Wash out your mouth kid. Why don't you wash out your bladder pops?

Yeah, I know, it's been a long day and my creative juices have been reducing to a creative glaze but then got burnt. So you get that title instead. It's a pretty common trope, wash your mouth out with water for saying bad words as a kid. Or was that just me? Either way, my palate is exquisite. I can taste the difference between Dove bar soap, great value moisturizing bar soap, and every day essentials moisturizing soap. You wine connoisseurs have nothing on me. Funny think is, I never got my mouth washed out so take that as you will. It might be why I enjoy crayons so much. 

Without further ado, bladder irrigation, wash that sucker out. The patient is a 50ish year old male with a history of a TURP a few years ago but no other history. A few months back, he started to have some trouble with urinary retention and started to pass some clots before becoming totally plugged. I can't even imagine that, one of the great parts of life is being able to relieve yourself of a full bladder, drain the main vein as we say. At the time, there was nothing untoward on exam and he was given continuous bladder irrigation (CBI) which is a catheter with one lumen running fluid into the bladder, and one going out taking the fluid and urine out to a bag. Yet here he was again, several weeks later with another episode of inability to urinate. So back on the CBI. 

CBI is pretty commonly used to prevent clotting in the urethra, usually after prostate surgeries or if there is bleeding in the bladder or urethra. The constant flow should prevent clot build up and thereby prevent retention. So we hang some 3L bags of normal saline and start running it through the gentleman's bladder. The basic idea is to allow healing of whatever is bleeding, while preventing the aforementioned clots. So as the output becomes more clear and less cherry cool aide, hopefully the catheter can be taken out. Simplifying our job, was the fact he was alert and did not have any issues with sensation so he could tell us if something felt wrong. Between that, and making sure our output was at least equal to what had gone in, it was mostly stress free (for us). 

What if the patient can't respond? Rates of irrigation depend on the severity of the bleeding and risk of clotting. Even at 50mL/minute, an average 400-500mL bladder can fill in 10 or so minutes. Max capacity is about 700mL normally, so not all that big when you have a 3L bag running. That can get out of hand real fast if the catheter gets clogged or kinked, before you know it the bladder is too full and could rupture or at the very least be traumatized. Both of which are obviously bad, leading to pain and discomfort, to peritonitis, sepsis, and emergency surgeries and all the risks associated with that. So please, keep an eye on your folks who have CBI, especially if they are unable to communicate, which could be likely in an elderly patient with a UTI secondary to shoving things into his or her bladder. Before I forget, I don't know what happened as I was off the next two days so I hope he did ok. 

I mentioned the risk of UTIs due to shoving things places, which is an unfortunately common route of nosocomial infection. In 2021, over 24,000 hospital acquired UTIs were reported, and who knows how many were not? These can cause significant morbidity and mortality in certain populations and lead to an average extension of 4 days to a hospital stay. I would never, ever use an anecdote as proof but I think this is a good example. A gentlemen with a chronic foley, clot clogs up the catheter, comes in for the issue, they take his catheter out, can't get one in so they take him to the hospital yours truly works at. Urologist can't get one in, so he goes down to get a suprapubic one put in. As he went down to IR, his UA came back very positive for a UTI. And when he came back, his mental status deteriorated fast. I won't go more into it but his stay probably just got extended (insert self aggrandizing comment here). It's scary how fast some bacteria in your urinary tract can screw you up. 

All that to say be careful, I know they beat it into our heads as nurses to take care when doing peri care and really be diligent protecting the catheter as much as is feasible. The man in the paragraph above is the first time I have seen how fast an infection could turn a situation from bad to worse (thank goodness for my preceptor being a badass). There is a lot to talk about with the bladder, urinary tract, UTIs, and all that fun stuff, however that is for another time. I really think intravesical treatments are cool for some reason, even though it's basically just splashing stuff around the bladder. One article I saw presented a case of a MRSA UTI cured by CBI with vancomycin added to the irrigation bags. Is there a reason we don't do this now? I gotta look cause it makes sense to me, even if the article isn't that recent. Maybe you'll be lucky enough to get a future post about intravesical antibiotics? Depends how motivated I am. 

Love y'all, check out the podcast and share both with anyone you think might find this interesting. Thanks!

References 

CONTINUOUS BLADDER IRRIGATION WITH VANCOMYCIN FOR THE TREATMENT OF METHICELUN-RESISTANT STAPHYLOCOCCUS AUREUS by Hajjar et al., in the Journal of the American Geriatrics Society in 1996

Evaluation of functional parameters, patient-reported outcomes and workload related to continuous urinary bladder irrigation after transurethral surgery by Reichelt et al., in Translational Andrology and Urology 2021

Healthcare Associated Urinary Tract Infections by Nicastri and Leone from the International Society for Infectious Diseases in 2021

Image of a transitional carcinoma viewed with cystoscopy from Merck Manual

Manual and continuous bladder irrigation: Best practices by Lucas & Ward in Nursing 2022