What are the next steps for a patient with blood in the Foley (Foley catheter) catheter, suspected catheter-associated urethral trauma, and penile edema?

Management of Blood in Foley Catheter with Suspected Urethral Trauma

Stop immediately and do not attempt further urethral catheterization—remove the traumatic catheter, perform retrograde urethrography to assess injury extent, and establish urinary drainage via suprapubic tube if significant urethral trauma is confirmed. 1

Immediate Actions

Remove the current Foley catheter immediately to prevent further injury to the urethral tissue and surrounding structures. 1 The American Urological Association explicitly warns against repeated attempts at urethral catheterization, as this increases the extent of injury and delays appropriate drainage. 2, 1

Critical Assessment Steps

Before any intervention, evaluate for these key clinical findings that indicate urethral injury:

• Blood at the urethral meatus (present in 37-93% of urethral injuries) 2
• Penile edema (as noted in your patient) 2
• Perineal or scrotal hematoma 3
• High-riding or non-palpable prostate on digital rectal examination (indicates urethral disruption with superior displacement) 4, 3
• Inability to void or urinary retention 3

Diagnostic Imaging Required

Perform retrograde urethrography (RUG) before any further catheterization attempts. 2, 1, 4 This is a Grade C recommendation from the American Urological Association and is the gold standard for diagnosing urethral injuries. 2, 4

RUG Technique:

• Position patient obliquely with bottom leg flexed (or supine if contraindicated by other injuries) 2
• Introduce a 12Fr Foley catheter or catheter-tipped syringe into the fossa navicularis 2
• Place penis on gentle traction 2
• Inject 20 mL undiluted water-soluble contrast material 2
• If a catheter is already in place with blood present, perform a pericatheter retrograde urethrogram by injecting contrast through a 3Fr catheter held in the fossa navicularis 2

The RUG will demonstrate whether there is partial or complete urethral disruption, which directly guides management. 2

Definitive Management Based on Injury

If Significant Urethral Trauma Confirmed:

Place a suprapubic tube for urinary drainage. 1 This is the preferred method recommended by the American Urological Association for patients with significant urethral trauma, including meatal splitting or deeper injuries. 1

• Suprapubic tubes can be placed percutaneously or via open technique depending on clinical setting 2
• Small caliber percutaneous catheters will require upsizing in the setting of hematuria or prolonged use 2
• Prompt urinary drainage is critical, especially in trauma patients receiving aggressive hydration who require close volume monitoring 2

If Partial Urethral Injury:

In the acute setting of a partial urethral disruption, a single attempt with a well-lubricated catheter may be attempted by an experienced team member only. 2 However, given the presence of penile edema and blood in your patient, this should be approached with extreme caution and only after RUG confirmation.

Urologic Consultation

Obtain urgent urology consultation for all patients with catheter-induced urethral trauma. 1 Meatal lacerations and deeper urethral injuries typically require surgical repair to prevent meatal stenosis and ensure proper healing. 1

The urologist may need to perform:

• Exploration and limited debridement of non-viable tissue 1
• Primary closure when possible 1
• Delayed urethroplasty if complete disruption is present 2

Common Pitfalls to Avoid

Never perform blind catheter passage prior to retrograde urethrogram when blood is present at the meatus or when urethral injury is suspected. 2 This critical error can convert a partial injury into complete urethral transection, leading to catastrophic complications including stricture formation, impotence, and urinary incontinence. 3

Approximately 23% of urethral injuries are missed at initial evaluation, and blind catheterization significantly increases morbidity. 4, 3

Do not rely on CT scan alone to evaluate urethral injuries—CT has limitations in detecting urethral trauma and RUG remains the gold standard. 4

Special Considerations for Catheter-Induced Trauma

Iatrogenic urethral trauma from catheterization can cause serious complications beyond simple mucosal injury:

• Intra-urethral balloon inflation can occur, particularly if there is urethral sphincter spasm or false passage from previous trauma, leading to urethral erosion and fistula formation 5
• Pseudoaneurysm formation of the bulbar artery is a rare but life-threatening complication that presents with profuse bleeding after catheter removal 6
• Complete urethral erosion through to the penoscrotal junction can occur with prolonged unsecured catheterization 7

Prevention for Future Catheterizations

• Use the smallest appropriate catheter size 1
• Ensure adequate lubrication and gentle technique 1
• Always secure catheters properly to prevent traction injury 7
• Remove catheters as soon as clinically appropriate 1