What is the most appropriate next step for a patient with a history of gonorrheal (gonococcal) infection, who is unable to empty their bladder, has failed transurethral catheterization, has a normal urinalysis, and has a full bladder on ultrasound?

Suprapubic Catheterization

In a patient with urinary retention, failed transurethral catheterization, and history of gonorrheal infection (suggesting possible urethral stricture), the most appropriate next step is flexible cystoscopy (Option B) to visualize the urethral obstruction, identify the etiology, and facilitate catheter placement under direct vision. 1

Clinical Reasoning

Why Failed Catheterization Occurred

• History of gonorrheal infection is a critical risk factor for urethral stricture formation, which is the most likely cause of failed catheterization in this patient 2
• Urethral strictures commonly present with inability to empty the bladder, weak stream, and difficulty with catheterization 2
• The normal urinalysis makes active infection less likely but does not exclude chronic structural damage from prior gonococcal urethritis 2

Why Flexible Cystoscopy is the Correct Answer

Flexible cystoscopy allows direct visualization of the urethral obstruction (stricture, false passage, or other pathology) and facilitates safe catheter placement under direct vision using guidewire technique. 1

• In a prospective study of 54 patients with failed catheterization, bedside flexible cystoscopy successfully achieved bladder drainage in 52 patients (96%) by identifying the obstruction and placing a guidewire under direct vision, followed by graduated dilation and Council-tipped catheter placement 1
• This approach avoids the complications of blind repeated catheterization attempts, including false passage creation, urethral perforation, and increased edema 1
• Flexible cystoscopy can be performed at bedside with topical lidocaine anesthesia, making it practical and minimally invasive 1

Why Other Options Are Incorrect

Option A (Repeat transurethral catheterization): Blind repeated catheterization attempts increase patient morbidity and can cause catastrophic complications including complete urethral transection, stricture formation, false passages, and urethral perforation 3, 1

Option C (Anti-gonorrhea treatment): While the patient has a history of gonorrheal infection, the normal urinalysis suggests no active infection 4. The current problem is mechanical obstruction (likely stricture) from prior infection, not active gonorrhea requiring antimicrobial therapy 2

Option D (Alpha blocker): Alpha blockers are used for functional bladder outlet obstruction from benign prostatic hyperplasia, not for mechanical urethral obstruction from stricture 2. This patient's failed catheterization indicates structural pathology requiring direct visualization and intervention 1

Clinical Algorithm

1. Perform flexible cystoscopy to visualize the urethra and identify the location, length, and severity of obstruction 1

2. Under direct vision, pass a 0.038-inch guidewire through the area of obstruction 1

3. Dilate the stricture using graduated dilators over the guidewire if needed 1

4. Place a Council-tipped catheter over the guidewire to establish bladder drainage 1

5. If cystoscopy fails or reveals complete urethral disruption, place a suprapubic catheter for urinary drainage 5, 3

Important Caveats

• If urethral trauma is suspected (blood at meatus, pelvic fracture, perineal hematoma), retrograde urethrography must be performed before any catheterization attempt 5, 6, 3
• However, this patient's presentation with prior gonorrheal infection and normal urinalysis suggests chronic stricture rather than acute trauma 2
• After establishing drainage, definitive stricture management (dilation, urethrotomy, or urethroplasty) should be planned based on stricture characteristics 2