What are the guidelines for using a Foley catheter in patients with pelvic fractures?

Foley Catheter Management in Pelvic Fractures

Do not blindly insert a Foley catheter in patients with pelvic fractures if blood is present at the urethral meatus—perform retrograde urethrography first to avoid catastrophic complications including complete urethral transection, stricture formation, impotence, and urinary incontinence. 1, 2, 3

Initial Clinical Assessment

Before any catheterization attempt, perform a digital rectal examination (DRE) to screen for urethral injury 3:

• High-riding or non-palpable prostate indicates urethral disruption with superior displacement 3
• Blood in the rectum or rectal wall weakness suggests associated rectal injury (present in up to 5% of urethral trauma cases) 3
• Perineal or scrotal hematoma signals potential urethral injury 3
• Blood at the urethral meatus is the most common finding (present in 37-93% of urethral injuries) 1, 3

Critical pitfall: Urethral injuries occur in 7-25% of pelvic ring fractures, yet approximately 23% are missed at initial evaluation 3. Blind catheter insertion without proper evaluation can cause complete urethral transection and permanent complications 3.

Catheterization Algorithm

If NO blood at meatus AND negative DRE findings:

• Standard urethral catheterization with 14-16 Fr Foley catheter is appropriate 2
• No imaging required before catheterization 2

If blood at meatus OR positive DRE findings:

• Perform retrograde urethrography (RUG) before any catheterization attempt 1, 2, 3
• RUG is particularly critical with higher degrees of soft tissue disruption, bone displacement, or multiple fractures 1

Based on RUG results:

Complete urethral disruption:

• Place suprapubic tube (SPT) for urinary drainage 2, 4
• Do NOT attempt urethral catheterization 2
• Avoid repeated catheter attempts as this increases injury extent and delays drainage 2

Partial urethral disruption:

• May allow a single attempt with well-lubricated catheter by experienced provider 2
• If unsuccessful, proceed to SPT placement 2

Intact urethra:

• Standard Foley catheter placement is safe 2

Timing Considerations for Imaging

When hemodynamic status permits and urethral injury is suspected, late contrast CT-scan with urologic study is recommended over performing RUG before CT 1. This is because performing RUG before CT can increase the rate of indeterminate and false-negative CT-scans 1.

However, in hemodynamically unstable patients: Establish urinary drainage promptly—this takes priority over imaging 2, 4.

Suprapubic Tube Management

• SPT may be placed percutaneously or via open technique depending on clinical setting 2
• Small caliber percutaneous SPT catheters will require upsizing in cases of hematuria, prolonged use, or in preparation for future definitive surgical repair 2
• Prompt urinary drainage is essential in pelvic fracture urethral injury (PFUI) 2

Special Considerations

Primary realignment: May be considered in hemodynamically stable patients with PFUI, but should not involve prolonged endoscopic attempts 2. Traditional management remains SPT placement with delayed urethroplasty (at least 3 months post-trauma) 1, 4. Attempts at immediate sutured repair of posterior urethral injury are associated with unacceptably high rates of erectile dysfunction and urinary incontinence 1.

Concomitant bladder injuries: Present in 15% of pelvic fracture urethral injuries 1. For patients with bladder injuries requiring surgical repair, urethral catheter drainage without SPT is the standard approach 2.

If catheter already placed before evaluation: Perform a pericatheter retrograde urethrogram to identify potential missed urethral injury 2.