When is a Foley catheter indicated for a patient with a pelvic fracture?

Foley Catheter Management in Pelvic Fracture Patients

In patients with pelvic fractures, a Foley catheter should NOT be blindly inserted before performing retrograde urethrography if blood is present at the urethral meatus, as this could worsen urethral injury. 1

Initial Assessment for Urethral Injury

• Perform retrograde urethrography in all patients with pelvic trauma who have blood at the urethral meatus before attempting catheterization 1
• If retrograde urethrography shows urethral disruption (partial or complete), avoid blind catheterization attempts 1
• If no blood is present at the meatus and suspicion of injury is low, a Foley catheter may be placed without prior imaging 1
• If a Foley catheter has already been placed before evaluation and blood is present, perform a pericatheter retrograde urethrogram to identify potential missed urethral injury 1

Catheter Management Algorithm for Pelvic Fracture Patients

For patients WITHOUT blood at urethral meatus:

• Standard urethral catheterization with 14-16 Fr Foley catheter is appropriate 2
• No additional imaging is required if suspicion of injury is low 1

For patients WITH blood at urethral meatus:

1. Perform retrograde urethrography before catheterization 1

   • Position patient obliquely (if no severe pelvic/spine fractures) or supine with penis on stretch (if severe fractures present) 1
   • Use 12 Fr Foley catheter or catheter-tipped syringe in the fossa navicularis 1, 2
   • Inject 20 mL undiluted water-soluble contrast material 1

2. Based on urethrography results:

   • Complete urethral disruption: Place suprapubic tube (SPT) for urinary drainage 1
   • Partial urethral disruption: A single attempt with a well-lubricated catheter may be made by an experienced provider 1
   • No urethral injury: Proceed with standard catheterization 1

Establishing Urinary Drainage in Pelvic Fracture Urethral Injury (PFUI)

• Prompt urinary drainage is essential in patients with PFUI 1
• Suprapubic tube (SPT) placement is appropriate when urethral catheterization is contraindicated 1
• SPT may be placed percutaneously or via open technique depending on clinical setting 1
• Avoid repeated attempts at urethral catheter placement as this can increase injury extent and delay drainage 1
• SPT placement does not increase risk of orthopedic hardware infection in patients undergoing open reduction internal fixation (ORIF) for pelvic fractures 1, 3

Special Considerations

• Primary realignment may be considered in hemodynamically stable patients with PFUI, but should not involve prolonged endoscopic attempts 1
• For patients with bladder injuries requiring surgical repair, urethral catheter drainage without SPT is the standard approach 1
• In some trauma centers, delaying catheterization until after CT imaging may be considered to allow a full bladder to tamponade pelvic bleeding 4
• Typical catheter size for adults is 14-16 Fr, with 16 Fr being most commonly used for routine catheterization 2
• Small caliber percutaneous SPT catheters will require upsizing in cases of hematuria, prolonged use, or in preparation for future definitive surgical repair 1

Troubleshooting Poor Drainage

• Verify collection bag is positioned below bladder level 5
• Check for catheter blockage from blood clots, sediment, or mucus 5
• Ensure proper catheter positioning in the bladder 5
• Consider gently flushing with 30ml sterile saline to check patency 5
• If drainage issues persist, catheter replacement may be necessary 5