What is the most appropriate next step for a patient with a history of recurrent gonococcal (gonorrheal) infections, presenting with abdominal pain, inability to urinate, and a distended bladder, after a failed transurethral catheter insertion?

Suprapubic Cystostomy is the Most Appropriate Next Step

In a patient with recurrent gonococcal infections presenting with acute urinary retention, distended bladder, and failed transurethral catheterization, suprapubic cystostomy (percutaneous bladder drainage) is the most appropriate immediate intervention to relieve the obstruction and prevent bladder rupture or renal complications. 1

Clinical Reasoning

Why Immediate Bladder Decompression is Critical

• Acute urinary retention with a distended bladder is a urological emergency that requires immediate decompression to prevent bladder rupture, upper tract damage, and post-obstructive diuresis 1
• The CT confirmation of bladder distension indicates significant urinary volume that must be drained urgently 1
• Failed transurethral catheterization suggests urethral obstruction, likely from gonococcal urethral stricture—a known complication of recurrent Neisseria gonorrhoeae infections 2

Why Each Option is Appropriate or Not

Option A (IV Fluids): Contraindicated—IV fluids would worsen bladder distension and increase risk of bladder rupture in a patient who cannot void 1

Option B (Ceftriaxone): Important but not the immediate priority—while treating the underlying gonococcal infection with ceftriaxone 500 mg IM is essential 3, antibiotics alone cannot relieve the mechanical obstruction causing acute retention 1

Option C (Retry Transurethral Catheter): Potentially harmful—repeated blind attempts at urethral catheterization risk creating false passages, worsening urethral trauma, and increasing spongiofibrosis 4. This approach delays definitive management.

Option D (Cystoscopy with Dilation): Inappropriate timing—while cystoscopy is the gold standard for diagnosing and treating urethral strictures 5, 6, attempting this procedure in a patient with acute retention and a severely distended bladder is technically difficult and risks bladder perforation 1

Recommended Management Algorithm

Immediate Management (First Hour)

1. Perform suprapubic cystostomy to decompress the bladder urgently 1

   • This can be done percutaneously at the bedside under local anesthesia with ultrasound guidance
   • Provides immediate relief and prevents upper tract complications

2. Administer ceftriaxone 500 mg IM plus doxycycline 100 mg orally twice daily for 7 days to treat gonococcal urethritis and likely chlamydial coinfection 3

   • The updated 2020 CDC guidelines recommend 500 mg (not 250 mg) for uncomplicated gonorrhea 3

Definitive Management (After Stabilization)

1. Perform retrograde urethrography 24-48 hours after bladder decompression to define the stricture length and location 5

   • This staging is essential before planning definitive treatment

2. Cystoscopy with urethral dilation or internal urethrotomy once the patient is stabilized and infection is controlled 5, 6

   • Cystoscopy is superior to urethrography for evaluating post-infectious strictures and allows immediate treatment 6
   • For initial strictures, endoscopic dilation is preferred over urethroplasty 5

Follow-up Considerations

• Screen for other sexually transmitted infections including HIV and syphilis, as gonorrhea frequently coexists with other STIs 2
• Retest in 3-6 months due to high reinfection rates 2
• If stricture recurs after initial endoscopic treatment, urethroplasty should be considered rather than repeated dilations 5

Critical Pitfalls to Avoid

• Never administer IV fluids to a patient in urinary retention—this worsens the obstruction and can precipitate bladder rupture
• Avoid repeated blind catheterization attempts—each failed attempt increases urethral trauma and subsequent fibrosis 4
• Do not delay bladder decompression to perform cystoscopy—the distended bladder must be drained first to prevent complications 1
• Always treat for concurrent chlamydial infection—coinfection rates are high, and untreated chlamydia contributes to urethral complications 3