Meatal Dilatation for Male strictures or stenosis

Gastroenterology & Endoscopy News - Leg Stimulation Fails in Trial of Fecal Incontinence Treatment

Gastroenterology & Endoscopy News - Leg Stimulation Fails in Trial of Fecal Incontinence Treatment

Prevention of Catheter-Related Bloodstream Infections, 2015

In the television show The Sopranos, a later-season plot involved the owners of a trash collection company that had to keep the mob boss, Tony, on the payroll in to stay in business. This arrangement persisted for years, until the son of the owner took over and could not understand why he had to let Tony siphon off his profits just to keep the company open.

Similarly, health care–associated infections (HAIs) once appeared to be just the “cost of doing business” for practitioners in the hospital, a risk that patients were subjected to in order to receive the benefits of intensive interventions siphoning off the gains made in the outcomes of critically ill patients. Much like the extortive mob boss, HAIs were expensive, costing as much as $4.5 billion per year,1 and ruthless killers, causing nearly 100,000 deaths annually.2 Much of these costs can be attributed to catheter-related bloodstream infections (CRBSIs), which account for 11% of all HAIs.

Infectious Disease Special Edition - Prevention of Catheter-Related Bloodstream Infections, 2015

Reducing the Neonatal risk of knotting in fine bore drainage tubes.

Catheterisation of neonates and babies is common and due to the size of the urethra feeding tubes (sizes 4ch to 6ch) are often used which can lead to potential complications such as spontaneous knotting of the tube within the bladder. Although uncommon, 0.2 cases per 100,000¹ catheterisations reported, it is important to understand the factors which are believed to contribute to the risk of knotting and ensure steps are taken to minimize this happening.

Babies born with disorders such as myelomeningocele or other congenital cord lesions such as sacral agenesis will often present with a neuropathic bladder. Pre 1950’s babies born with such disorders often died until shunting devices were developed but it wasn’t until the 1960s and 1970s that the ‘neuropathic bladder’ was identified as a complication of these disorders and surgery such as a vesicostomy, ileal conduit or ureterostomy were performed to protect the upper tracts and kidneys. Renal impairment had been reported within 6 months of age and as prevention of renal damage is a priority management of the neuropathic bladder must start at birth with an aim to replicate, where possible, normal bladder function. Clean intermittent catheterisation combined with an anticholinergic has been identified as an effective initial form of management, however, this may lead to potentially more cases of spontaneous knotting from ‘catheterising’ being reported if people are not aware of the complication.

The first reported case of knotting following transurethral catheterisation was reported in 1976² with further cases being reported, more commonly in neonates and children and mostly boys with almost all cases reporting the use of a feeding tube having been used.

Feeding tubes are often used as are they are available in smaller sizes than catheters with 4Fr/Ch and 6Fr/Ch being commonly used. However, feeding tubes tend to be much longer than catheters with lengths of up to 125cm, encouraging clinicians to insert more tubing than necessary into the bladder.

Feeding tubes and catheters sizes 6Fr/Ch and under are very fine and flexible, when excessive tubing has been introduced into the bladder it can form a loop, then as the bladder decompresses, the tubing can become knotted or entangled. When it comes to removal of the tubing, the loop/knot may tighten as it meets resistance on withdrawal making removal of the catheter urethrally traumatic or impossible requiring surgical intervention.

Most reported cases felt the risk of knotting could be avoided or prevented with a better understanding of the urethral anatomy in neonates and young children and selecting a more suitable catheter.^3,4,5

A new-born male urethra measures approximately 5cm and increases to about 8cm by the age of 3. The female urethra is much shorter and has a slower development time measuring approximately 2.18cm at birth, increasing to around 2.54cm by the age of 5. It is therefore recommended that no more than 6cm of length should be inserted into a male new-born and 5cm in a female and in babies with very low birth weight <750 grams, <5cm should be inserted in boys and <2.5cm in girls.³

In addition, clinicians should be encouraged to pass a catheter until urine starts to flow and then introduce the catheter approximately another centimetre to ensure the catheter is positioned in the bladder without excess.

Where possible the catheter should be passed, the urine allowed to drain and the catheter removed, however, there are incidences when the bladder may need to be on continuous drainage. When left in situ it is important to secure the catheter effectively to prevent inadvertent advancement of the catheter into the bladder.⁴

Wymedical have launched a size 5Fr/Ch catheter, at the request of a Paediatric nurse, which is 25cm in length to try to overcome the temptation of introducing an excessive length of tubing into the bladder and therefore reduce the risk of knotting and licensed for purpose. The Wycath uncoated catheter, WUP05, is DEHP free and is available on prescription enabling parents of new-born babies to be able to undertake intermittent catheterisation from birth and reduce the risk of damage to the upper tracts. The families can be discharged from hospital and managed at home under a close eye of a urology team until further surgery is required.

References

1.       Foster H, Ritchey M. Bloom D. Adventitious knots in urethral catheters: report of 5 cases. J Urol 1992; 48 1496-8

2.       Harris VJ, Ramilo J. Guide wire manipulation of knot in catheter used for cysto-urethrography. JUrol 1976; 116 529

3.       Carlson D, Mowery B. Standards to prevent complications of urinary catheterisation in children: should and should knots. J Soc Pediatric NUrs 1997; 2:37-41

4.       Arena B, McGillivary D, Dougherty G. Urethral catheter knotting: be aware and minimise risk. Canadian Journal of Emergency Medicine 2002; 4(2): 108-110

5.       Sarin YK.Spontaneous intravesical knotting of urethral catheter. APSP J Case Rep 2011; 2:21

Why is their a lack of catheter innovation?

Excellent article by Prof Mandy Fader.

http://www.bbc.co.uk/news/health-33256507

Unfortunately some of the difficulties in smaller businesses introducing innovation is the patents held by the larger organisation. Wymedical has introduced innovation with improved catheter tip technology and quality coating to ease patient comfort and trauma. Coloplast however own a patent on packaging and refuse to allow Wymedical (and other smaller companies) to package their innovative catheters in a package suitable for patients with dexterity issues, as often elderly patients suffer with.

This leads to patients wanting to use the new catheters more suited to their situation (one catheter doesn’t fit all requirements) but having difficulty simply getting the catheter out of the packaging due to some large corporate blocking companies because they own a ridicules patent.

Similar issues will occur with any Bio technology more likely to be developed by smaller innovative businesses. There are over 7.500 patents related to catheter with a significant number around the packaging of a catheter. The patent process was aim to protect innovation, but more often these days it’s used for large corporates to protect their profits and restrict innovation.

What is the incentive of a small business to spend hard earn revenue on R&D for Bio technology if a larger corporate such as Coloplast can block the innovation because of the way the catheter is packaged.

As the article points out there is little incentive for the large corporates to innovate with catheter technology when huge profits are being made out of the existing catheters. Better to put the R&D budget into other areas while you can block innovation through poorly approved patents on something as basic as how you package a catheter.

How can this be to the benefit of patient care and innovation?  

WyCath H2O Intermittent Catheterisation Male

Conference Exhibitee to Exhibitor

 

25 years ago I was a continence advisor attending the ACA conference, if I was asked back then what I would be doing now I wouldn’t have said running my own company and exhibiting at conference.

The first ACA conference I attended was in Scarborough, having previously worked in a hospital environment and been appointed as a continence advisor in the community attending a conference was very different if not a little overwhelming.

Back then the ACA conference was run differently, each branch took turns to organise the annual conference. I remember being on the organisers committee when the London branch hosted the conference in Bournemouth and I am still in possession of my t-shirt.

As a clinician I looked to the ACA conference to update my clinical skills and also my knowledge of the products on the market, not just new products but to refresh myself on existing lines. It was a great opportunity to network with other clinicians and to reflect on my practice and not forgetting collecting post-it notes and pens!

As an exhibitor many of my objectives remain the same, I still look to keep my knowledge up to date and enjoy listening to some of the speakers of areas within continence and urology which are still of interest to me.

Exhibiting at a conference for any company is a big financial commitment, however, it can be beneficial. As a small company, we have to weigh up the benefits of supporting a conference, I do not have a salesforce so conferences enable me to see clinicians whom I may not have met and to catch up with those I haven’t had the opportunity to visit for a while. However, I often leave conferences disappointed when I look at the delegate list and note that only a fraction of the attendees have visited. As clinicians roles are forever changing keeping abreast of all products within the speciality of continence and urology can only improve patient care.

It is easy to be lured to the big stands, however it is often the smaller companies who bring to market innovative niche products which can bridge a gap and make the biggest impact on the patient.

Please try and take time to visit all the stands big or small as you never know what could be lurking in the corners…..