Long-term urethral catheter drainage.

SIR,-On behalf of my coauthors, I wish to thank Sir Eric Riches and Dr S L 0 Jackson for their comments (24 November, p 1367). In our enthusiasm to persuade others to adopt the domiciliary approach to long-term urethral catheter management we did not stray into an account of alternative measures, some of which are better suited to hospitalised patients. Sir Eric and Dr Jackson have correctly stated that suprapubic drainage can be useful, and agree that Malecot and De Pezzer catheters have been supplanted by modem catheters which were designed for urethral use. In the case of retention due to trauma or postoperative immobilisation, we would advocate the use of a suprapubic cannula of 8 or 12 gauge of the type made by Porges or Dow Corning. This avoids the risk of urethral trauma, and facilitates multiple attempts at voiding per urethram as the patient improves. It is surprising that this technique is not more commonly employed in neurological or orthopaedic units, at least in the West of Scotland. When permanent suprapubic drainage is chosen we follow the technique described by Sir Eric, inserting a self-retaining catheter at an angle to reduce the risk of leakage. Permanent suprapubic catheters can readily be changed provided that there is no undue delay between the removal of the old and the insertion of the new. Unfortunately some catheters fall out owing to defective balloons, cutting out of the stitch if this technique is used, or other reasons. If this occurs in a patient in his own home, the delay can lead to partial closure of the track, making insertion of a new catheter painful or even impossible. Dr Jackson describes the use of suprapubic catheters in the younger-chronic-sick ward. The Foley-type self-retaining catheter is certainly better than catheters of the De Pezzer and Malecot types, being less likely to harbour crystals and much easier to remove. Sexually active males who suffer from urinary incontinence may well prefer the condom-type urinal, and in common with others we are involved in attempts to improve existing designs. This correspondence emphasises the need for tailoring management to suit the individual patient, and indicates some of the differences between hospital and community care. Perhaps it is useful to state that the urodynamic service here provides a vigorous programme for diagnosing and treating urinary incontinence and voiding problems, reducing the need for catheterisation. ERIC GLEN