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Three Part Question

In [adult males requiring urethral catheterisation] does the use of [local anaesthetic lubrication] reduce [pain of insertion]?

Clinical Scenario

A male patient presents to the emergency department with acute urinary retention requiring urethral catheterisation. You ask the nursing staff where the local anaesthetic gel is and they tell you that it has been removed following a safety alert as it contains chlorhexidine, which may cause anaphylaxis. You catheterise the gentleman who appears to suffer a lot of pain with the procedure. Following this you decide to look at the evidence for the use of local anaesthetic lubrication in catheterisation.

Search Strategy

The search was undertaken using the NHS Evidence interface utilising Medline, Embase, CINAHL and the British Nursing Index (BNI). The first 10 pages of a Google Scholar search were also reviewed as were the references from the relevant papers. Finally the Cochrane Library was searched.

Medline 1950—present
((exp ANESTHETICS, LOCAL/ OR exp LIDOCAINE/ OR exp ANESTHESIA, LOCAL) OR Lidocaine.ti,ab. OR Lignocaine.ti,ab. OR Optilube.ti,ab OR Instillagel.ti,ab OR (exp LUBRICATION or exp LUBRICANTS)) AND ((exp CATHETERS, INDWELLING/ OR exp URINARY, CATHETERS/) OR (Urinary AND Catheter.ti,ab. OR (Bladder AND Catheter.ti,ab.) OR (Indwelling AND Catheter.ti,ab.) OR (In-dwelling AND Catheter).ti,ab. OR (Urethral AND Catheter.ti,ab)))

[Limit to: Humans and (age groups all adults 19 plus years)]

Embase ((exp BLADDER CATHETERIZATION/ OR exp URETHRAL CATHETERIZATION) OR (urinary AND catheter$).ti,ab. OR (urethral AND catheter$).ti,ab. OR (bladder AND catheter$).ti,ab. OR (indwelling AND catheter$).ti,ab. OR (in-dwelling AND catheter$).ti,ab.) AND ((exp LOCAL ANESTHETIC AGENT / OR exp LIDOCAINE / OR exp LOCAL ANESTHESIA) OR (Lidocaine).ti,ab. OR (Lignocaine).ti,ab OR (exp LUBRICATING AGENT) OR (Lubricating AND Gel).ti,ab. OR (lubrica$).ti,ab. OR (Instillagel).ti,ab. OR (Optilube).ti,ab.) [Limit to: Human and English Language and (Human Age groups adult 18–64 or Age 65+] CINAHL ((exp LIDOCAINE) OR (Lidocaine).ti,ab. OR (Lignocaine).ti,ab. OR (Instillagel).ti,ab. OR (Optilube).ti,ab. OR (Local AND Anaesthetic).ti,ab. OR ((Lubricat*).ti,ab. OR (Lubricant*).ti,ab. AND (gel*).ti,ab.)) AND ((exp CATHETERS, URINARY/ OR URINARY CATHETER INSERTION OR URINARY CATHETERIZATION) OR (Indwelling AND catheter).ti,ab. OR (In-dwelling AND catheter).ti,ab. OR (bladder catheter).ti,ab.) BNI ((exp URINARY, CATHETERS/) OR (exp UROLOGY NURSING/)) AND (Lubrica*).ti,ab

Search Outcome

In total, there were 674 results (including duplications), of which 2 were relevant to the three-part question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Garbutt RB et al, 2008, Australia	73 males requiring urethral catheterisation All patients received local anaesthetic gel and were randomised to receive either immediate catheterisation (no delay) or catheterisation 2 min later	Randomised trial	Median Pain score no delay versus delay (interquartile range)	No delay: 22.2 (23.4) delay: 27.8 (35.3) p=0.47	Single-centre convenience sampling Small delay time may minimise any possible differences This trial does not directly answer the three-part question
Siderias.J et al, 2004, USA	36 males randomised to catheterisation with local anaesthetic or plain lubricataion	Randomised trial	VAS pain score LA versus plain	LA 38mm +/-28 plain 58mm +/-30	Single centre Convenience sampling Less conventional study protocol
			Mean pain score difference	20mm 20mm (95% CI 0.4-32; p=0.04)
			Patient preference to same treatment again LA versus plain	61.1% versus 38.8% (p=0.048)

Comment(s)

Urethral catheterisation is commonly undertaken in the emergency department. It is also recognised as one of the most painful procedures carried out in the emergency setting (Singer et al 1999). It is not surprising, therefore, that the use of local anaesthesia has been considered for urological procedures for over 100 years. Yet despite the long tradition of local anaesthesia in urology, there is paucity of trials examining its effects on the pain of catheterisation. For many years, it has been widely accepted that use of local anaesthesia is standard practice for catheterisation. Given the longer male urethra, we might expect that the use of local anaesthesia is particularly likely to be beneficial for male catheterisation. Ideally a large multicentre randomised control trial is needed to fully clarify the benefits of local anaesthetic gels in catheterisation. There has been some concern that the use of chlorhexidine-containing gels may lead to anaphylaxis (Medical Device Alert 2012). The evidence suggests that the use of local anaesthetic does reduce the pain of male urethral catheterisation. We must ensure, however, that patients do not have a history of allergy or sensitivity before using chlorhexidine-containing gels.

Editor Comment

LA, local anaesthetic; VAS, visual analogue scale.

Clinical Bottom Line

The use of local anaesthetic gel improves the pain of procedure and should be used for the catheterisation of men.

References

1. Garbutt RB, McD Taylor D, Lee V, et al. Delayed versus immediate urethral catheterization following instillation of local anaesthetic gel in men: A randomized, controlled clinical trial. Emerg Med Australas 2008;20:328–32.
2. Siderias J, Guadio F, Singer AJ. Comparison of topical anesthetics and lubricants prior to urethral catheterization in males: a randomized controlled trial. Acad Emerg Med 2004;11:703–6.
3. Singer AJ, Richman PB, Kowalska A, et al. Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures. Ann Emerg Med 1999;33:652–8.
4. Medical Device Alert: All medical devices and medicinal products containing chlorhexidine,[Online] MDA/2012/075 (accessed 16 Jun 2014). 2012. http://www.mhra.gov.uk/home/groups/dts-bs/documents/medicaldevicealert/con197920.pdf