureteral calculi is to “flush” them with high fluid
intake and Diuretics. Some clinicians would go to the extent of
instituting intravenous fluids and diuretics together. This practice
should be deprecated for more than one reason.
The total load of fluid from the body is normally handled by both the
functioning kidneys simultaneously. A kidney that is obstructed by a
stone usually has a suppressed filtration. The majority of fluid load
therefore is taken up by the unaffected kidney, which will excrete most of
the fluid. The calculus will remain where it is. If the stone is impassable,
then such a practice theoretically will virtually bring on a colic and make
the matters worse. The sensible thing to do in such situation is to keep a
normal fluid intake and prevent dehydration. Intravenous
supplementation of fluid is indicated in the rare event of severe vomitting
with a threat of dehydration.
3. Catheter Myths: One of the commonest practices hard to eradicate is
the use of Rubber catheters. They must be totally abandoned for the
reasons mentioned above. Besides, in a busy Hospital practice, a
more sensible solution is to use an indwelling Foley type of catheter.
The reason is simple. In the majority of cases of acute urinary
retention, the cause of retention is not obvious and would need
further evaluation. It would be sensible to buy some time till the
appropriate investigations are performed to define the cause. Simple
Rubber catheters still find useful place as tourniquets and as suction
catheters, where they can be rightfully used (although better
substitutes are now available in both places).
4. Managing Incontinence: Use of catheters should be discouraged
prior to patient evaluation for Incontinence. The bedside clinical
evaluation of any incontinence involves physical examination, nursing
observations, dry intervals and residual volume estimation. Presence
of catheter will preclude all these tests and clearly interfere with the
evaluation. A proper diagnosis of incontinence should therefore
dictate the appropriate therapy. Indwelling Catheters are then

3. required only in cases of refractory incontinence in the female
patients.
5. Catheter Leakage: Another common problem encountered in the
wards is “urine leaking out by the side of the catheter”. This is often
described as Catheter leak. One is often tempted to pass a larger
catheter to stop such a leak. A logical explanation for this
phenomenon is bladder spasms. The commonest causes are Catheter
blockage, trigonal irritation and infection. Blockage must be excluded
by gentle irrigation. Trigonal irritation can be minimised by using a
good quality catheter and by inflating the Foley balloon by the
minimal amount of water( 5 to 10 mls only). Sepsis should be
appropriately treated. Spasms refractory to these measures are
controlled effectively (but temporarily) with oral anticholinergics such
as Oxybutynin and Propantheline in large doses. Passing a larger
catheter is not only illogical but can be hazardous since it will not
control the leak and in females it may further dilate the urethra,
making future management difficult.
6. Slow Decompression: It is commonly advised in a case of chronic
urinary retention to pass a catheter and use slow and controlled
drainage (often referred to as slow decompression). The rationale is
that if such bladders are decompressed rapidly, then bleeding can
occur from the bladder and from the Kidneys. There are now enough
studies to show that such a procedure does not prevent the bleeding if
it is to occur. Such haematuria is usually self-limiting and does not
produce any significant complications.
7. Condom Drainage: Condoms are often used external urinary
collection devices in males. There are proper custom made devices
like
Conveen Sheath, Uri drop and Gold Seal, which come in different
sizes, fit the penis well and are inexpensive. Condoms are poor
substitutes for this purpose, since they kink very often and can cause
obstruction without the notice of the nursing staff.
Illogic practices are certainly more ubiquitous. Urology is one field
where these practices are carried from generations. Better substitutes
are now available with the advances in knowledge but more after
some rational thinking.
That is the easy part. The difficult part is how to eradicate these customs
from Institutions. If one can achieve it easily, he can mould the world.
We can then boast to practise the modern Medicine in the real sense.