OSPE: Urethral urinary catheterization (Foley catheter)

Equipment

• Catheterization kit with sterile gloves and drapes
• Appropriate Foley catheter, commonly 14-16 Fr adult female, 16-18 Fr adult male, as per local protocol
• Sterile lubricant or lidocaine jelly
• Antiseptic solution and swabs
• Sterile water syringe for balloon inflation, using the volume printed on the catheter
• Closed urinary drainage bag and securement device
• Disposable underpad, gauze, specimen container if needed

OSPE checklist

Female catheterization technique

1. Position supine with knees flexed and hips abducted, or frog-leg position.
2. With your non-dominant hand, separate the labia and keep this hand in place. It is now considered contaminated.
3. Clean from anterior to posterior, using a separate swab for each stroke.
4. Identify the urethral meatus, located above the vaginal opening.
5. Insert lubricated catheter gently until urine appears.
6. Advance another 2-3 cm before inflating the balloon.
7. If the catheter enters the vagina, leave it there as a landmark, use a new sterile catheter, and reattempt.

Male catheterization technique

1. Position supine.
2. If uncircumcised, gently retract foreskin. Clean glans and meatus using aseptic technique.
3. Hold penis upright, about 60-90 degrees to the body, to straighten the urethra.
4. Instill lubricant or anesthetic gel.
5. Advance the catheter slowly and gently until urine returns, then advance it to the bifurcation/Y-port before balloon inflation.
6. Inflate balloon only after confirming catheter is fully in the bladder.
7. Gently withdraw until resistance is felt.
8. Replace the foreskin after the procedure to prevent paraphimosis.

Indications to state in viva

• Acute urinary retention
• Accurate urine-output monitoring in critically ill patients
• Sterile urine specimen when necessary
• Perioperative bladder drainage for selected procedures
• Neurogenic bladder requiring intermittent catheterization
• Bladder outlet obstruction with renal compromise

Contraindications and red flags

Do not pass a urethral catheter if urethral injury is suspected

• Blood at urethral meatus
• Pelvic fracture or major perineal trauma
• Perineal, scrotal, or penile hematoma
• High-riding/non-palpable prostate
• Known urethral disruption

• Known urethral stricture
• Recent urethral surgery
• Artificial urinary sphincter
• Previous difficult catheterization

Common OSPE errors

• Not checking indication or allergy
• Breaking sterile technique
• Inflating balloon before urine return or before full advancement
• Forcing the catheter when resistance occurs
• Forgetting to replace foreskin
• Leaving drainage bag above bladder level or on the floor
• Not securing catheter
• Failing to document the procedure
• Using an indwelling catheter for convenience or uncomplicated incontinence

One-line OSPE closing statement

“The catheter is draining freely into a closed system below bladder level. The patient is comfortable, the catheter is secured, and I will document the indication, catheter size, balloon volume, urine output and characteristics, and plan for daily review of removal.”

Lord’s anal dilatation

Principle

Indication

• Historically used for chronic anal fissure that failed conservative therapy.

Basic operative outline

1. General or regional anaesthesia; lithotomy or prone jack-knife position.
2. Gentle anal examination to exclude another pathology.
3. Gradual, controlled manual dilatation of the anal canal.
4. No incision is made in the classic procedure.
5. Postoperative measures: analgesia, warm sitz baths, stool softening, high-fibre diet, and avoidance of constipation.

Major complication

• Faecal incontinence, including flatus incontinence, soiling, or impaired continence, due to uncontrolled tearing/disruption of internal and sometimes external sphincter fibres.
• Other risks: bleeding, pain, fissure recurrence, infection, and sphincter injury.

Current status: important viva point

1. Stool regulation, fibre, fluids, and sitz baths.
2. Topical calcium-channel blocker such as diltiazem or nifedipine, or topical nitrate.
3. Botulinum toxin in selected patients.
4. Tailored lateral internal sphincterotomy for persistent chronic fissure in appropriately selected patients, with continence risk assessed beforehand.

One-line exam answer

Lord’s anal dilatation is a historical treatment for chronic anal fissure in which the anal sphincter is manually stretched under anaesthesia to relieve sphincter spasm; it is now largely abandoned because uncontrolled sphincter injury can cause faecal incontinence.

Viva questions

• Why does fissure occur posteriorly? Relative poor perfusion in the posterior midline plus sphincter spasm.
• Why is the procedure avoided? Unpredictable sphincter damage and continence disturbance.
• What is the common modern surgical alternative? Tailored lateral internal sphincterotomy.
• What suggests an atypical fissure? A lateral or multiple fissure, which warrants evaluation for Crohn disease, tuberculosis, HIV, syphilis, herpes, or malignancy. Sabiston Textbook of Surgery, p. 1830.

Lord’s anal dilatation: preoperative, operative, and postoperative outline

1. Indication

Historical indication

• Chronic anal fissure with internal sphincter hypertonia, usually after failure of conservative measures.

Do not use for

• Acute fissure, which usually responds to conservative management
• Atypical or lateral fissure until underlying disease is excluded
• Active anorectal sepsis, fistula, abscess, inflammatory bowel disease with active perianal disease, suspected malignancy, or severe diarrhoeal disease
• Patients with pre-existing faecal incontinence or major continence risk, especially obstetric sphincter injury, previous anal surgery, neurological disease, or sphincter injury

2. Preoperative preparation

A. Assessment

1. Confirm that symptoms and examination are consistent with chronic anal fissure.
2. Record:
   • Pain, bleeding, constipation, stool pattern
   • Previous topical treatment, botulinum toxin, or surgery
   • Obstetric history, prior anorectal operations, baseline continence
   • Comorbidities and anticoagulant/antiplatelet medication
3. Inspect the anus gently. Digital rectal examination and proctoscopy may be too painful in the outpatient setting and may be deferred until anaesthesia if needed.
4. For atypical lesions, consider appropriate work-up and biopsy/examination under anaesthesia.

B. Consent

• The objective is reduction of sphincter spasm to improve blood supply and healing.
• The procedure is historical and has been replaced in many centers by more controlled approaches.
• Specific risks: pain, bleeding, haematoma, fissure persistence or recurrence, sphincter injury, flatus incontinence, faecal soiling, and frank faecal incontinence.
• Alternatives: fibre and stool-softening regimen, topical diltiazem/nifedipine or nitrate, botulinum toxin, fissurectomy, and tailored lateral internal sphincterotomy.

C. Bowel and anaesthetic preparation

• Follow local policy for fasting, anaesthetic assessment, venous thromboembolism assessment, and antibiotic prophylaxis. Routine antibiotics are not usually required for a clean anorectal procedure unless patient-specific factors dictate otherwise.
• A rectal enema or suppository may be used immediately before surgery according to unit protocol.
• Anaesthesia is usually general, regional, saddle block, or caudal/epidural, allowing complete sphincter relaxation.
• Administer perioperative analgesia.

3. Classical Lord’s anal dilatation: operative steps

Position and preparation

1. Place the patient in lithotomy or prone jack-knife position.
2. Ensure padding and safe positioning.
3. Prepare and drape the perianal region using sterile technique.
4. Perform gentle inspection and examination under anaesthesia:
   • Confirm fissure site and chronicity.
   • Exclude abscess, fistula, suspicious mass, anal stenosis, or another anorectal lesion.
   • Assess sphincter tone.

Dilatation

1. Lubricate the anal canal and gloved fingers generously.
2. Introduce a finger gently into the anal canal.
3. Classical descriptions progressively introduce the fingers of both hands, with fingers kept straight rather than hooked.
4. The anal canal is stretched slowly and symmetrically, avoiding sudden forceful expansion.
5. The traditional Lord method is commonly described as dilating with four fingers of each hand for approximately 4 minutes. This is the historical “four fingers for four minutes” technique.
6. The stretch is applied in more than one direction by gentle hand rotation to produce circumferential dilatation.
7. At completion, reassess for bleeding or mucosal tear. Achieve haemostasis with gentle pressure if required.
8. No sphincter incision is made, and the fissure itself is not routinely excised in the classical technique.

Key safety point

4. Controlled manual anal dilatation is different

5. Postoperative management

Immediate postoperative care

1. Monitor recovery from anaesthesia and vital signs.
2. Assess for:
   • Significant rectal bleeding
   • Severe pain
   • Urinary retention
   • Nausea/vomiting
   • Early continence disturbance
3. Most uncomplicated cases can be managed as a day-care procedure, depending on local policy and patient factors.
4. Give regular simple analgesia. Avoid opioid-related constipation where possible.

Bowel regimen

• High-fibre diet and adequate oral fluid intake
• Stool softener or osmotic laxative as prescribed
• Avoid straining and prolonged toilet sitting
• Warm sitz baths, especially after defecation, for symptom relief and hygiene

Local care

• Keep the anal area clean with water after bowel movements.
• Use a pad temporarily if there is minor spotting, mucus, or transient soiling.
• Avoid rectal manipulation unless advised.

Follow-up

• Pain during defecation and bleeding
• Fissure healing
• Constipation or recurrent fissure
• Flatus incontinence, urgency, seepage, or faecal incontinence
• Need for further medical or surgical treatment

Complications to mention in an exam

Early

• Pain
• Bleeding or haematoma
• Urinary retention
• Mucosal tear
• Perianal thrombosis
• Infection, rarely

Late

• Failure of fissure healing
• Recurrence
• Flatus incontinence
• Faecal soiling or urgency
• Faecal incontinence due to sphincter damage

Viva summary

Lord’s anal dilatation is a historical operation for chronic anal fissure. Under anaesthesia, the anal canal is gradually stretched manually to reduce internal sphincter hypertonia and improve fissure blood flow. The classical technique uses progressive insertion of fingers of both hands with controlled stretching for about four minutes. Because the injury is uncontrolled and may cause permanent continence disturbance, it has largely been superseded by medical therapy, botulinum toxin, fissurectomy, and tailored lateral internal sphincterotomy.