Bleeding from the urethra | Yes / No |
Blood in the urine | Yes / No |
Pull on the catheter | Yes / No |
Partial slipping of an indwelling catheter | Yes / No |
Spontaneous extrusion of an indwelling catheter | Yes / No |
Forcible extrusion of an indwelling catheter | Yes / No |
Catheter bypassing | Yes / No |
Difficulty in inserting a new catheter per urethra | Yes / No |
Split of the urethra (water-pipe) – traumatic hypospadias | Yes / No |
Epididymitis/orchitis | Yes / No |
Autonomic Dysreflexia | Yes / No |
Predisposing factor for autonomic dysreflexia: Please specify: ---------------------- Common features of autonomic dysreflexia are sweating and head ache. Dysreflexia is often precipitated by obstruction to urine drainage. A SCI patient may develop dysreflexia when a catheter gets blocked or when the urine bag becomes full and is not emptied promptly. The confirmation of the predisposing factor for the occurrence of dysreflexia is prompt relief of dysreflexic symptoms when the predisposing factor is corrected e.g. urine bag is emptied, or a blocked catheter is changed. | |
Ulcer over the penis in those wearing a sheath | Yes / No |
Skin excoriation over the penis in those wearing a sheath | Yes / No |
Pressure mark on the thigh due to catheter or tubing | Yes / No |
Stones in the urinary bladder | Yes / No |
Obstruction to urinary drainage because of twisting of the penile sheath | Yes / No |
Acute folding of the urethral catheter | Yes / No |
Sharp bend of the drainage tube | Yes / No |
Others (specify) | Yes / No |