Differential Diagnosis for a 93-year-old Male with a Malfunctioning Foley Catheter

The patient presents with complaints of pain and concern for a malfunctioning Foley catheter, which has been in place for approximately one and a half weeks. A bladder scan reveals a distended bladder, >999 mL, despite the Foley being noted to drain. The following differential diagnoses are considered:

• Single most likely diagnosis
  • Urinary Retention due to Catheter Obstruction or Kinking: The patient's symptoms of discomfort and the finding of a distended bladder despite the catheter draining suggest that the catheter may be partially obstructed or kinked, preventing adequate urine drainage.
• Other Likely diagnoses
  • Bladder Outlet Obstruction: This could be due to benign prostatic hyperplasia (BPH), bladder neck contracture, or other causes, which are common in elderly males and can cause urinary retention.
  • Detrusor Underactivity: This condition, where the bladder muscle does not contract effectively, can lead to incomplete bladder emptying and urinary retention.
  • Constipation: Constipation can cause external pressure on the urethra, leading to urinary retention, especially in the elderly.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Urinary Tract Infection (UTI) or Sepsis: A malfunctioning catheter can be a source of infection, and in an elderly patient, UTI can quickly progress to sepsis, which is life-threatening.
  • Bladder Rupture: Although less common, a distended bladder can rupture, leading to severe complications, including peritonitis and sepsis.
• Rare diagnoses
  • Neurogenic Bladder: Conditions affecting the nerves controlling the bladder, such as spinal cord injuries or multiple sclerosis, can lead to urinary retention, though this would be less common in the context provided.
  • Malignancy: Bladder or prostate cancer could cause obstruction leading to urinary retention, though this would be less likely without other supporting symptoms or history.

Orders in the ER

Given the differential diagnoses, the following orders should be considered in the ER:

• Immediate attempt to irrigate the Foley catheter to rule out obstruction.
• If irrigation is unsuccessful, consider replacing the Foley catheter.
• Bladder scan post-intervention to assess for adequate drainage.
• Urinalysis and urine culture to evaluate for UTI.
• Complete Blood Count (CBC) and blood cultures if there is suspicion of sepsis.
• Imaging (e.g., ultrasound or CT scan) if there is concern for bladder rupture or other complications.
• Consider consulting urology for further evaluation and management, especially if simple interventions do not resolve the issue.