What is the management for a urinary catheter-induced urethral injury?

Management of Urinary Catheter-Induced Urethral Injury

Establish urinary drainage immediately via either urethral catheter (if passable) or suprapubic catheter, then pursue conservative management with delayed definitive repair for most injuries, reserving immediate surgical repair only for hemodynamically stable penetrating injuries without life-threatening associated trauma. 1

Immediate Management: Secure Urinary Drainage

The first priority is establishing urinary drainage as soon as possible. 1, 2

• Attempt gentle urethral catheter placement first if there is no contraindication and the injury appears partial. 1, 2
• Place a suprapubic catheter if urethral catheterization fails or if there is complete urethral disruption. 1
• Urethral catheterization has equivalent efficacy to suprapubic cystostomy when feasible, so routine suprapubic tube placement is not mandatory. 1

Critical Pitfall to Avoid

Never attempt forceful catheter passage or immediate urethroplasty for posterior urethral injuries, as this leads to unacceptably high rates of erectile dysfunction and urinary incontinence. 1, 2

Diagnostic Evaluation

Perform retrograde urethrography to define the extent and location of injury. 1, 2

• Retrograde urethrography has 95.9% diagnostic accuracy and should be done when urethral injury is suspected. 2
• Repeat urethrography every two weeks until complete healing is documented. 1
• Look for blood at the meatus (present in 37-93% of cases), inability to void, perineal/genital ecchymosis, or high-riding prostate on exam. 1, 2

Definitive Management Algorithm

For Anterior Urethral Injuries (Iatrogenic Catheter Trauma)

Initial conservative management with urinary drainage is the treatment of choice. 1

• Place urethral or suprapubic catheter and observe. 1, 2
• Attempt endoscopic realignment before considering surgery. 1
• Delayed surgical repair (urethroplasty) should be considered only if conservative treatment fails after endoscopic approach. 1
• For incomplete injuries, trans-urethral catheter placement alone may suffice. 1

For Posterior Urethral Injuries

Conservative management with planned delayed surgical treatment is recommended. 1

• In hemodynamically stable patients with complete posterior urethral disruption, immediate endoscopic realignment is preferred over immediate urethroplasty, as it is associated with improved outcomes. 1
• If endoscopic realignment is unsuccessful, place suprapubic catheter and perform delayed urethroplasty, preferably within 14 days from injury. 1
• Traditional management with suprapubic tube placement and delayed urethroplasty remains acceptable, though endoscopic realignment has become more common with improved techniques. 1, 3

For Penetrating Injuries

Immediate direct surgical repair is recommended for uncomplicated penetrating anterior urethral injuries in hemodynamically stable patients. 1

• Selected incomplete penetrating injuries may be managed conservatively with trans-urethral catheter. 1
• For large anatomic defects (>2-3 cm in bulbar urethra, >1.5 cm in penile urethra), perform urethral marsupialization with suprapubic catheter and delayed reconstruction with graft or flap at >3 months. 1

Expected Complications and Long-Term Outcomes

Urethral stricture formation is the most common long-term complication, occurring in 78% of iatrogenic catheter injuries. 4

• Strictures may require urethral dilation (common) or internal urethrotomy (less common). 3, 4
• The rate of stricture after primary realignment of posterior injuries ranges from 14-100%, with most patients eventually requiring repeated instrumentation or formal urethroplasty. 1
• Impotence occurs in approximately 42% of posterior urethral injuries, likely related to injury severity rather than management approach. 3
• Catheter-associated urinary tract infection occurs in 13% of cases, with rare progression to sepsis. 5
• Some patients may require long-term indwelling suprapubic or urethral catheter. 4

Follow-Up Protocol

Use urethrography or ureteroscopy for follow-up imaging. 1, 2

• Perform urethrography every two weeks until complete healing is documented for blunt anterior injuries. 1
• Monitor for development of stricture disease with regular outpatient visits. 4
• Be prepared for additional hospital admissions, intensive care needs, and multiple outpatient visits, as traumatic catheterization significantly increases resource utilization. 5

Key Clinical Pearls

• Most iatrogenic catheter injuries occur in elderly men (median age 69-74 years) with pre-existing urologic conditions like benign prostatic hyperplasia or urethral stricture. 5, 4
• The most common mechanisms are balloon inflation in the urethra (70%) or creation of false passage (30%). 4
• Gross hematuria is the most common presenting sign (50% of patients). 5
• Mechanical trauma from catheters represents the complication with highest morbidity, suggesting need for improved catheter design and insertion technique. 6