What is the most appropriate management for a patient with a history of chronic gonorrhoea, presenting with urinary retention, subrapubic dullness, and failed Foley catheter insertion?

Management of Urinary Retention with Failed Foley Catheter Insertion in Chronic Gonorrhea Patient

Proceed immediately with suprapubic catheterization to decompress the bladder, as this patient likely has urethral stricture from chronic gonorrhea and failed urethral catheterization is a specific indication for suprapubic tube placement. 1

Immediate Management Algorithm

Step 1: Confirm Urinary Retention and Bladder Distension

• The presence of suprapubic dullness on examination confirms significant bladder distension requiring urgent decompression 2
• Failed Foley catheter insertion in the context of chronic gonorrhea strongly suggests urethral stricture disease, as chronic gonococcal infection is a well-documented cause of urethral stricture formation 3

Step 2: Proceed with Suprapubic Catheterization

• Suprapubic catheterization is the definitive next step when urethral catheterization fails or is difficult 4
• This approach is specifically indicated for patients with urethral stricture, as it eliminates the risk of further urethral damage from repeated catheterization attempts 1
• Use ultrasound guidance during placement to significantly reduce the risk of bowel perforation and vascular injury 1, 4

Step 3: Avoid Repeated Urethral Catheterization Attempts

• Do not attempt multiple passes with progressively larger catheters or dilators in the acute setting, as this risks creating false passages and worsening urethral trauma 5
• Forcing a catheter through a stricture can cause urethral erosion, bleeding, and potentially complete urethral disruption 4

Why Suprapubic Catheterization is Superior in This Case

• Suprapubic catheters are strongly recommended over indwelling urethral catheters for patients requiring chronic catheterization, with lower rates of urinary tract infection (RR 2.60 for urethral vs. suprapubic), significantly less discomfort (RR 2.98), and elimination of urethral trauma risk 5, 1
• In patients with known or suspected urethral pathology (stricture from chronic gonorrhea), suprapubic access preserves the urethra for future definitive reconstruction 1
• Patients can attempt normal voiding trials without requiring recatheterization once the acute retention is managed 1

Definitive Management Planning After Acute Decompression

Stricture Evaluation

• Once the bladder is decompressed via suprapubic catheter, arrange for retrograde urethrography (RUG) with or without voiding cystourethrography (VCUG) to delineate stricture length, location, and severity 5
• Urethroscopy can identify and localize the stricture but cannot assess length or proximal urethra adequately 5

Treatment Options Based on Stricture Characteristics

• For short bulbar strictures (<2 cm): Options include urethral dilation, direct visual internal urethrotomy (DVIU), or urethroplasty, though urethroplasty has superior long-term success rates (90-95% vs. 35-70% for endoscopic approaches) 5
• For longer or complex strictures: Urethroplasty is the definitive treatment, and the suprapubic catheter can remain in place until definitive reconstruction 5
• Endoscopic treatment success depends heavily on stricture location and length, with highest success in bulbar strictures <1 cm 5

Critical Pitfalls to Avoid

• Never delay bladder decompression: Prolonged retention can lead to bladder decompensation, hydronephrosis, and renal injury 2
• Do not attribute the retention solely to infection: While gonorrhea can cause acute urethritis, the 2-day history of complete retention with failed catheterization indicates structural obstruction (stricture) rather than simple inflammatory edema 6, 3
• Avoid blind or forceful catheterization attempts: This risks creating false passages, complete urethral disruption, and converting a manageable stricture into a complex reconstruction problem 5
• Do not place a suprapubic catheter without discussing risks: Engage in thorough discussion of risks including bleeding, bowel perforation, vascular injury, and need for specialized catheter changes 1

Post-Procedure Management

• Remove the suprapubic catheter as soon as clinically appropriate after definitive stricture treatment to minimize infection risk and other catheter-related complications 1
• If the patient requires long-term catheterization before definitive repair, suprapubic catheterization remains superior to urethral catheterization for reducing UTI rates and urethral complications 5, 1
• Treat any active gonococcal infection with appropriate antibiotics per current CDC guidelines, though this will not reverse established stricture disease 6