Suprapubic Revisited

Q. I’m 36, female and going on my 20th year as a C5-6 complete quad. I’ve used an indwelling Foley catheter since my injury. Within the last two years I’ve been struggling with leakage of urine almost every day, and the balloon of the Foley comes out through my urethra at least once a week. This is very painful and gives me cold sweats and horrible headaches.
 
Also, my catheter keeps getting plugged up with sediment even though I drink enough fluid. When it gets plugged up, it barely drains, which causes excessive abdominal spasms and unbearable pain.
 
This is leaving me exhausted and frustrated and is making it difficult to go about my normal work week.
 
Despite all my problems, my urologist has not offered any suggestions. I researched bladder management options and think that a suprapubic catheter would alleviate many the problems that the indwelling Foley has caused.
 
My concerns with a suprapubic are that I wear a lumbar sacral support corset for my scoliosis. Is it possible to wear a corset with a suprapubic? Will the pressure created by the corset cause leakage? Will I be able to get into a bathtub or swimming pool with the suprapubic catheter? Will the abdominal spasms lessen with a suprapubic catheter?
 — Claudia

A. Claudia, the first thought that comes to mind when a urologist hasn’t offered any options after going through all the problems you describe is that — in my opinion — you should consult with another urologist, preferably one that has experience in working with people with spinal cord injuries.

To answer your questions, let’s start with the Foley catheter. Paula Wagner, a urology nurse practitioner from U.C. Davis Medical Center in Sacramento, Calif., says her office generally advises patients with neurogenic bladders that an indwelling Foley is not a good long-term option for anyone. Unfortunately, the problems you are having with your indwelling Foley are a classic example of why. Once the sphincter and urethra get stretched to the point that the balloon at the end of a Foley comes out, especially if it happens more than once, it is likely to keep happening.

Wagner points out that there are exceptions: When a Foley is working for a person long term, as the saying goes, “If it ain’t broke, don’t fix it.”

In answer to your questions about a suprapubic, the official name for the procedure is suprapubic cystostomy. The procedure consists of a 10-minute surgery that creates a hole just below the belly button, directly into the bladder. A Foley catheter is placed in the hole and urine drains into a collection bag. After surgery, the Foley stays in for four to six weeks — until the hole scars up and heals to create what looks like a “bladder piercing.” Once the suprapubic hole has healed, the Foley gets changed once a month.

Activities like bathing and swimming are no problem with a suprapubic. Manufacturers that make Foleys also make plugs that fit into the end of the catheter. When you want to bathe or swim, simply disconnect the Foley from the collection bag, plug it, and hop in the tub. Or if you are going swimming, just tuck the Foley into your swimsuit.

As far as wearing a support corset with a suprapubic catheter goes, there are a couple of things to think about. In order to get it to work with the suprapubic, all you have to do is make a hole in the support corset where the suprapubic catheter comes out — then fit the corset over the hole and run the Foley through it.

Whether the corset — or stress incontinence from coughing, sneezing or laughing — will make you leak after you have a suprapubic is difficult to tell until after you have the procedure. Suprapubic Foley catheters are large, generally 20Fr, 22Fr, or 24Fr in width. Since a wider catheter also has larger “eyes” (holes at the bladder end of the catheter) there is very little resistance for the urine to flow out of the suprapubic, and urine will always take the path of least resistance.

Unfortunately, gravity also plays into the leakage equation, and the urethra is at the bottom of the bladder. Because your urethra and sphincter have been stretched from long-term indwelling Foley use, it may be that a suprapubic catheter alone will not stop the leakage. If leakage still happens, an option to discuss with your urologist would be a midurethral sling. This is a minimally invasive surgical procedure that places a synthetic sling under the mid part of the urethra. The sling compresses the urethra to help stop leakage — similar to stepping on a garden hose to stop water from flowing through it. According to journal articles, the surgery can usually be done on an outpatient basis, and the surgical procedure itself takes about 30 minutes.

Concerning the amount of sediment in your bladder — unfortunately a suprapubic isn’t likely to decrease it. Wagner says a person can be doing everything right and still have sediment in the bladder. Some people never have sediment and some people do; a lot of it comes down to luck of the draw — genetics. Still, because a suprapubic Foley is larger and the “eyes” are larger than an indwelling Foley (indwelling Foley’s are usually between 14Fr and 18Fr), sediment may pass through it.

If sediment is still an issue with the suprapubic Foley, Wagner offers several options to discuss with your urologist. One is draw saline into a sterile 60cc syringe (you can use distilled water if your insurance doesn’t cover saline), disconnect the Foley from the collection bag, insert the syringe into the end of the Foley and inject the solution, flushing the catheter clean. Then draw back on the syringe and pull out all of the solution and sediment. Do this once a day and it should help keep the sediment at bay.

Another option Wagner suggests discussing with your urologist — especially if you are having repeated urinary tract infections — is injecting a prescription mix of Neosporin Gu (liquid Neosporin antibiotic) and sterile saline. You add 1cc of Neosporin Gu to a 1 liter bottle of sterile saline and shake. Then pour out 40cc’s of the mixture into a sterile container, draw it into a 60cc syringe and inject it into the Foley and clamp the catheter for 30 minutes. Make sure to set an alarm — you never want to leave a urinary tube clamped off for too long, or you could have problems with reflux and/or dysreflexia.

The answer to your final question — will a suprapubic lesson your abdominal spasms?

Again I would discuss this with your urologist — however it would seem that the larger catheter and “eyes” combined with the above steps to keep the catheter from getting plugged with sediment would help urine flow and alleviate the abdominal spasms. Be sure to ask you urologist if the abdominal spasms are, in fact, bladder spasms — a urodynamics test will be able to determine this. If the spasms are bladder spasms, your urologist may suggest an anticholinergic (anti-spasm) drug like Ditropan.

If your urologist recommends an anticholinergic, be sure to ask about new drug called Gelnique, a topical gel that quiets the bladder like oral Ditropan but doesn’t have the side effects like dry mouth and fuzzy thinking that anticholinegics are notorious for. To find out more information on Gelnique, see the October 2009 Bladder Matters column.

Best of luck. As always, please keep us posted on how things turn out.

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