What is the management for urethral sphincter spasm after Foley catheter removal in a patient with blunt abdominal trauma without renal or bladder injury?

Management of Urethral Sphincter Spasm Post-Foley Removal in Blunt Abdominal Trauma

In a patient with blunt abdominal trauma without renal or bladder injury who develops urethral sphincter spasm after Foley catheter removal, the primary management is conservative with pharmacologic muscle relaxation using skeletal and smooth muscle relaxants, combined with temporary urethral catheter reinsertion if urinary retention occurs. 1

Initial Assessment and Diagnosis

When urethral sphincter spasm occurs post-catheter removal, first confirm there is no occult urethral injury that was missed during initial trauma evaluation:

• Perform retrograde urethrography if any blood at the meatus, inability to void, or signs of urethral trauma are present, as this has 95.9% diagnostic accuracy 2
• Rule out false passage or urethral trauma from the initial catheterization itself, which can cause secondary sphincter spasm 3
• Assess for autonomic dysreflexia symptoms (sweating, increased spasms, hypertension) which indicate significant urethral irritation or obstruction 3

A critical pitfall is assuming sphincter spasm is benign without imaging—in trauma patients, spasm may mask partial urethral injury that requires different management. 2, 4

Conservative Management Algorithm

For confirmed sphincter spasm without structural urethral injury:

• Administer skeletal and smooth muscle relaxants as first-line therapy 1
  • Diazepam is specifically effective for external sphincter spasticity 5
  • Alpha-adrenergic blockers (adrenolytic agents) help relax the internal sphincter mechanism 5
• Provide adequate analgesia, as pain can perpetuate sphincter spasm 1
• Trial of voiding after 4-6 hours of pharmacologic therapy 1

Catheter Reinsertion Strategy

If urinary retention persists despite medical management:

• Reinsert a well-lubricated 14-16 Fr urethral catheter by an experienced provider 4, 6
• Use a single gentle attempt only—repeated attempts increase risk of creating false passage and worsening spasm 4, 3
• If urethral catheterization fails or meets significant resistance, place suprapubic catheter rather than forcing urethral access 4
• Leave catheter in place for 2-3 weeks to allow complete resolution of sphincter irritation 6

The evidence strongly supports urethral catheterization over routine suprapubic tube placement when urethral access is achievable, as both have equivalent efficacy but urethral catheters have lower morbidity. 7

Follow-Up Protocol

• Perform urethrography before catheter removal to confirm no structural injury developed 7, 2
• Trial of void after catheter removal with post-void residual measurement 1
• Continue muscle relaxants for 1-2 weeks after successful voiding resumes 1, 5

Special Considerations in Trauma Context

In blunt abdominal trauma patients specifically:

• Sphincter spasm may be reactive to pelvic hematoma or retroperitoneal inflammation even without direct urethral injury 8
• Associated pelvic fractures increase risk of occult urethral injury—maintain high suspicion and low threshold for imaging 4
• If patient has neurologic injury from trauma, spasm may be neurogenic rather than reactive, requiring longer-term management 3, 9

Never assume sphincter spasm is purely functional in trauma patients—always exclude structural injury first, as missed urethral trauma can lead to stricture, fistula, or chronic retention. 2, 3