Is it appropriate to still expect that urinary catheter insertion is a basic skill all doctors are proficient in? There is reluctance by other hospital staff to insert urinary catheters due to perceived difficulty. This reluctance may result in deskilling of general hospital staff with exploitation of urology staff. We therefore evaluated referrals made to Urology within an academic tertiary hospital, with a focus on referrers' urinary catheter management.
Over 3 months, one urology junior clinical fellow recorded data on all their referrals. Non-catheter and catheter-related referrals were documented, with the latter's clinical indication, reason for referral and urological outcome examined. Referrals for catheter insertion were divided into simple or complex, based on associated procedures to successfully catheterise.
Over these 3 months, 215 patient referrals were collected from GPs, Emergency Department and other specialty staff. In all, 125 non-catheter referrals included ureteric colic, testicular/scrotal disease and pyelonephritis. The 90 catheter referrals were made by 74 doctors (mostly trainee grade) and 16 nursing staff (mostly Emergency Department).
For the catheter referrals, 42 of 90 (46.7%) were catheter insertion requests (Table 1) with 27 of 42 (64%) not attempting to catheterise before referring. Of these referrals, 30 had simple urethral catheterisations performed with eight other patients requiring complex catheterisation: flexible cystoscopic-assisted catheterisation (five patients), suprapubic catheterisation (one), urethrogram (one) and percutaneous nephrostomy (one).
|Simple catheterisation||Complex catheterisation||No catheter required||Total|
|Referrers not attempting catheter prior||18||5||4||27|
|Referrers attempting catheter prior||12||3||0||15|
The remaining 48 of 90 (53.3%) catheter-related referrals were management of indwelling catheters (IDC). IDC for patients admitted for urinary retention (18 patients), haematuria (12), recent urological surgery (five) and urine bypassing the catheter (five). Also, advice was sought on timing of trial without catheter (TWOC) for urethral or suprapubic catheters (eight).
The two most common indications for catheterisations were urinary retention (37 patients) and haematuria (27). Clot retention haematuria was managed with a three-way catheter irrigation, but 11 of 15 (73%) of these referrals requested urology to insert the catheter, of which five patients had a two-way catheter in situ. Referrals for urine output monitoring (10 patients), management of long term catheters (11) and postoperative urological patients (five) were managed in a standard way.
What can we learn and improve from our snapshot observation on the workload of Urology staff? Some referrers did not perform a bladder scan for residual volume, leading to patients being misdiagnosed with retention (residual volumes of <500 mL) and potentially having an unnecessary catheter. The use of a bladder scan must be encouraged to aid in the diagnosis and following management.
Gross haematuria management involves a three-way catheter and continuous bladder irrigation. In our institution, there was apprehension by referrers to insert three-way catheters as ‘they had never inserted one before’ and to commence bladder irrigation. Thus, most of these referrals either did not have a catheter placed initially or had a two-way catheter inserted. Three haematuria referrals were re-directed to the haematuria clinic from the Emergency Department. A ‘one stop’ haematuria clinic for both visible and invisible haematuria is efficient [1, 2]. The BAUS and the Renal Association published joint guidelines  advocating direct referral for visible haematuria to Urology for imaging and cystoscopy; this should be an outpatient investigation.
Referrers for bypassing of in situ catheters should first flush and/or deflate then re-inflate the catheter's balloon. If unsuccessful with associated suprapubic pain, anticholinergics can be prescribed for bladder spasm. A noteworthy cause can be catheter compression underneath the patient, which is both easily rectified and missed.
Non-negotiable blind urethral catheterisation was managed with cystoscopic assistance (five patients) compared with suprapubic catheter insertion (one). We performed one ward-based insertion of a suprapubic catheter without ultrasonographic guidance, as the patient's submeatal stenosis made cystoscopy impossible. The National Patient Safety Guidelines  and the BAUS , state the risks with blind trocar puncture suprapubic catheterisation and advocate ultrasonographic guidance.
Lastly, urology postoperative catheter referrals underwent TWOC within 2 weeks. These patients had in situ catheters and associated symptoms (bladder spasm, haematuria) presenting to Accident and Emergency. Operations included endoscopic resection of the bladder/prostate, robot-assisted prostatectomy and bladder fistula repair, necessitating direct urology input.
We would like to encourage junior staff to master basic skills in their clinical years to become capable interns  by performing enough ‘normal’ catheterisations so that ‘abnormal’ situations can be recognised. Table 2 shows basic catheter issue management for the junior reader's benefit. In our experience, referring teams initial management of common urological conditions, e.g. urinary retention and gross haematuria, showed poor understanding of the condition. Perhaps this is an effect of the increasingly litigious environment we practise in.
|Urology referral||Possible cause||Simple measures before Urology referral|
|Retention||BOO, neuropathy||Bladder scan, catheterise, TWOC with α-blocker in 1–2 weeks.|
|Haematuria||Trauma, tumour||Three-way catheter and irrigation (if clots ++), if voiding consider Haematuria Clinic.|
|By-passing catheter||Catheter blocked, bladder spasm||Flush or deflate/inflate catheter, anticholinergics.|
Urology nurse practitioners [7, 8] expanding their skill set could address common catheter-related issues that do not need the urology trainee expertise, the Accident and Emergency Department or in-hospital management .
In closing, evidence is presented on catheter insertion being considered a specialty procedure. A high dependence on urology staff to deal with urinary catheterisation, basic catheter management and clinical conditions requiring catheters is occurring. We hope to highlight a pressing need for improved education and training of medical students, junior doctors and nursing staff in the insertion and issues of simple urinary catheters. Otherwise, we may indeed find that urology has become a catheter service.