Should a Foley catheter be removed in a patient suspected to have catheter-associated urethral trauma and penile edema?

Should the Foley Catheter Be Removed in Suspected Catheter-Associated Urethral Trauma with Penile Edema?

Yes, remove the Foley catheter immediately and establish alternative urinary drainage via suprapubic tube placement. Continued catheterization in the setting of suspected urethral trauma will worsen the injury and delay appropriate management 1.

Immediate Management Algorithm

Step 1: Remove the Traumatic Catheter

• The catheter must be removed immediately to prevent further injury to the urethra and surrounding tissue 1.
• Repeated catheterization attempts or leaving a traumatic catheter in place increases the extent of injury and delays appropriate drainage 1, 2.
• Catheter-associated urethral trauma is as common as symptomatic urinary tract infections in catheterized patients, with intervention-requiring trauma occurring in 0.5% of catheter days 3.

Step 2: Establish Alternative Urinary Drainage

• Suprapubic tube (SPT) placement is the preferred method for urinary drainage in patients with significant urethral trauma 1, 2.
• SPT can be placed percutaneously or via open technique depending on clinical stability 2.
• Do not attempt to reinsert a urethral catheter, as this will compound the existing injury 1.

Step 3: Perform Retrograde Urethrography

• Obtain retrograde urethrography to assess the extent of urethral injury before any further urethral instrumentation 4, 1.
• The study is performed by introducing a catheter into the fossa navicularis, placing the penis on gentle traction, and injecting 20 mL of undiluted water-soluble contrast material 4.
• If the patient has pelvic trauma or blood at the urethral meatus, retrograde urethrography is mandatory before attempting any catheterization 4, 2.

Step 4: Obtain Urgent Urology Consultation

• All patients with suspected urethral trauma from catheterization require urgent urology consultation 1.
• Urethral lacerations and meatal splitting typically require surgical repair to prevent meatal stenosis and ensure proper healing 1.
• The urologist will perform exploration, limited debridement of non-viable tissue, and primary closure when possible 1.

Key Clinical Indicators Supporting Removal

Evidence of Catheter-Associated Trauma

• Penile edema in the setting of catheterization suggests significant urethral or periurethral injury 5.
• Catheter-associated trauma requiring intervention (prolonged catheterization or cystoscopy) occurs in 32% of trauma cases, accounting for 0.5% of all catheter days 3.
• In one quality improvement study, the incidence of catheter-associated trauma during placement was 41.1% before protocol implementation, with 53.4% requiring urologic procedures 6.

Risks of Continued Catheterization

• Chronic indwelling catheters cause mechanical trauma to the urethra and glans penis, including ventral penile erosion in severe cases 5.
• Forceful extraction or continued presence of a traumatic catheter causes deep lacerations or urethral disruption in the majority of cases 7.
• Leaving a catheter in place after trauma delays definitive management and increases the risk of complications including stricture formation and fistula development 1.

Common Pitfalls to Avoid

• Do not attempt to replace the catheter with a larger size to "improve drainage" in the setting of suspected trauma—this will worsen the injury 1.
• Do not leave the catheter in place "temporarily" while awaiting urology consultation—the catheter itself is causing ongoing injury and must be removed 1.
• Do not perform blind catheter passage if there is any suspicion of urethral injury; imaging must be obtained first 4, 2.
• Do not attribute penile edema solely to infection or fluid overload without ruling out mechanical trauma from the catheter 5.

Special Considerations

If Blood is Present at the Meatus

• Blood at the urethral meatus after catheterization indicates urethral injury until proven otherwise 4, 2.
• Even if a catheter has already been placed, perform a pericatheter retrograde urethrogram to identify potential missed urethral injury 4, 2.

If Pelvic Trauma is Present

• In patients with pelvic fractures, blind catheter insertion before retrograde urethrography can worsen urethral injury 2.
• Suprapubic tube placement is the appropriate initial drainage method for complete urethral disruption 2.
• A single attempt with a well-lubricated catheter by an experienced provider may be attempted only in cases of partial urethral disruption confirmed by imaging 4, 2.

Prevention for Future Catheterizations

• Use the smallest appropriate catheter size (14-16 Fr) to minimize urethral trauma 1.
• Ensure adequate lubrication and gentle technique during all catheter insertions 1.
• Remove catheters as soon as clinically appropriate—ideally within 24 hours after surgery in most cases—to prevent ongoing trauma and complications 4, 1.