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Urology/Catheter: to cap it, or not to cap it --was: Incomplete ejaculation in a catheterized...

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QUESTION: Dear Doctor,

I'm a 35-y.o. patient with spinal muscular atrophy -- bedridden, with intense deformation of the spine.

This year, because of growing difficulty in passing urine (up to the point of nearly complete retention), I have started seeing urologists. The situation for the time being is that I'm on a Foley catheter (Ch 14) and supposed to remain with it for the following two weeks, in which we (me and the doctor) shall see if the urinary function return. The rationale that this wait-and-see approach has been adopted is -- if I understand it correctly -- that there's been a really large amount of sediment accumulated in my bladder and the doctors first want to see if the reason for voiding problems would not have been obstruction from that sediment. I seem to have some anatomical abnormality in the urethra -- the doctors somehow refrain from calling it a stricture, but they sure have a huge difficulty in catheterizing me -- and the first catheter (Tiemann, Ch 10) got clogged up twice in a matter of 7 days, so I can well see that the urethra might do likewise.

My present question, however, concerns an issue not so much to do with this general urological condition, but rather with the circumstances of dealing with a catheter. It has been my first time of living a period of my life (I hope it is going to be a finite period of time) with a dwelling catheter. I'm getting used to the sensation of having the tube in -- after a few days it stops being too uncomfortable, especially if one is immobile. I've even got used to an occasional erection -- these actually seem to be less frequent since I've had the catheter in. At least, that's true of daytime...

Today, however, there happened what I have been apprehensive of for a few days. I had wondered what would happen if I continue for a longer time without an ejaculation. And yes, today in the morning, I woke up to what was clearly an onset of a nocturnal emission. Every element of it was present, except -- there was no release. The blockage, the pressure, the sudden discomfort and the shock at waking to experience all of that stopped the action in midst. (Honestly, I don't see it in my muscles to propel the seamen through the narrow pathway of the catheterized urethra; but I cannot be sure.). The aftermath is that I feel somewhat like on the first or the second day after catheter insertion: sensing a mild discomfort in the urethra and the bladder, a mild urge to urinate, and a dose of general fatigue. I should probably add at this point, however, that the day is dull (low atmospheric pressure), and that I was starting to feel a bit of similar discomfort yesterday evening already -- due to being gently constipated (I had already noticed this correlation of symptoms before).

Here's my question. What happens if one experiences an ejaculation without the release, with a Foley catheter in? There has been no "mess", other than just the minimal urethral secretion, in the morning. So, what could have happened to the seamen? Could it have entered the bladder -- notwithstanding the balloon that locks against the bladder neck? Could it have been partly reabsorbed in the prostate or in the urethra, so that only a small amount of it was left to ooze out? Should I be concerned about this and about any potential future nocturnal emissions? I am trying to keep the amount of potential sexual stimuli to the minimum, but even the mechanical irritation of the urethra and the resultant nightly erections are probably bound to lead to repetitions of what I experienced today.

I look forward to your answer, Doctor. Thank you in advance.

ANSWER: Bartek:

You will need a good list of questions to ask your urologists about your bladder issues.  For example, is there an obstruction in the urinary passage?  What about self intermittent catheterization or a suprapubic tube if you don't void well enough on your own?

Ejaculation with any semen coming out just means the semen went into the bladder.  No harm doing this and the balloon does not prevent it. Semen is not "reabsorbed in the prostate or urethra".  No reason for concern about this issues.  The only way to avoid all such issues is to find a means where the catheter is not full time in the bladder such as intermittent catheterization or a suprapubic catheter placement.

---------- FOLLOW-UP ----------

QUESTION: Thank you, Doctor.

Yes, I certainly hope that my urologists can get to the bottom of the problem. Intermittent catheterization is not much of an option for me, I guess, because of the difficulty of putting a catheter in and because of the fact that my disability is too big to allow me to do it myself. I am aware of the suprapubic catheter option. And as much as I hope I could be restored to urinating on my own, I realize that should all efforts fail this would probably be the way to go.

Concerning the ejaculation issue: it happened to me today again and this time I allowed the process to take its course. I felt a sudden pressure in the urethra, but nothing came out. I felt some fluid move inside the urethra, and even tried to squeeze it out with the muscles of the abdomen, but there was no discharge. In the morning there was some blood inside the catheter: not much though. There was no further bleeding. However, I developed very high fever, which I only managed to stop with medication in the evening. I also had some discomfort in the bladder and (possibly) in the urethra. I guess that the state of inflammation appeared there because of the ejaculate discharge entering the bladder. I've started taking furazidin in the evening and this seems to be curing most of the discomfort in the bladder.

My specific concern and the follow-up question is this:
I understand that most of the semen has got into the bladder and will exit through the catheter together with urine. But what is the likelihood of some of the semen getting "trapped" in the prostate/urethra when having a catheter? Is there a natural mechanism of transport inside the urethra (perhaps through a production of mucus?) that would push it toward one or the other end of it, so that it would be evacuated? The reason for my asking this is that I suppose such trapped residue of semen in the urethra or in the prostate could easily lead to a recurrent infection of them, and I'm a bit worried about it.

ANSWER: Bartek:

It is pretty unlikely that any significant amount of semen will become trapped as you've described.  There are no specific studies on any "natural mechanism of urethral transport" such as you've described.  The area is just too small.  We know that there is regular mucus production that slowly makes its way to the tip of the penis and presumably that's what will happen with any semen that doesn't pass into the bladder.  

Since semen is sterile, it is not the likely cause of your infection; your catheter is a more likely suspect.

---------- FOLLOW-UP ----------

QUESTION: Thank you so much, Doctor, for your concise and comprehensive answers -- they put my worries to rest. I'm really grateful for your help.

I wonder if I wouldn't be stretching your patience if I allowed myself to ask you one more question outside the strict topic of this thread, but related to my current urological situation. I cannot resist this opportunity to make use of your expertise -- I hope you forgive me.

Here's the question:
The young urologist who was changing my Tiemann for the Foley that I am with now (the change happened a little over one week ago), advised me to not stay with the catheter permanently attached to the drain and the bag (I solely use a night-bag, since I'm in bed 24/7), but rather to cap it and to attach it to the drain only when I feel an urge to urinate. I wasn't really able to draw from him a coherent explanation for why I should be doing that. The only thing he seemed to be pointing out was that a shrinking bladder might start bleeding. But it hadn't bled for the entire week I had been with the Tiemann that was inserted first, although I never capped the catheter unless absolutely necessary for other reasons (logistics in sitting up for a stool, for example). When I told him about it and said that, from what I had read on the Internet, avoiding (as much as possible) detaching the catheter from the drain was deemed best from the point of view of bacteriological safety, he said that it all doesn't really matter that much and that whether I open the catheter only to release the accumulated urine or whether I keep it permanently attached to the drain is basically a question of personal preference.

For the time being, I am staying with the catheter permanently attached, but this idea of "bladder shrinking" set me thinking. Do you think that letting my bladder be drained continuously could have a detrimental effect on its function, and in particular -- on the detrusor muscle? Can it affect negatively the result of my attempt to urinate naturally on my control visit in two weeks' time? I'd like to remind you that I suffer from a neuromuscular disease (the SMA) -- although, if I'm not mistaken, the disease (mainly?) affects the skeletal muscles, and the detrusor is a smooth muscle (correct?). Should I therefore, at some point, switch to the system of "catheter capping" (to call it that way)? If so, when should I do it?
Or maybe letting my bladder relax now is what can have most beneficial effects on it? In the description of my urography the bladder has been characterized as "(very) highly enlarged" (I'm finding it difficult to come up with an accurate intensifier corresponding to the one used in my native language). Do you think that such period of continuous drainage could actually help it get in shape to some degree?

I'm really sorry to have drowned you with questions again, Doctor, but I would really like to do what I can to improve my chances of returning to natural micturition and of delaying the perspective of having to reconcile myself to a suprapubic.

Answer
Bartek:

If you have an enlarged, weakened or overstretched bladder, then leaving the foley to continuous drainage will help shrink it and may help it to eventually work better.  Capping the catheter will tend to stretch the bladder and may help it from becoming too small and shrunken over time, but whent he catheter doesn't drain it may tend to increase the risk of infection.  You are right that anytime you open or change the drainage of a catheter it does tend to increase the infection risk.

The capping option makes the most sense for patients with permanently enlarged bladders that can't respond to continuous drainage by shrinking.  At that point, it becomes a choice.  I don't have enough information about your particular situation to make a recommendation except it might be reasonable to get some good advice from a tertiary care center urology dept.  

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Stephen W. Leslie, MD

Expertise

Questions concerning erectile dysfunction, kidney stones and prostate disorders including prostate cancer. I have a special interest in kidney stone disease prevention.

Experience

Full time practicing urologist with 30 years experience. Associate Professor of Surgery and Chief of Urology at Creighton University Medical Center. Editor in Chief of eMedicine Urology internet textbook. Author of only NIH approved book written for patients by a urologist on the subject of kidney stones "The Kidney Stones Handbook". Inventor of the "Parachute" and "Escape" kidney stone baskets and the "Calculus" stone prevention analysis computer program.

Organizations
American Urological Association, Ohio State Medical Association, Sexual Medicine Society

Publications
Men's Health, Journal of Urology, Urology, Healthwatch Magazine, Emergency Medicine Monthly, eMedicine, "The Kidney Stones Handbook", and numerous articles in various newspapers. He is also the editor of the Urology Board Review by McGraw-Hill used by urologists to study for their Board Certification Examinations.

Education/Credentials
Graduate of New York Medical College with residencies completed at Metropolitan Hospital New York, Albany Medical Center and University of Wisconsin-Madison.

Awards and Honors
Thirlby Award of the American Urological Association. Rated as one the country's Best Urologists by the Independent Consumer's Research Institute

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