Slideset of a lecture delivered to the Emergency Medicine residents of the Hostra-Northwell School of Medicine at NSLIJ.

1. Making it Rain
Urologic Procedures in the ED
David A. Marcus, MD
EMIMDoc.org - @EMIMDoc
Program Director, Combined Residency in Emergency/Internal/Critical Care Medicine at LIJ Med Ctr
Asst. Prof. of Emergency Medicine - Hofstra-Northwell School of Medicine

2. Where to Review
(Click on the images for links)

3. The Agenda
• Urethral Catheterization
– Basic
– Advanced
• CBI
• Phimosis and Paraphimosis
• Priapism

4. A General Approach to Procedures
Informed Consent (Written or Verbal)
Gather Your Supplies
Anesthesia/Analgesia
Prepare Kit
Sterility
The Procedure
Reassessment and Follow Up

5. Fair Warning
Don’t

6. Doin’ the Dance

7. Stick a Tube in It!

8. Urethral Catheterization
Indications
• Acute urinary retention
• Outflow obstruction causing renal compromise
• Monitoring urinary output in critically ill
• Urologic study of lower GU tract
• Sterile urine sampling (remove immediately)

9. Urethral Catheterization
1. Fully retract the foreskin
2. Stabilize foreskin with gauze
3. 10ml of 2% Viscous Lidocaine
4. Prepare equipment
5. Don sterile gloves
6. Grasp penis firmly, upward
with non-dominant hand
7. Using dominant hand, apply
betadine in spiral
8. Insert catheter to the HUB!
9. Inflate balloon, stabilize
tubing
10.REDUCE THE FORESKIN
Confirm retention!

10. Urethral Catheterization
1. Fully retract the foreskin
2. Stabilize foreskin with gauze
3. 10ml of 2% Viscous Lidocaine
4. Prepare equipment
5. Don sterile gloves
6. Grasp penis firmly, upward
with non-dominant hand
7. Using dominant hand, apply
betadine in spiral
8. Insert catheter to the HUB!
9. Inflate balloon, stabilize
tubing
10.REDUCE THE FORESKIN
Confirm retention!

11. Urethral Catheterization
Confirm retention!
1. Identify the urethra – may be
retracted superiorly if post
menopausal.
2. If not obvious, use non-
dominant finger to identify
meatus by palpation
3. If prolapse, may need to
“recreate” normal anatomy
4. Using dominant hand, apply
betadine in spiral
5. Insert ½ total catheter
6. Inflate balloon, stabilize tubing

12. Urethral Catheterization
Contraindications
• Trauma with:
– Severely fractured pelvis
– Pubic Symphysis diastasis
Relative Contraindications
• Trauma with:
– High riding prostate
– Blood at urethral meatus
– Penile, Scrotal, Perineal hematoma
– Radiologic evidence of bladder injury

13. Foley Kindness
http://www.procedurettes.com/Procedurettes/Penis-thesia.html

14. Continuous Bladder Irrigation
Indication: Retention in setting of hematuria
• 3-way 22F - 26F catheter via usual technique
• Connect saline bag to one port, receptacle to the
other.
• Irrigate
– Manually using 60 ml aliquots of saline
– By gravity, using saline at approximately 1 L/hr
– Make sure that Volume IN = Volume OUT
• Stop once irrigation runs clear and bladder
emptying

15. Continuous Bladder Irrigation
Indication: Retention in setting of hematuria
• 3-way 22F - 26F catheter via usual technique
• Connect saline bag to one port, receptacle to the
other.
• Irrigate
– Manually using 60 ml aliquots of saline
– By gravity, using saline at approximately 1 L/hr
– Make sure that Volume IN = Volume OUT
• Stop once irrigation runs clear and bladder
emptying

16. Difficult Cases
• The Edematous Penis

17. Difficult Cases
• The Edematous Penis

18. Difficult Cases
• The Buried Penis

19. Difficult Cases
Urethral Strictures
• 12-14 Fr catheter
• Silicone
BPH
• 18-24 Fr
• Coudet tip
• Maintain correct
orientation

20. Difficult Cases
The Non Deflating Catheter – Initial approach
1. Try cutting off the inflation port
2. Insert needle/syringe into balloon port lumen
and try to aspirate
3. Consider cutting the tube closer
4. Insert small guidewire (central line kit) into
balloon lumen to clear debris/puncture
balloon, then attempt aspiration. CAUTION

21. Difficult Cases
The Non Deflating Catheter – Advanced Method
1. Overinflate balloon with > 50 ml Saline
2. Apply gentle traction to catheter
3. Puncture balloon using 25g/27g spinal needle
4. Use POCUS if available for dynamic guidance
5. Allow balloon to drain
6. Remove catheter and inspect for missing
fragments

22. Can’t I Just Pop It?

23. More Problems…

24. More Problems: Phimosis
https://commons.wikimedia.org/wiki/File:Phimosis_explained.jpg

25. More Problems: Phimosis
https://commons.wikimedia.org/wiki/File:Phimosis_explained.jpg

26. Phimosis and the Dorsal Slit
• Only an emergency if pt must be catheterized
• Medical management leading to circumcision
is preferred

27. Phimosis and the Dorsal Slit
1. Gather your supplies:
– Sterile gloves, drape
– 1% Lido w/out Epi
– 5 cc syringe
– 27g needle
– Straight clamp
– Straight scissor
– Needle holder
– 4.0 Absorbable Suture
– Nerves of steel

28. Phimosis and the Dorsal Slit
2. Consider procedural sedation
3. Administer parenteral analgesics
4. Cleanse and drape, get sterile
5. Administer local anesthesia
OR
Dorsal
Penile
Nerve
Block

29. Phimosis and the Dorsal Slit
6. Wait 10 minutes
7. Advance closed clamp between foreskin and
glans, to sulcus, release adhesions
8. Open clamp to grasp and crush area of slit for
3-5 minutes. Be sure to confirm you are not
in urethra first!
9. SNIP!
10.Suture each side

30. More Problems: Paraphimosis
Paraphimosis is an
ACTUAL Emergency
https://www.supercoder.com/coding-newsletters/my-urology-coding-alert/reader-
questionsturn-to-55450-for-swollen-penis-reduction-45713-45713-article

31. Paraphimosis
• MUST be reduced in the ED as soon as it is
identified.
• Techniques:
– Manual reduction
– Make it sweet
– The puncture method
– The Ice-Glove method
– Babcock clamps

32. Paraphimosis Reduction
• In most cases, provide analgesia. Consider
penile ring block, procedural sedation, topical,
parenteral analgesia.
• In all cases, lubricate the glans penis and
foreskin
• Start with manual compression of the distal
penis (5-10 min.).

33. Paraphimosis Manual Compression

34. Paraphimosis Reduction
Stacking the Deck:
• Sugar coat it (up to 1 hour)
• D50 Compress (up to 1 hour)
• Ice-Glove (10-15 min)

35. Sweetening the Deal
Granulated Sugar
• Penis must be
immersed in sugar.
• Consider using a
modifying urinal
• Requires a lot of
sugar!
• See example at
Procedurettes.com
D50 Compress
• 1 amp D50 into long
gauze wrap
• Wrap Penis
• Wait.

36. Paraphimosis Reduction
Manual failed?
• Puncture Method (20g needle)
• Babcock Clamp (6-8)
• Dorsal Slit…

37. STILL Can’t Get the Foley In?
It’s ok, you can still…

38. Suprapubic Catheterization
Indications
• Can’t insert foley
• Urethral transection

39. Suprapubic Catheterization
Indications
• Can’t insert foley
• Urethral transection

40. Suprapubic Catheterization

41. Suprapubic Catheterization
Suprapubic Pearls
• You can always use any kind of central line kit
if no SPC kit is available
• Provide Gram Negative ABx BEFORE
PROCEDURE if suspecting UTI
• POCUS >>> Blind

42. Suprapubic Catheterization
The Procedure –Part 1
1. Gather supplies
2. POCUS
3. Syringe/22g spinal
needle + 1% Lidocaine
4. 2cm above pubic
symphysis
5. 10-20 deg. Inferiorly
6. Advance-Aspirate-
Infiltrate… Until GOLD!

43. Suprapubic Catheterization
The Procedure –Part 2
1. Stabilize the needle
and remove the
syringe
2. Pass the guidewire
3. Make an incision
4. Follow through per
your specific kit.
5. Feed Foley through
sheath, inflate balloon,
remove sheath

44. Suprapubic Catheterization
Harm Reduction
• Wait for the bladder to fill
• Use POCUS for dynamic guidance
• If performing blindly, WAIT FOR THE BLADDER TO
FILL.
• Extreme caution in patients with
abdominal/pelvic surgical hx, adhesions, scarring,
etc.
• WAIT FOR THE BLADDER TO FILL

45. Priapism – Also an Emergency
• High Flow: Rare, usually a/w trauma, non-
emergent. PAINLESS.
• Low Flow: Most common type, ischemic. ED
management required. PAINFUL.
• Medical Management: SubQ or PO Terbutaline
• Invasive Management: Injections vs
Aspiration+/-Irrigation

46. Priapism
Making the Dx:
– Cavernosal blood gas: pO2<30, pCO2>60, pH<7.25

47. Priapism
Gather your supplies:
1. Anesthesia (1 cc syringe, 27g needle, 1% Lido w/out
Epi)
2. Sterility: Drapes, gloves, mask, betadine, 4x4’s
3. Injection: 25g needle + 3 cc syringe
4. Aspiration: 19g butterflies and 30 cc syringes
5. VBG Syringe
6. Meds:
1. If simple injection: 0.5 mg Phenylephrine + 2 ml Saline
2. If irrigating: Phenylephrine 10mg in 500 ml Saline

48. Priapism
Techniques
• Simple Injection
– 25g or 27g needle + 3cc syringe
– 0.5 mg Phenylephrine + 2 ml Saline
– Aspirate to confirm location then inject at 10 or 2
o’clock positions, base of penis
– Repeat q30 minutes x 3 injections total
• Aspiration/Irrigation

49. Simple Injection
http://www.emed.ie/Abdominal/Genitourinary/Priapism.php
The Procedure
1. Analgesia/Anesth
2. Cleanse and Drape
3. Inject q 20 min (up
to 3x)
4. Observe
detumescence

50. Aspiration/Irrigation
The Procedure
1. Analgesia/Anesth
2. Cleanse and Drape
3. Insert 19g-21g butterfly into one
corpus under aspiration, stop
advancing when blood returns
4. Stabilize needle
5. Aspirate 30cc under gentle negative
pressure while squeezing penis,
continue until RED BLOOD.
6. Reassess
7. Irrigate (20-30 ml IN-and-OUT)
8. Compress?

51. Today’s Procedures
• Urethral Catheterization
– Simple & complex (edema, buried, stricture, BPH,
prolapse)
– The nondeflatable balloon
• CBI
– Manual or by gravity
– Assure that volume IN = volume OUT
• Phimosis and the Dorsal Slit
– Usually not an emergency

52. Today’s Procedures
• Urethral Catheterization, CBI
• Phimosis and the Dorsal Slit
• Paraphimosis
– EMERGENCY!
– Manual Reduction
– Sweeten the Deal
– The Ice Glove
– Puncture
– Babcock
– The Dorsal Slit

53. Today’s Procedures
• Urethral Catheterization, CBI
• Phimosis and the Dorsal Slit
• Paraphimosis
• Suprapubic Catheterization
– It’s just a modified Seldinger
– 2 cm above the Pubic Symphysis, aim down 10 deg.
– If no kit, use a CVC kit
– Use POCUS
– If no POCUS, wait for the bladder to fill!

54. Today’s Procedures
• Urethral Catheterization
• Phimosis and the Dorsal Slit
• Paraphimosis
• Suprapubic Catheterization
• Priapism
– Low flow = Pain = EMERGENCY
– Simple injection 25g (0.5 mg Neo + 2 ml Saline)
– Aspiration/Irrigation
• 19g butterfly + 30 cc syringe
• Aspirate 30 cc and then until bright red blood
• Irrigate (Neo 10 mg in 500 ml Saline)

55. A General Approach to Procedures
Informed Consent (Written or Verbal)
Gather Your Supplies
Anesthesia/Analgesia
Prepare Kit
Sterility
The Procedure
Reassessment and Follow Up

56. Have Mercy! The Case for Penile Anesthesia
Topical Local Regional
EMLA upon arrival
for priapism
Urethral Viscous
Lidocaine for cath
Ring Block
•25g needle at
base of penis, into
Buck’s Fascia.
•Stay out of
corporal bodies
(aspirate).
•Inject
circumferentially.
Dorsal Nerve Block

57. More GU Procedures To Know
• Bartholin Cyst I&D
• Manual Testicular Detorsion
• Retrograde Urethrography

58. Image Credits
All non-clinical images were found using the “labeled for reuse”
Google search tool.
All clinical images, except where otherwise noted, are from:
• Roberts, James R., Catherine B. Custalow, Todd W. Thomsen,
and Jerris R. Hedges. 2014. Roberts and Hedges' clinical
procedures in emergency medicine.
If any copyright infringements are found, contact the author for
image removal.