What is the management approach for a patient with penile trauma and swelling caused by a chronic Foley (indwelling urinary) catheter?

Management of Penile Trauma and Swelling from Chronic Foley Catheter

Remove the catheter immediately and establish alternative urinary drainage via suprapubic cystostomy to prevent further mechanical trauma, while assessing the extent of urethral and penile injury. 1

Immediate Assessment and Catheter Management

Remove the Offending Catheter

• The chronic indwelling catheter must be removed immediately to halt ongoing mechanical trauma to the urethra and glans penis 2, 3
• Chronic catheterization causes urogenital trauma as commonly as symptomatic urinary tract infections, with ventral penile erosion being a well-documented complication 2
• Continued catheterization with penile trauma is considered a preventable "Never Event" in patients requiring long-term bladder management 3

Establish Alternative Urinary Drainage

• Place a suprapubic catheter (SPT) to maintain urinary drainage while allowing the urethra and penis to heal 1
• Suprapubic catheterization is specifically recommended for cases with associated perineal injuries and urethral trauma 1
• Urethral catheterization should be avoided when there is evidence of urethral injury or significant penile trauma 1

Diagnostic Evaluation

Assess Extent of Urethral Injury

• Perform retrograde urethrography before any attempt at urethral catheter replacement if there is blood at the meatus, difficulty with catheterization, or visible penile trauma 1, 4
• Retrograde urethrography has 95.9% diagnostic accuracy for detecting urethral injuries and should be done without delay 4
• A critical pitfall is assuming symptoms are benign without imaging—trauma may mask partial urethral injury requiring different management 4

Imaging for Penile Trauma

• Obtain CT of the pelvis including the penis to assess the full extent of urethral perforation, catheter misplacement, and soft tissue injury 5
• CT imaging is valuable for detecting urethral trauma and documenting incorrect catheter positioning that may not be apparent on physical examination 5
• Ultrasound can be used to assess penile injuries and determine the extent of tissue damage 6

Look for Specific Complications

• Assess for ventral penile erosion, which occurs when chronic catheters cause pressure necrosis of the glans and penile shaft 2, 3
• Check for urethral perforation, which may present with persistent urine leakage around the catheter site or inability to drain adequately 5
• Evaluate for scrotal edema and perineal swelling, which indicate more extensive tissue injury 2

Conservative Management During Healing Phase

Suprapubic Drainage Duration

• Maintain suprapubic catheter drainage for 2-3 weeks to allow complete resolution of urethral inflammation and healing of traumatic injuries 4
• Perform follow-up urethrography every two weeks until complete healing is confirmed before considering urethral catheter replacement 1

Wound Care for Penile Trauma

• Provide local wound care for any penile erosions or skin breakdown
• Monitor for signs of infection including increased erythema, purulent drainage, or systemic signs 7
• Consider urology consultation for significant tissue loss or deep erosions requiring surgical debridement 7

Surgical Intervention

Indications for Surgical Repair

• Delayed surgical repair should be considered if conservative management fails after 3-4 weeks of suprapubic drainage 1
• Immediate surgical exploration is indicated for complete urethral disruption, significant tissue loss, or associated bladder neck injuries 1
• Urethroplasty with graft or flap reconstruction may be necessary for large anatomic defects (>2-3 cm in bulbar urethra, >1.5 cm in penile urethra) 1

Timing of Definitive Repair

• Preferably perform delayed urethroplasty within 14 days from injury if endoscopic approaches are unsuccessful 1
• Interval urethroplasty at >3 months is indicated for complex cases requiring graft or flap reconstruction 1

Prevention of Recurrence

Catheter Selection and Technique

• Use the smallest appropriate catheter size (14-16 Fr) to minimize urethral trauma if future catheterization is required 7, 8
• Ensure proper catheter securement to prevent traction and movement that causes erosion 2, 3
• Avoid taping the catheter to the anterior abdominal wall in a way that creates tension on the ventral penis 2

Long-Term Bladder Management Alternatives

• Consider permanent suprapubic catheterization for patients requiring long-term drainage rather than chronic urethral catheterization 8
• Evaluate for intermittent catheterization programs if the patient has adequate hand function and cognitive ability 3
• Remove catheters as soon as clinically appropriate to prevent ongoing trauma and reduce infection risk 7

Common Pitfalls to Avoid

• Never assume penile swelling and trauma are benign without imaging—partial urethral injuries may be masked by external findings 4
• Do not attempt repeated urethral catheterization in the presence of trauma, as this increases injury extent and delays appropriate drainage 1
• Avoid inflating the Foley balloon in the urethra rather than the bladder, which causes severe urethral trauma and is a preventable Never Event 3
• Do not delay imaging in patients with suspected urethral injury, as early diagnosis significantly impacts management and outcomes 5