Sunday, December 18, 2011

Urine Samples and Catheter Insertion for Intact Boys

By Danelle Frisbie © 2011


We receive two common types of forced retraction reports from parents: those that happen at well-baby checkups in the United States, often before a parent even knows what is happening, and those that happen when a parent ends up in the hospital with a baby who is catheterized (due to illness or surgery).

Before we address catheterization specifically, and the correct way to catheterize an intact male baby or child, it should be noted that frequently there is truly not a need for catheterization in the first place. With some surgeries, and post-op recovery, it is going to be necessary. However, often, in surgical cases for babies and toddlers, simply wearing a diaper and having another couple ready for change during and/or post-OR, is another option, especially if the toddler will be under general anesthesia for less than 4 hours.

Urinary Tract Infection

Besides surgery, the most common reason for catheterization is to check for the existence of a urinary tract infection (UTI). UTIs occur with much more frequency in girls than they do in boys due to the short urethra and proximity to the anus (contamination with fecal matter or bacteria from the hands of a care-taker are the two biggest causes of UTIs). UTIs are easily treated with antibiotics, but they should not be ignored or left untreated because bacteria can quickly spread up the urinary tract, through the bladder, into the kidneys, and do serious or permanent damage. UTIs are bacterial infections and once they have taken hold, merely drinking cranberry juice will not kill off bacteria, as some pop parenting reports suggest. Regularly consuming 100% cranberry extract capsules (a much higher concentration than you would get from cranberry juice) for older children and adults can reduce the likelihood of UTIs in the future by priming the health of the urinary tract, but it cannot 'cure' an already established bacterial infection. Even if symptoms disappear, the strongest bacterial strains may remain, causing future kidney problems. Therefore, if you suspect UTI, do not wait, and do not mess around with treatment if a UTI is confirmed. If antibiotics are prescribed for a UTI, be sure your baby or child takes the full does, on time, and does not miss any days or stop early (which can also lead to the most powerful bacteria lingering on when the child is asymptomatic).

There are some children (girls especially) who seem overly susceptible to contracting UTIs and may have a bout with several each year until they are older, out of diapers, without parents' hands helping them to wipe, and always wiping themselves 'front to back.' While it is not a subject regularly brought up at the physician's office, self-touching or exploration of the genitals (masturbation) with hands that have not yet been washed and have fecal particles on them is another way that UTIs can be contracted - again, especially among girls whose urethra is shorter and less protected. This does not make masturbation 'wrong' or 'dirty' -- it merely is a reality that we need to wash our hands before and after changing or wiping babies or toddlers, and encourage them to do the same before they touch their own bodies. This is also one of the reasons masturbation and circumcision became intertwined in U.S. history in the first place -- it was theorized that if we remove the prepuce (which houses the most nerves of any male body part, and a relatively equal number to the female clitoris) we would thereby diminish boy's and men's sexual desire to masturbate, and in turn, we'd also see fewer UTIs (among other illnesses previously blamed on masturbation).

In reality, when forced retraction is not part of the picture, UTIs are no more common in intact baby boys (boys who have their full, intact prepuce and penis) than in circumcised boys. The prepuce, in fact, serves to protect against UTIs. Additionally, breastfeeding reduces the rate of urinary tract infection for both male and female babies, as human milk is powerfully charged with antibodies and white blood cells, among other protective, immunological features.

Urine Sampling

Today, the two most commonly used methods of collecting a urine sample from non-toilet using babies and children in U.S. emergency rooms are the "clean catch" and "bag specimen." Neither method is done without contamination of sample, but research suggests that between the two, clean catch is the way to go. (1, 2) Note: Studies do show that there is no significant variation between clean catch versus a standard urine sample obtained through other means for older children and adults who can urinate into a sterile cup on their own. (3, 4, 5, 6, 7)

A clean catch receptacle designed by UriAid especially for use with children, women, or little ones who may be laying down during urine sample collection. 

A clean catch works by wiping down the genitals of an infant or child with sanitizing wipes (provided by the clinic), and holding a sterile specimen bottle under the stream of urine - after the baby/child has started to urinate. This is considered to be the 'gold standard' of non-invasive urine sampling, but is more difficult to time with babies. Breastfeeding may help to fill and release the bladder.

For older children who can tell you when they need to go, a clean catch can be done at home. Wipe down the outside of the genitals and the perineum (between the urethra and rectum) with a wet cloth. Have your child drink a lot of liquid or nurse, and stand by or sit on the toilet with the faucet water running (this helps to psychologically induce 'flow'). Your child may also want to stand over a cup in the bathtub if he is more comfortable with this. Write your child's name, date of birth, and the date and time the sample was taken on the outside of the cup. Take it to your local urgent care or emergency room within 2 hours of the time it was taken (if more time has passed, it is likely they will ask you to repeat the sample). If your child truly has a UTI, it may be difficult for them to push out urine even when they feel the intense urge to 'go.' This urgency and frequency, coupled with being unable to eliminate urine, is a key indicating factor that there is indeed a UTI present, and a full round of antibiotics are justified. Babies who cannot tell you that they desperately need to go, but cannot, and that it constantly hurts, and stings when they try, are those who we are especially concerned with - their cry of discomfort, fever to fight infection, and possible reduction in wet diapers, are the only indications we often have of a UTI.

Urine collection pad kit.

The National Institute for Health and Clinical Excellence (NICE) suggests that the use of urine collection pads is the next best method of urine collection in a non-toilet using baby or child. This is a special pad made specifically for collecting urine that is placed into a baby's diaper after a wipe-down with a sanitizing wipe. The pad needs to be changed every 30-40 minutes (whether the child wets or not) so as to reduce the rate of contamination. (8) One reason that we see higher rates of UTIs in the first place during the first year of life is due to the diapering of our babies - a situation that helps to move fecal bacteria from the anus to the meatus (urethral opening). The same is true for collection pads - it is merely contact with the perineal area that increases contamination of sample - so change often. (9) 

Pediatric urine collection bag. 

Another form of urine collection (which sees no less contamination of sample than the urine collection pad, and is more cumbersome, so may not be the method of choice) is the urine collection bag. The bag has a U shaped sticky area (similar to a bandaid, but with less adhesive) on the round opening that is placed over the genitals after they are wiped down. The bag lays out of the way (to the top or bottom of baby's genitals) as urine is collected. A diaper can be put on over the the collection bag. If being used at home, the urine from the collection bag can then be transferred to a sterile collection cup and submitted to your local urgent care or emergency room within 2 hours, just as it would be with a clean catch. A 2009 study published in the Journal of Pediatrics found that bag-obtained specimens produced a significantly higher number of false-positive results (parents were told their child had a UTI, when in fact, he did not). In addition, there was a higher number of false-negatives (parents were told their child did not have a UTI, when he in fact did). (10) 

 Infant with urine collection bag in place. 

Neither pads or bags may be left on a baby for more than 40 minutes or it will increase the likelihood of a bacterial infection even if your baby does not already have an infection. Leaving babies in diapers all day also increases infection potential - so give your little one some 'diaper free' time whenever you are able. Babies who are not yet crawling can do tummy time on a waterproof mat with a towel or cloth diaper laid out under him/her. Many parents today incorporate 'elimination communication' into their routine as well, which also reduces time in diapers.

Catheters

Occasionally, medical staff will suggest they need to collect an uncontaminated sample, or verify the results of a sample previously obtained through non-invasive means, with catheterization.

Adult intact male with Foley catheter in place to demonstrate how the catheter would appear inside your son. Infants and children have a shorter urethra (and shorter penis) which is one reason they have a tendency to get more UTIs. Therefore, the catheter itself will be smaller and shorter, without as far to go to reach the bladder. The balloon you see here (for the Foley) would be present if your son is catheterized for a surgery, but not present for a brief urine sample. The catheter goes directly from the urethra to the bladder - above the prostate gland that you see pictured here between the penis and bladder.

There are two types of catheters that are most commonly used with infant or young boys: the Foley catheter and the intermittent or Robinson catheter. The Foley catheter is used most often during surgery when the instrument needs to stay in place. This is done with a small balloon at the tip of the catheter that is inflated with sterile water once inside the bladder.  The intermittent/Robinson catheter is a flexible catheter that is used most often when medical staff are checking for urinary tract infection. It is designed for the brief drainage of urine - to obtain a quick sample - and cannot stay in place without being held.

When an intact male baby or child is catheterized, retraction of the prepuce (foreskin) is not necessary or indicated.

In the United States there is quite a well founded concern that forced retraction will come into play when an intact male child is catheterized. However, it is the female patient for whom catheterization is actually more diverse and confounding. Age, weight, childbirth, past surgeries, female genital cutting, and many natural variations in the female body make catheterization of a girl or woman much more complex than catheterization of a boy or man, intact or otherwise. In general (unless hypospadias is a factor) the meatus (urinary opening) is going to be somewhat centrally located directly behind the opening to the prepuce, and fairly easy to 'hit on feel.'

The prepuce will typically be tightly adhered to the glans (penis head) of a baby or young toddler with little slack or room for movement, as seen in the photograph below. Even in boys as old as 10 years, many will still not have a retractible prepuce. In Pediatrics, Rudolph and Hoffman note, "The prepuce, foreskin, is normally not retractile at birth. The ventral surface of the foreskin is naturally fused to the glans of the penis. At age 6 years, 80 percent of boys still do not have a fully retractile foreskin. By age 17 years, however, 97 to 99 percent of uncircumcised males have a fully retractile foreskin." The average age of retraction is 10 1/2 years -- some will retract naturally, on their own, sooner, and some later. Each is within the range of normal, but no one should retract a baby or child except for the boy himself when he chooses to do so.

In their bulletin, Care of the Uncircumcised Penis, the American Academy of Pediatrics stresses, "...foreskin retraction should never be forced. Until natural separation occurs, do not try to pull the foreskin back - especially an infant's. Forcing the foreskin to retract before it is ready may severely harm the penis and cause pain, bleeding and tears in the skin."

Simply put, there is never a reason to forcibly retract the prepuce. Writes Doctors Opposing Circumcision in their article, Forced Retraction of Intact Boys: An Epidemic:
Only in the instance of significant hypospadias or epispadias (congenital malposition of the urethral opening) might retraction be necessary, and even then only if it is unavoidable collateral damage for which there should be specific follow-up care.
If your son has already been the victim of forced retraction, see Forced Retraction: Now What? for more information on how to handle things from here on out.

Intact baby boy and where the catheter will go. 

If retraction of intact boys is not going to take place for catheterization, how then should it be done? By feel alone.

Nurse K. at Johns Hopkins Hospital in Baltimore, Maryland (top ranked urology hospital in the nation), writes,
I know for certain as a result of working with many intact boys that the catheter can be inserted without retracting the foreskin. There is no reason whatsoever that the foreskin would need to be retracted for a simple catheter insertion procedure. The catheter used on an infant will be tiny and should be easily slipped into the small opening at the tip of the foreskin, right into the meatus. Parents: be firm and tell others that retracting the foreskin is not acceptable! Not even 'just a little.' If you must, you be the one to hold your son's penis and slide the catheter into place. They can take it from there. Or, specifically ask for someone who has catheterized an intact baby without retraction.
Just as the skilled hand of a midwife can determine a baby's position by feel alone, without need for seeing or intervention, so can a nurse or practitioner catheterizing an intact boy without laying eyes on the meatus itself. There is simply no need to see the meatus in order to 'hit' it with a catheter. With one hand on the penis for steadying, the small tube can gently be moved into the prepuce, and pressed against the glans, so it will either hit the spongy tissue of the glans, indicating the need for ever-so-slight readjustment, or it will glide smoothly into the urethra. With a small amount of patience and practice, nurses can become skilled in catheterizing an intact boy so that it rarely takes more than the first try to get it.

Because the prepuce on an infant boy is typically quite stationary and non-mobile, there is not much prepuce slack, and there are not many places to 'go' with the catheter. If the first try does not work, a mere glance to the right or left, up or down, will. In an older, retracting child, after separation from the glans has started to occur naturally, he may wish to retract his foreskin enough on his own for a catheter to be inserted directly into the meatus (if he is awake during the procedure). But even for older children, simply holding the penis steady with one hand, while gliding the catheter into the prepuce opening, until it touches the glans where it can be pressed into the urethra, works quite well and uneventfully. If your practitioner is not willing to take the extra moment to catheterize without forced retraction, ask to see another staff member, or request a set of sterile gloves, while you take your son's penis, and his health, into your own hands.


For additional resources on raising intact boys see: How to Care for Your Intact Son


References

1) Hardy JD, Furnell PM & Brumfitt W. Comparison of sterile bag, clean catch and suprapubic aspiration in the diagnosis of urinary tract infection in early childhood. British Journal of Urology1976;48(4):279-83.

2) Alam MT, Coulter JB, Pacheco J, Correia JB, Ribeiro MG, Coelho MF & Bunn JE. Comparison of urine contamination rates using three different methods of collection: clean-catch, cotton wool pad and urine bag. Annals of Tropical Paediatrics. 25(1):29-34, 2005 Mar.

3) Lohr JA, Donowitz LG & Dudley SM. Bacterial contamination rates for non-clean-catch and clean-catch midstream urine collections in boys. Journal of Pediatrics 1986; 109:659-660.

4) Lohr JA, Donowitz LG & Dudley SM. Bacterial contamination rates in voided urine collections in girls. Journal of Pediatrics 1989;114:91-93

5) Bradbury SM. Collection of urine specimens in general practice: to clean or not to clean? J R Coll Gen Pract [Occas Pap] 1988;38:363-365.

6) Morris RW, Watts MR & Reeves DS. Perineal cleansing before midstream urine: a necessary ritual. Lancet 1979;2:158-159

7) Immergut MA, Gilbert EC, Frensilli FJ & Goble M. The myth of the clean catch urine specimen. Urology 1981; 17:339-340.

8) Rao, S. et al (2004). An improved urine collection pad method: a randomised clinical trial. Archives of Disease in Childhood. 89: 8, 773–775.

9) Rao, S. et al (2003). A new urine collection method; pad and moisture sensitive alarm. Archives of Diseases of Childhood. 88: 9, 836.

10) Welch, Thomas R. Bagging the Bag. Journal of Pediatrics 2009; 154(6):A1.

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