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Filiform and Follower Urethral Catheterization


Urethral catheterization can be difficult for various reasons, including false passage during recent or past catheter placement attempts, prior urethral trauma resulting in urethral stricture, enlargement of the prostate gland (eg, benign prostatic hyperplasia, prostate cancer), or prior surgery on the urinary tract (eg, transurethral prostatectomy [TURP], hypospadias repair). In these scenarios, urologists are often called to the operating room or bedside to assist with the placement of urethral catheters when the primary team is unsuccessful.

These difficult catheterizations often require additional equipment such as specialty wires, catheters, or bedside flexible cystoscopy. However, predating the advent of flexible cystoscopy, the urologist was able to place the catheter blindly by drawing on a broader understanding of urethral anatomy and increased tactile experience. Foremost in their armamentarium were filiforms and followers. These tools allow blind negotiation of the true path of the urethral lumen and ultimately access the bladder. Filiforms are smaller than urethral catheters and more likely to pass through narrowings of the urethra. The followers can then be used to dilate the narrowing to a size suitable for passage of a urethral catheter.

When this technique is successful, it eliminates the need for cystoscopy or suprapubic tube placement if a flexible cystoscope is not available. Furthermore, dilation can be therapeutic and may give the patient a better chance at being able to void spontaneously when the catheter is removed. In fact, filiforms and followers are still widely used for dilation in men with known urethral stricture disease.

Moreover, a study by Granieri et al found that nationally in the United States, in an emergency department setting, urethral dilation is more common than suprapubic tube (SPT) placement for the treatment of acute urinary retention due to urethral stricture; however, SPT placement has seen increased use. Data were culled from the 2006-2010 Nationwide Emergency Department Sample, with 85% of men with acute urinary retention undergoing urethral dilation and 15% being treated with SPT placement.

Although the filiform/follower technique was once commonly employed in difficult catheterizations, a survey noted that less than 10% of urology residents in the United States would use filiforms and followers if they failed on their initial attempt to place a Foley catheter (with up to 74% instead opting to use flexible cystoscopy). This downward trend in the use of filiforms and followers is due in combination to the increased availability of flexible cystoscopy and the challenges senior urologists face in teaching residents to correctly use tactile sensation.

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