Suprapubic Swelling: Immediate Assessment and Management
Establish immediate urinary drainage via suprapubic catheter if there is concern for urethral injury or catheter-related complications, while simultaneously ruling out life-threatening conditions like Fournier's gangrene or bladder trauma. 1, 2
Immediate Clinical Assessment
Look for these specific red flags:
- Signs of necrotizing infection (Fournier's gangrene): Fever, systemic toxicity, crepitus, skin discoloration, or foul-smelling discharge around the suprapubic area, perineum, or genitals 3
- Urethral injury indicators: Blood at the meatus, inability to void, perineal/genital ecchymosis, or recent catheterization trauma 1, 2
- Bladder trauma signs: Gross hematuria with recent pelvic trauma, penetrating injury, or inability to void 4
- Infection at catheter site: Erythema, warmth, purulent drainage, or fluctuance suggesting abscess formation 5
Management Algorithm Based on Clinical Presentation
If Fournier's Gangrene is Suspected (Most Critical)
This is a surgical emergency with high mortality—act within hours, not days. 3
- Start broad-spectrum antibiotics immediately covering gram-positive, gram-negative, aerobic/anaerobic bacteria, plus anti-MRSA coverage (piperacillin/tazobactam 4.5g q6h + clindamycin 600mg q6h for stable patients; add linezolid 600mg q12h or vancomycin for unstable patients) 3
- Perform emergency surgical debridement of all necrotic tissue as soon as diagnosis is suspected, with serial revisions every 12-24 hours until tissue is viable 3
- Consider suprapubic cystostomy if there is extensive penile/perineal involvement, urethral damage, or periurethral abscess 3
- Involve multidisciplinary team (general surgery, urology, intensivist, plastic surgery) immediately 3
If Urethral Injury is Suspected
Perform retrograde urethrography immediately (95.9% diagnostic accuracy) before attempting any catheter manipulation 1, 2
- If partial injury: Attempt gentle urethral catheter placement under direct vision 1
- If complete disruption or failed catheterization: Place suprapubic catheter immediately 1, 2
- Conservative management is preferred for blunt injuries with delayed definitive repair, reserving immediate surgical repair only for uncomplicated penetrating injuries in stable patients 1, 2
- Repeat urethrography every 2 weeks until complete healing is documented 1, 2
If Bladder Trauma is Suspected
Obtain CT cystogram or conventional cystogram to differentiate intraperitoneal from extraperitoneal rupture 4
- Intraperitoneal rupture: Mandatory open surgical repair in double-layer fashion with absorbable suture, followed by urethral catheter drainage for 2-3 weeks 4
- Extraperitoneal rupture: Conservative management with urethral catheter drainage for 2-3 weeks (85% heal within 10 days) 4
- Avoid routine suprapubic tube placement after bladder repair—urethral catheterization alone is standard and results in shorter hospital stay 4
If Simple Catheter Site Infection/Abscess
If fluctuant mass with purulent drainage:
- Obtain imaging (ultrasound or CT) to assess for abscess collection 5
- Drain any abscess percutaneously or surgically 5
- Start antibiotics (cephalexin or broader spectrum based on severity) 5
- Remove or replace indwelling catheter if present 5
Critical Pitfalls to Avoid
- Never delay drainage establishment in any suspected urethral injury—this worsens outcomes 2
- Never attempt forceful catheterization if urethral injury is suspected—this can convert partial to complete disruption 1, 2
- Never delay surgical debridement if Fournier's gangrene is suspected—mortality increases dramatically with each hour of delay 3
- Never perform immediate urethroplasty for posterior urethral injuries due to high rates of erectile dysfunction and incontinence 2