Management of Traumatic Foley Removal with Intact Balloon and Blood at Meatus
In a patient with traumatic Foley catheter removal (balloon intact) presenting with blood at the urethral meatus but no active bleeding, perform retrograde urethrography immediately before attempting any catheter replacement to identify urethral injury, and establish urinary drainage via suprapubic tube if complete urethral disruption is confirmed. 1, 2
Immediate Assessment
Do not blindly insert another urethral catheter. The presence of blood at the urethral meatus is a critical warning sign that mandates imaging before any further urethral instrumentation. 1, 2
Diagnostic Imaging Priority
- Perform retrograde urethrography as the first-line diagnostic test in all patients with blood at the urethral meatus following traumatic catheter removal. 1, 2
- If a catheter is already in place and blood is present, perform a pericatheter retrograde urethrogram to identify potential missed urethral injury. 1
- This imaging will differentiate between complete urethral disruption, partial urethral injury, or isolated mucosal trauma. 1
Management Algorithm Based on Urethrography Findings
Complete Urethral Disruption
- Place a suprapubic tube (SPT) for urinary drainage if retrograde urethrography demonstrates complete urethral disruption. 1
- Prompt urinary drainage is essential in patients with urethral injury. 1
- SPT may be placed percutaneously or via open technique depending on clinical setting and institutional expertise. 1
- Avoid repeated attempts at urethral catheter placement, as this increases injury extent and delays appropriate drainage. 1
Partial Urethral Disruption
- A single attempt with a well-lubricated catheter by an experienced provider may be considered if partial urethral disruption is identified. 1
- If this single attempt fails, proceed to suprapubic tube placement. 1
- Monitor for gross hematuria development after catheter placement, which may indicate worsening urethral trauma or coagulopathy. 2
Isolated Mucosal Injury (No Disruption)
- If urethrography shows only mucosal injury without disruption, gentle placement of a small-caliber urethral catheter (14-16 Fr) by an experienced provider is appropriate. 2, 3
- Use the smallest appropriate catheter size to minimize further urethral trauma. 2, 3
Monitoring and Follow-Up
- Monitor vital signs for hemodynamic changes, though hypotension from the injury itself is uncommon unless associated with other trauma. 2
- Allow free drainage of urine after catheter insertion while monitoring for persistent or worsening gross hematuria. 2
- Maintain a closed urinary drainage collection system with the bag positioned below the catheter insertion site. 2
Critical Pitfalls to Avoid
The most dangerous error is attempting blind re-catheterization without imaging. This can convert a partial urethral injury into complete disruption, create false passages, or cause pseudoaneurysm formation. 1, 4, 5
- Traumatic catheter removal with balloon inflation in the urethra can cause significant urethral injury including false passage formation, urethral erosion, and even pseudoaneurysm of the bulbar artery. 6, 7, 4, 5
- Multiple failed catheterization attempts by inexperienced providers significantly worsen outcomes and can lead to long-term complications including urethral stricture and fistula formation. 5
- In patients with neurogenic bladder or spinal cord injury, lack of urethral sensation may mask severe injury, making imaging even more critical before re-catheterization. 5, 8
Special Considerations
- If the patient is hemodynamically unstable or has other injuries requiring operative management, coordinate urological consultation for intraoperative assessment. 1
- Primary realignment may be considered in hemodynamically stable patients with complete urethral injury, but should not involve prolonged endoscopic attempts. 1
- Small caliber percutaneous SPT catheters will require upsizing in cases of persistent hematuria or prolonged use. 1