French Structures: A Manual for Advanced Students
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In the unlikely event that the phimosis is too tight to allow any catheter, then a bedside surgical dorsal slit procedure may need to be done by Urology.
Conditions of Use
Most likely you are dealing with a stricture of the meatus meatal stenosis or the very distal urethra fossa navicularis. The first thing to try is a 12 French Silicone Foley catheter. Silicone catheters are relatively stiff and have narrow walls providing a reasonably good drainage lumen even from such a small catheter. Once passed, the catheter can be changed to a larger size every hours which will gently dilate the stricture painlessly. If not successful, then some type of dilation procedure will be needed. In general, dilation with balloon dilators or metal sounds should be left to the Urologists, but there is one technique that can be tried before giving up.
If this dilator can pass the obstruction by just one or two centimeters, it should then be possible to pass the 12 French Silicone Foley catheter. The guide wire can also be used to help stiffen the silicone catheter, if necessary.
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If this fails, you will probably need to call Urology for help. Proximal urethral obstruction in men could be from previous infections, instrumentation, surgery, scarring, trauma, false passages or cancer. Rarely is it due to BPH alone. When encountered, the most important thing to remember is not to force the catheter too hard!
The natural tendency is to push harder and try to make it go in, but this is only likely to create a false passage and make it more difficult to actually get the Foley safely into the bladder. This instrument uses a specially designed catheter that includes a fiberoptic light source and camera. This is attached to a mobile cart with a processing unit and monitor so the operator can visually see the progress of the catheter and whatever the difficulty or obstruction might be.
Most of the time, this is sufficient to allow successful passage of the catheter. Its use will substantially reduce unnecessary patient urethral trauma, pain, bleeding, length of stay and catheter associated urinary tract infections CAUTIs. This catheter has a slightly rounded ball tip and a curve. To insert, the curve should always be facing upwards or ventrally. Most of the time, this orientation will allow safe passage but again it should not be forced.
The urethra can be prepped with 10 — 20 cc of Lidocaine Jelly or plain lubricant injected via Toomey syringe.
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A gentle rocking or twisting motion, right to left and back again, along with slow, steady pressure is generally the most successful technique for passage in difficult cases. If this fails, try a 12 French Silicone catheter. Latex catheters of this size are too floppy for easy insertion and lack adequate internal lumen size compared to the pure silicone. The guide wire will either pass into the bladder or will encounter an obstruction and come back out the urethra. If the guide wire passes, you can try sliding the 12 French Silicone catheter over the guide wire.
The angio-cath is passed through the distal catheter eyelet and then pushed out through the solid Foley tip. With the metallic needle removed, the plastic angio-cath sheath will just allow passage of an 0. Irrigating the catheter lumen with water will help the guide wire pass through more easily. Then the catheter can be advanced over the guide wire and into the bladder.
If still not successful, call for Urology help. These tools can cause great damage and harm if not used properly by experienced surgical professionals and are best left to the Urologists. Catheter-associated urinary tract infection CAUTI is a catheter-associated complication, in which the duration of catheterization generally determines the development of bacteriuria.
The Infectious Disease Society of America guidelines define CAUTI in patients with indwelling urethral, indwelling suprapubic, or intermittent catheterization by the presence of symptoms or signs compatible with UTI and no other identifiable source of infection. The best way to limit CAUTI is to limit the need for catheterization, including catheter removal as soon as it is no longer required. An indwelling urethral catheter should be inserted using aseptic technique and sterile equipment.
Disconnection of the catheter junction should be minimized and the drainage bag along with its connecting tube must be kept below the level of the bladder. If concern for a CAUTI exists, a urine culture should be obtained from a freshly placed catheter prior to the initiation of antimicrobial therapy. If the catheter can be discontinued, a culture should be obtained from a voided midstream urine specimen, prior to the initiation of antimicrobial therapy. Paraphimosis results when the phimotic male preputial tissue foreskin is left retracted behind the glans, resulting in painful glandular edema and distal penile strangulation.
Usually it is challenging to reduce the foreskin in many cases, secondary to the edema. This condition is best avoided by ensuring the foreskin is reduced back over the glans, immediately after catheter placement on all male patients who are uncircumcised. This is extremely important to remember and make it a routine part of every catheterization procedure. Should a paraphimosis occur, reduction of the glans will need to be performed. This can usually be done manually.
If there is substantial edema and swelling preventing a manual reduction, using an elastic wrapping around the edematous portion of the penis, as described previously, is quite helpful. Ultimately, if manual reduction is not possible, an emergency dorsal slit procedure can be performed to permanently open the strangulating ring of the phimotic foreskin and relieve the ischemia. Bladder perforations rarely happen during routine Foley catheter placement, although when it occurs it is a very significant adverse event. Intraperitoneal bladder perforation can result in peritonitis, manifesting with guarding and a rigid abdomen on physical exam.
One should be suspicious in cases of continuous bladder irrigation where the inflow volume does not closely match the outflow volume. If suspicious, a cystogram X-ray would confirm the diagnosis. Bladder perforation may require exigent surgical repair and should be evaluated urgently by a urologist. It is always disconcerting to urologists when we are called to correct a Foley catheter problem that was preventable. These include mal-positioned Foley insertions by health care personnel as well as complete or incomplete traumatic catheter removals, usually by disoriented or confused patients.
The first indication of an incomplete insertion or Foley malposition is usually a lack of urinary drainage. Lack of urine drainage could be from low urine production dehydration, excess anti-diuretic hormone, acute tubular necrosis, renal failure, etc. A bladder scan can be used to determine if a Foley is not draining as there should not be any significant bladder residual if the catheter is working properly. If there is any doubt about the final position of the Foley, a formal bladder ultrasound is usually conclusive. Failure to easily irrigate fluid through the catheter is an indication of a problem.
If fluid irrigates in only and cannot be extracted, most likely there is a clog in the catheter somewhere and it should be removed and replaced. If the Foley is mal-positioned, often the irrigation fluid will leak out around the catheter. If this occurs, the Foley should be replaced although it can be repositioned without replacement in some cases.
This is just the visualization and exposure of too much of the Foley being visible beyond the tip of the penis. Normally, this should be no longer than the maximum span of your fingers from the tip of the thumb to the pinky with the hand spread completely out, which is typically about 9 inches or 23 cm. If the Foley has been traumatically removed, usually by a confused patient or by accident, the most important thing to do immediately is to examine the catheter balloon for any missing pieces.
Such balloon fragments or pieces can stay in the bladder and will form bladder stones if not removed. If the balloon is still intact, then at least there is no worry about missing balloon pieces. In general, it is recommended that a Foley catheter be replaced after complete traumatic removals, especially if there is significant bleeding. A 3 way catheter is almost never required as the bleeding is usually from the urethra and will usually stop with a simple Foley catheter replacement. If there is significant bleeding around the catheter, this can be managed by a penile tourniquet around the distal portion of the penis.
A rolled up dressing sponge or 4 x 4 pad works well as it safely spreads out the tension from the tourniquet. It should not be secured by a complete knot but only by a single half hitch throw to avoid unnecessary tension from the tourniquet. It should be removed after hours which almost always stops the bleeding. After traumatic extractions, replacement Foley catheters are typically left in place for days. If bleeding is not excessive, replacement of the catheter is not mandatory as sometimes trying to replace the Foley can cause additional trauma. The original reason and purpose of the catheter needs to be reviewed before reaching a final decision to leave the Foley out.
Use of antibiotics is optional in these situations but a short course of days would not be unreasonable. The most important step in preventing traumatic Foley catheter extractions is to first identify those patients at risk. Patients who are confused from dementia or anesthesia are probably most at risk, but other risk factors include any altered mental state, seizures or head trauma. Obviously, any patient who has previously traumatically removed his catheter is at increased risk to do it again!
Patients with Foley catheters are also at risk when being moved from the OR table to a bed or gurney. If the catheter and catheter bag are not secured properly, the Foley can be accidentally ripped out! Traumatic catheter removals can take place anywhere, but the ICU and Recovery Rooms are particularly prone to these events and should take extra precautions.
There are significant negatives to these measures. Sedation is not always a good choice medically for patients on multiple medications or where their neurological status needs to be closely monitored. Physical restraints can anger or terrorize patients, may not always be adequate and carries additional burdens of documentation. These include the following:.
It is recommended that nursing staffs be instructed in these measures and encouraged to utilize them when appropriate, particularly in high risk patients, to help minimize these painful and harmful events. These catheters can be placed via open surgery but are increasingly done in percutaneous fashion.
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There are a number of commercially available kits, which come with most of the supplies necessary for a bedside percutaneous placement. Percutaneous suprapubic tube kits are most appropriate for patients with acute retention, found to have palpable distended bladders on exam, where urethral access to the bladder for a standard Foley is diminished. They are also recommended as the route of choice when bladder drainage is required and a urethral catheter cannot be passed i. Other advantages of suprapubic tubes include increased patient comfort in patients who need permanent catheterization, ease and comfort of exchange, especially in those with extremity contractures and challenging external genitourinary anatomy; in addition, suprapubic tubes offer lessened morbidity in patients at risk for traumatic self-removal of catheter, prevention of penile trauma, urethral stricture formation, prostatic bleeding, penile erosions, urethral erosion and development of a patulous urethra in women, and less interference with sexual activity.
A Cochrane Review examined urethral and suprapubic routes for short-term catheterization in hospitalized adults; the study found, albeit admittedly based on low-quality evidence, that suprapubic catheters reduced the number of participants with asymptomatic bacteriuria, re-catheterization, and pain compared to indwelling urethral catheters. Evidence regarding symptomatic UTIs was inconclusive.
Suprapubic tube placement can have a significant adverse outcome, such as a bowel perforation, if not performed correctly. These catheters are contraindicated in the setting of bladder cancer, unavoidable bowel loops in the anticipated field of passage, uncorrected coagulopathies, presence of a subcutaneous vascular implant in the suprapubic area i. Replacement of a suprapubic tube within the first two weeks of placement should only be performed by personnel knowledgeable of these catheters usually the person that placed it initially.
A newly formed cystostomy tract is very easy to lose if the catheter is not replaced quickly and correctly.
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Subsequent to the first change, if done carefully, almost anyone can successfully replace suprapubic tubes. The catheter should be replaced with a same-size catheter used previously and 5-mL or mL balloons should generally be utilized. One should prepare and cleanse the suprapubic site with the old catheter in place. The old suprapubic tube balloon is then deflated and removed.
Briefly examine the old suprapubic tube to visually identify the distance between the catheter tip and its exit point at the skin the internal portion might be lighter in color compared to the external portion which will be darker due to oxidation. The cystostomy site should then be prepared, cleansed and prepped with antiseptic solution.
Lubricating jelly is applied to the new catheter tip and an attempt should be made to pass the catheter in a distance, similar in length to the placement of the previous suprapubic tube. If passed too far beyond the bladder neck, the balloon may be inflated in the prostate or urethra; if not passed far enough, the balloon may be incorrectly inflated in the suprapubic tract itself, not the bladder. There should not be any pain when inflating the retention balloon. Pain with inflation of the retention balloon or feeling resistance during balloon inflation are usually indicators that the catheter may not be in the correct position.
Irrigation of the catheter just after placement confirms correct placement if the catheter can be irrigated easily. This also rinses out debris and mucus from the bladder.
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It is not uncommon to see granulation tissue at the cystostomy tract on the lower abdominal wall. Silver nitrate sticks can be used to cauterize this tissue to prevent bleeding. Mucous-like drainage around the catheter at the suprapubic site is usually of no concern, unless associated with overlying erythema or other signs of infection, and can be managed with routine hygiene measures.
If a suprapubic tube is removed in planned or unplanned fashion , it should be replaced quickly as the suprapubic tract, even when mature, can quickly close within hours and prevent simple replacement, necessitating another surgical procedure to replace it. Familiarity with the fundamental principles underlying bladder drainage is important to all medical providers caring for patients in clinical environments where catheters are being placed, replaced, and removed. While urologists should always be a resource for questions related to catheters, patients receive better care and suffer less morbidity when the entire medical team has good understanding of how and when to safely achieve bladder drainage.
Acute urinary retention, defined as the sudden, complete inability to void, is often associated with suprapubic pain and tenderness. Chronic urinary retention or incomplete bladder emptying is clinically associated with urinary frequency, overflow incontinence, or impaired renal function. It is usually caused by prostatic enlargement, outflow obstruction such as from strictures, or atonic bladder disorders.
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When present, bilateral hydronephrosis is frequently associated with chronic urinary retention. Gross hematuria and clot retention have a multitude of possible etiologies, but common causes include prior traumatic Foley catheterizations, prostate enlargement, or a bladder tumor. Urosepsis with incomplete bladder emptying. High voiding pressures such as from an obstructing prostate or neurogenic bladder.
Use in lengthy surgical procedures where it is anticipated that the bladder would otherwise become overdistended and possibly damaged. Clinical situations where strict fluid inputs and outputs are required and the voiding record cannot otherwise be reliably determined. Contraindications to Foley Catheter Placement: Urethral catheter placement is absolutely contraindicated in cases of known or suspected urethral injury, such as in the setting of a pelvic fracture.
The Different Catheter Types Catheters come in sizes that measure the outside circumference in mm. Most catheters are made of silicone or latex but some straight catheters are also made from vinyl which tends to be stiffer and more rigid. John Smith, FWS. Plus :. Click here to see the difference between instructor-led vs independent study format. This study format includes:.
All FWS program providers teach from the same Wine Scholar Guild-developed Powerpoint presentations and are supplied with uniform teaching materials. For many, the classroom experience helps to hammer home the theory; a tutored tasting component brings each region to life. The page, full-color study manual 6th Edition provides all the information from which the test questions are derived.
You do not need to research you own study materials; everything you need to know is in the manual. Plus : A Foundation Unit covering: French wine law, grape varieties, viticulture, viniculture and a discussion of Old World vs. New World wine styles. The FWS online study modules offer interactive presentations that are put into a measurable, meaningful format designed for maximum retention of content and ease of use.
Each region of France is covered and dovetails nicely with the French Wine Scholar study manual. Industry Testimonials "The French Wine Scholar manual has once again proven why the Wine Scholar Guild is one of the best wine education programs in the world. What I particularly found helpful was the background information at the beginning of the manual. The detailed information on the vineyard cycle, the effect of temperature and wind, the vineyard pests and plagues, understanding different trellising methods, etc. The manual clearly explains the methods for both vineyard and winery work, which allow the student to fully appreciate the French wine regions.
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I have found many students are visual learners, and the quality of maps used by the French Wine Scholar manual are incredible. It really helps in understanding the material more thoroughly. I found the manual to be very well organized, enjoyable level of detail and a study guide I will continue to recommend. Thank you for sharing this manual with me. Indispensable for any wine trade professional who works with French wine. About Jessica: My passion for wine, and in particular French wine, was born during a French wine and cheese pairing workshop on a trip to Paris in I passed the WSET level 2 course with merit in the summer of Because my goal is to help people discover French wines through my tours, the French Wine Scholar certification was the next logical step.
It allowed me to dig deeply into the major winegrowing regions of France while providing a solid base of technical knowledge of winemaking processes, geography and soil science, insight into the wine industry, and even the continuing role of climate change in winemaking. FWS gave me an organized and methodical way of fitting all of these pieces together to allow me to explore both the big picture of French wine, and also what is happening on a regional level.
In , I plan to enroll in the WSET level 3 to zoom back out to a global level, and then complete some of the French regional Master-level courses, particularly those for my area of France - like the Sud de France Master for Languedoc-Roussillon. Hopefully there will also be a SW France Master course in the future!
The confidence and knowledge I gained through the FWS program will allow me to help people connect to French wine by cutting through the confusion and mystery and highlighting what is truly special and inspiring. Jessica Hammer, FWS. Disclaimer: WSG offers wine study courses that are targeted to both beginners and those more experienced in the wine industry.