What is the management of a urethral rupture during catheterization?

Management of Urethral Rupture During Catheterization

Immediately stop catheterization attempts and establish urinary drainage via suprapubic catheter, followed by retrograde urethrography to define the injury extent, then pursue conservative management with delayed definitive repair. 1, 2

Immediate Actions

Stop all further catheterization attempts to avoid converting a partial injury into complete urethral transection. 3 The passage of a catheter after suspected urethral injury is clinically misleading and surgically dangerous, as it can destroy any remaining viable tissue bridges. 3

Establish Urinary Drainage

• Place a suprapubic catheter as the preferred initial drainage method when urethral catheterization has caused injury or failed. 4, 1, 2
• Gentle urethral catheter placement may be attempted only if the injury appears partial and there are no contraindications, but suprapubic drainage should be used if this fails. 1
• Urinary drainage should be obtained as soon as possible in any traumatic urethral injury. 4, 2

A critical pitfall: Do not repeatedly attempt urethral catheterization after initial failure, as this causes progressive urethral damage. 5 One case report documented five catheterization attempts before recognition of urethral perforation, resulting in catheter balloon placement in the penile urethra with prolonged complications. 5

Diagnostic Evaluation

• Perform retrograde urethrography immediately to define the extent and location of injury, which has a diagnostic accuracy of 95.9%. 1, 2
• If retrograde urethrography is not immediately available, CT of the pelvis including the penis can detect urethral trauma and catheter misplacement. 5
• Repeat urethrography every two weeks until complete healing is documented. 4, 1, 2

Definitive Management Strategy

For Iatrogenic Anterior Urethral Injuries (Most Catheter-Related Injuries)

• Initial conservative management with urinary drainage is the treatment of choice. 1, 2
• Maintain suprapubic catheter drainage and pursue delayed definitive repair after accurate evaluation of injury extent. 4, 1
• Attempt endoscopic realignment before considering surgery if conservative management fails. 4, 1, 2
• Delayed surgical repair (urethroplasty) should be considered only after failure of conservative treatment following endoscopic approach. 4

The evidence strongly favors avoiding immediate surgical intervention. Historical data from 1977 demonstrates that suprapubic catheter drainage without local exploration produces sufficiently good results to make immediate local readjustment inadvisable except by surgeons with special experience in urethral trauma. 6

For Posterior Urethral Injuries (Less Common with Catheterization)

• Conservative management with planned delayed surgical treatment is recommended, allowing multidisciplinary management with experienced urologists. 4, 1
• Immediate urethroplasty for posterior injuries carries high complication rates including erectile dysfunction and incontinence. 2

Expected Outcomes and Complications

• Stricture rates after urethral injury range from 14-100%, with most patients eventually requiring repeated instrumentation or formal urethroplasty. 1
• In one series of catheter realignment (either immediate or within 5 weeks), 54% developed strictures during follow-up, but most responded well to internal urethrotomy or simple dilation. 7
• Impotence may result from the severity of the injury itself rather than from catheterization management. 7

Critical Pitfalls to Avoid

• Never attempt repeated forceful catheterization after initial failure or resistance, as this converts partial ruptures into complete transections. 3
• Do not delay establishing urinary drainage once urethral injury is suspected—suprapubic catheter placement is not an emergency surgery but should be done promptly. 2
• Avoid immediate surgical repair unless dealing with an uncomplicated penetrating injury in a hemodynamically stable patient with an experienced surgeon available. 1, 2
• Do not assume proper catheter placement based on urine drainage alone—imaging confirmation is essential when injury is suspected. 5