Clinical Geriatrics

Delirium occurs in 14-56% of elderly hospitalized patients.1 During these times of confusion, traumatic self-removal of an indwelling urinary catheter with the balloon inflated can occur, resulting in urologic consultation. The use of a “decoy” catheter in a patient with dementia has been previously described to prevent repeated catheter removal.2 We believe this is an underutilized, simple alternative to sedatives and restraints that may prevent the confused patient from removing his or her urinary catheter.

CASE PRESENTATION

A 90-year-old male resident in a nursing facility was found to have a fungating distal penile lesion consistent with penile carcinoma. A partial penectomy was performed without incident. Postoperatively, a urinary catheter was left for one week. The nursing facility where the patient resided did not allow residents to have indwelling catheters, necessitating the patient to remain hospitalized during the immediate recovery period. During this time, the patient was confused and repeatedly attempted to remove his catheter. Evaluation of the patient failed to identify an underlying cause for his confusion. Attempts at preventing the patient from removing his catheter with sedatives and temporary restraints were unsuccessful. Additionally, it was impractical to keep the patient sedated and restrained during his hospitalization.

In an effort to prevent traumatic self-removal of the indwelling catheter, the catheter was taped to the medial aspect of the patient’s leg. Simultaneously, a second “decoy” catheter was taped to the contralateral thigh. Believing the decoy catheter was in his bladder, the patient continually pulled at the decoy catheter for the remainder of his hospitalization, obviating the need for further sedation or restraints.

DISCUSSION

Delirium is a common finding in elderly hospitalized patients. Self-removal of indwelling Foley catheters with an inflated balloon is an undesirable consequence in a subset of confused patients with a urinary catheter. The stretch injury to the urethra is often minimal and treated with replacement of the catheter to tamponade the accompanying gross hematuria.3 Although rare, more severe injuries have been reported by traumatic removal of indwelling urethral catheters.4

Accidental removal of inflated balloon catheters often occurs by confused patients. Although sedation and/or restraints are commonly used to prevent the patient’s behavior, this is often distressing to both the patient and family. One option to prevent the patient from this destructive behavior is to overinflate the indwelling balloon, thus making it more difficult to remove without deflation; however, overinflation of the balloon can impede drainage. Additionally, the associated trauma from the patient’s continual pulling on the catheter is undesirable.

There are several technical points that should be emphasized when using a decoy catheter. We believe it is important to secure the indwelling Foley with tape to the level of the meatus to prevent the patient from getting his or her finger under the catheter and dislodging the tape. Additionally, the decoy catheter should be taped securely enough to prevent removal with simple pulling. The use of benzoin can aid in securing the tape to the skin.

CONCLUSION

In summary, we believe the use of a decoy catheter is an underutilized but effective technique that offers a simple alternative to sedatives and restraints in those situations in which a confused patient requires an indwelling catheter.