What causes a Foley catheter to suddenly dislodge and how should it be managed, particularly if a urethral stricture is suspected?

Foley Catheter Dislodgement in the Setting of Urethral Stricture

When a Foley catheter suddenly dislodges in a patient with suspected urethral stricture, do not blindly attempt reinsertion—instead, perform retrograde urethrography first to define the stricture anatomy, then proceed with either guidewire-assisted dilation, direct visual internal urethrotomy, or suprapubic cystostomy depending on the clinical urgency and stricture characteristics. 1

Why Urethral Strictures Cause Catheter Dislodgement

Urethral strictures create a mechanical barrier that predisposes to catheter problems through several mechanisms:

• Inadequate initial catheter placement: The stricture may prevent the catheter from fully advancing into the bladder, leaving the balloon segment in the urethra rather than the bladder 1
• Iatrogenic stricture formation: Traumatic or painful catheterization itself causes bleeding and extravasation, leading to fibrosis and stricture development, which then makes subsequent catheterizations progressively more difficult 1
• Catheter migration: Even if initially placed correctly, bladder spasms or small bladder capacity can push the catheter back through a tight stricture 2

The most common risk factors for stricture-related catheter complications include prior urethral catheterization or instrumentation, transurethral surgery, traumatic injury, and hypospadias surgery 1

Immediate Management Algorithm

Step 1: Do Not Blindly Reinsert the Catheter

Critical pitfall: Blind catheter insertion through a stricture risks creating a false passage, rectal injury, or inflating the balloon in the urethra rather than the bladder 1, 3

• Look for the "long catheter sign"—excessive catheter remaining outside the patient suggests the balloon is not in the bladder 2
• However, this sign may be absent if the catheter doubles back in the urethra 4

Step 2: Assess Clinical Urgency

For urgent situations (symptomatic urinary retention or need for catheterization before another surgical procedure):

• Option A: Guidewire-assisted urethral dilation over a guidewire to prevent false passage formation 1
• Option B: Direct visual internal urethrotomy if the stricture is too dense to dilate adequately 1
• Option C: Immediate suprapubic cystostomy if initial maneuvers are unsuccessful or when definitive stricture treatment is planned soon 1

For non-urgent situations: Proceed with formal stricture evaluation before attempting recatheterization 1

Step 3: Define Stricture Anatomy Before Definitive Management

Perform retrograde urethrography (RUG) with or without voiding cystourethrography (VCUG) to determine:

• Stricture location (anterior vs. posterior urethra) 1
• Stricture length (critical for treatment selection) 1
• Luminal diameter and severity 1

Alternative imaging includes ultrasound urethrography or cystoscopy, though RUG remains the gold standard 1, 5

Definitive Stricture Management Options

For Short Bulbar Strictures (<2 cm):

• Urethral dilation or direct visual internal urethrotomy (DVIU): Success rates 35-70%, highest for strictures <1 cm 1
• Urethroplasty: Higher long-term success (90-95%) but more invasive 1
• Initial endoscopic treatment is reasonable for undifferentiated strictures without trauma, lichen sclerosus, or malignancy 5

For Recurrent or Long Strictures:

• Urethroplasty is preferred over repeat endoscopic management 5
• Success rates for dilation/DVIU drop dramatically for strictures >2 cm 1

For Patients Dependent on Chronic Catheterization:

• Consider suprapubic cystostomy for "urethral rest" prior to definitive urethroplasty 1
• This avoids repeated traumatic catheterizations that worsen stricture disease 1

Post-Intervention Catheter Management

After successful catheter placement or stricture intervention:

• Catheter duration after dilation/DVIU: 24-72 hours is sufficient; no benefit to longer duration 1, 6
• Catheter duration after urethroplasty: 2-3 weeks with confirmatory urethrography before removal 1, 6
• Urethral catheter alone is preferred over combined urethral and suprapubic drainage after bladder or urethral repair 1, 6

Critical Warnings

Never inflate a Foley balloon without confirming bladder position, especially in patients with:

• Known urethral stricture 1
• Spinal cord injury (risk of autonomic dysreflexia if balloon inflated in urethra) 2
• History of difficult catheterization 1

If balloon inflation in the urethra is suspected, confirm with imaging (pelvic X-ray with contrast through catheter, CT, or ultrasound) before attempting removal 2, 4, 7

Repeated failed catheterization attempts worsen the injury—stop after one attempt by an experienced provider and proceed to suprapubic drainage 3