Immediate Management of Non-Functioning Foley Catheter with Suprapubic Pain
Replace the catheter immediately with a new, appropriately sized Foley catheter (14-16 Fr for adults), as the current catheter is likely obstructed despite attempted irrigation and the patient's suprapubic pain indicates bladder distension requiring urgent decompression. 1
Initial Assessment and Catheter Replacement
Remove and replace the current catheter rather than continuing attempts at irrigation, as persistent obstruction despite flushing indicates catheter failure (blockage from clot, debris, or malposition) 1, 2
Use a 14-16 Fr catheter as this is the standard appropriate size for adults that minimizes urethral trauma while maintaining adequate drainage 1, 2
Ensure proper catheter placement by confirming urine return immediately after insertion and verify the balloon is inflated within the bladder (typically 10 mL for standard Foley) 1
Position the drainage bag below bladder level to prevent reflux and ensure gravity-dependent drainage 2
Rule Out Contributing Factors
The suprapubic pain combined with absent urine output suggests bladder distension, but several underlying causes must be addressed:
Evaluate for urinary tract infection, as this commonly causes catheter-associated complications including obstruction from debris and bladder spasms that can occlude the catheter 1, 3
Obtain urine culture before initiating antibiotics if infection is suspected based on fever, cloudy/malodorous urine, or systemic signs 1
Assess for constipation through abdominal examination and history, as fecal impaction can cause external compression of the bladder and catheter dysfunction; treat with laxatives if present 1, 4
Check for bladder spasms which can collapse the catheter lumen and prevent drainage despite patency 4
When Conservative Measures Fail
If catheter replacement does not restore urine output or suprapubic pain persists:
Obtain urgent urology consultation for persistent symptoms unresponsive to catheter replacement, as this may indicate bladder pathology (stones, clots, tumor), urethral injury, or need for cystoscopy 1
Consider bladder ultrasound to confirm bladder distension if diagnosis is uncertain, though clinical presentation of suprapubic pain with no output is highly suggestive 3
In trauma patients or those with recent pelvic procedures, obtain retrograde cystography to rule out bladder rupture before further catheter manipulation 1, 5
Suprapubic catheter placement may be necessary if urethral catheterization repeatedly fails or urethral injury is suspected 3
Prevention of Recurrence
Remove the Foley catheter within 24-48 hours when clinically appropriate to minimize ongoing bladder irritation, infection risk, and trauma 1, 2
Avoid routine prophylactic antibiotics as they do not prevent catheter-associated complications and promote resistant organisms 3, 1
For patients requiring long-term catheterization with recurrent blockage, consider a regular catheter change schedule rather than waiting for obstruction to occur 2
Maintain a closed drainage system at all times to minimize infection risk, which can lead to debris formation and catheter obstruction 2
Critical Pitfalls to Avoid
Do not continue aggressive irrigation of an obstructed catheter, as this can cause bladder rupture in a distended bladder or worsen urethral trauma 6
Do not delay catheter replacement while pursuing diagnostic workup in a patient with suprapubic pain and no output, as bladder distension itself causes morbidity and can lead to bladder rupture 6
Do not treat asymptomatic bacteriuria if discovered incidentally, as this leads to antimicrobial resistance without clinical benefit; only treat symptomatic UTI 3, 6