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The difficult catheter placement: can we protect hospitalized patients from iatrogenic catheter injury and reduce unnecessary urology consults?
Charlotte Q. Wu, MD, Nnenaya Q. Agochukwu, MD, Roland Assi, MD, David G. Hesse, MD.
Yale New Haven Hospital, New Haven, CT, USA.

BACKGROUND: Foley catheterization is a necessary and sometimes life-saving procedure for many patients. Factors that lead to perceived difficult foley insertion by hospital staff may be related to patient co-morbidity, prior urologic history or lack of proper insertion technique. Here we examine factors common to patients whose catheters could not be inserted by hospital staff, or who were traumatically catheterized. METHODS: In a five month period, 52 patients were prospectively identified to have difficult catheter insertion defined as a request for urology consultation. Patient factors assessed included sex, age, BMI, and urologic history with particular attention to BPH, stricture, and/or prostate surgery in men. Non-patient factors assessed included consult reason, number of catheter attempts by staff, and presence of iatrogenic injury. A foley insertion score of 1-3 was assigned based on difficulty of insertion by a junior urology resident or urology PA with: 1-easy insertion, 2- difficult insertion, 3- highly difficult insertion with need for urologic interventions. Statistical analysis with Chi-square was used to characterize and compare the groups. RESULTS: 11 (21%) female and 41 (79%) male patients were identified. Average age was 73 years. 32/52 (62%) had foley score of 1. 20/52 (38%) had foley score of 2-3, which was significantly associated with male sex (p=0.02), positive urologic history in men (p=0.0079), stricture history (p=0.0018), and history of prostate surgery (0.02). There was no significant association between history of BPH and foley difficulty score (p=0.5). In women, the most common reason for foley consult was perceived unusual external anatomy, though only 1/5 had unusual anatomy. Traumatic insertion was the reason for consultation in 6 cases with 2/6 requiring cystoscopic intervention. All traumas had BPH, and 50% of all BPH patients had trauma versus 1/27 (4%) of patients without BPH, p=0.0005. Having urologic history was not associated with trauma (p=0.15), nor was history of stricture (p=0.15), or history of prostate surgery (p=0.5). There was no difference in nursing catheterization attempts of easy insertions (24/32; 75%) versus difficult insertions (15/19; 79%). CONCLUSIONS: Patients with truly difficult foley placement who warranted urologic consultation were men with history of stricture or prostate surgery or men with complex genital anatomy. Medical staff should be wary of this when attempting catheterizations on these patients, and urology consultation should not be delayed. Patients with easy insertions were typically female with perceived unusual external anatomy or limitations of body habitus. A number of unnecessary urology consults may be avoided by targeting education initiatives to address these issues. BPH was significantly associated with iatrogenic catheter injury though was not associated with ease of foley catheter insertion by urology. Additional educational initiatives should target proper foley insertion technique on BPH patients.

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