Fatal complication from Foley’s catheter: a case report

Abstract

Introduction and importance:

Foley’s catheterization is a common and routinely performed procedure, yet it carries risks including urinary tract infection, urethral trauma, and, more rarely, bladder perforation. Reports of simultaneous bladder and bowel injury during catheter exchange are exceedingly uncommon.

Case presentation:

We report an 86-year-old woman with hypertension, heart failure, and a history of uterine cancer treated with chemotherapy and pelvic radiotherapy 2 decades earlier. After a routine Foley’s catheter exchange, she developed paraumbilical pain and decreased urine output. She was hemodynamically stable on arrival to the emergency department, but imaging revealed a catheter-associated perforated viscus. Emergency laparotomy identified both bladder and jejunal perforations. The bladder was repaired, and the affected small bowel was resected followed by a primary anastomosis. Initially, her postoperative course was uneventful, but she developed septic shock on day 3, resulting in her death.

Clinical discussion:

Complications from Foley’s catheter placement are rare when appropriate indications and insertion techniques are followed. The combination of bladder and bowel injury without a preexisting fistulous tract is scarcely documented in the literature. This case highlights a potentially underrecognized risk in patients with multiple risk factors such as prior radiation.

Conclusion:

Although simultaneous bladder and bowel injury during Foley’s catheter exchange is exceptionally rare, careful patient assessment, proper insertion technique, and increasing knowledge about its indication may reduce morbidity. Increased clinician awareness of this complication may improve early recognition and outcomes.

Introduction

In 1935, Frederick Foley first presented Foley’s catheter, an invention of the self-retaining balloon anchorage system for multiple purposes in daily medical practice. Since then, different types of Foley’s catheters have been developed according to size, material (rubber or silicone), structure (coude tip or straight tip), number of channels (two-way or three-way), and more recently an impregnated catheter with an antibacterial/silver film[1].

Bladder injuries could be traumatic or iatrogenic, blunt or penetrating. Cystography can be used to categorize it as either intraperitoneal or extraperitoneal injury, which makes up 32% and 63% of cases, respectively. This classification is crucial for the management of bladder injuries, where extraperitoneal injuries are managed conservatively, while intraperitoneal injuries are treated surgically[2]. Based on the Centers for Disease Control, about 12–15% of patients are catheterized during their hospital course. Bladder perforations in patients with chronic indwelling Foley’s catheter are uncommon, occurring only in 0.002% of all hospitalizations[3].

HIGHLIGHTS

• Foley’s catheter insertion is a simple procedure with low complication rates.

• A few cases reported bladder and bowel injuries after a Foley’s catheter exchange.

• Careful consideration of when and whether to insert a Foley catheter is warranted.

Intestinal injury is the third most common injury associated with blunt abdominal trauma. While in penetrating injuries, the small bowel is most frequently injured, followed by the colon[4]. All bowel injuries will require laparotomy, and the options include either primary repair, bowel resection with or without anastomosis or stoma creation[5]. There are few cases published describing intestinal perforation during suprapubic tube exchange^[6,7^]. However, a limited number of cases were reported involving the bowel during Foley’s catheterization^[8,9^]. We present an 86-year-old woman with multiple comorbidities and a history of chemotherapy and pelvic radiotherapy developing jejunal injury after a Foley’s catheter exchange. This case report has been reported in line with the SCARE checklist[10].

Case presentation

An 86-year-old woman with a complex past medical history presented to the emergency department (ED) complaining of acute abdominal pain and decreased urine output. Her medical history included hypertension, heart failure on a trifascular pacemaker, and osteoporosis with suspected primary hyperparathyroidism. A critical factor was her history of uterine cancer, which was treated with chemotherapy and pelvic radiotherapy over 20 years ago. She had chronic urinary retention since January 2022, managed with a chronic indwelling Foley’s catheter, which was exchanged monthly. She had been offered clean intermittent catheterization but refused, preferring the indwelling catheter.

Before presenting to our ED, her indwelling Foley’s catheter (size 16 Fr silicone) was routinely exchanged by a home healthcare team. The procedure was documented as uneventful. Nine hours after the exchange, the patient developed decreased urine output, followed by continuous, worsening, colicky paraumbilical abdominal pain. She reported gross hematuria and vomited once in the ED.

On examination, vital signs were stable: blood pressure 112/52 mmHg, temperature 37.2°C, pulse 75 beats per minute, and oxygen saturation 98% on room air. The abdominal examination revealed significant paraumbilical tenderness. The Foley’s catheter was flushed, producing turbid fluid. Urinalysis showed positive leukocyte esterase and whie blood cell >50/high-power field, consistent with pyuria. However, imaging findings rapidly superseded the initial suspicion of a complex urinary tract infection.

Abdominal X-rays showed both air under the diaphragm (pneumoperitoneum) and air–fluid levels. Urgent CT abdomen and pelvis with intravenous (IV) contrast confirmed the definitive diagnosis, which was injury of the mid small bowel loop caused by the Foley’s catheter tip (Fig. 1). General Surgery and Urology were immediately consulted, and IV antibiotics were started.

Figure 1.

Sagittal view of CT abdomenopelvis with IV contrast showing the Foley’s catheter projecting through the bladder dome into the ileal bowel loop.

The family was counseled and made aware of the situation. A detailed management plan was given to both the patient and her family, and they agreed to proceed. We elected to go for urgent exploratory laparotomy rather than diagnostic laparoscopy to expedite her surgical intervention. The American Society of Anesthesiologists physical status score was 3E. The exploratory laparotomy has revealed a perforation in the distal jejunum that was adherent to the dome of the bladder, where the fully inflated Foley’s catheter balloon was lodged (Fig. 2A). The catheter balloon was deflated and removed, revealing the defect clearly (Fig. 2B and 2C). A segmental small bowel resection was performed (Fig. 2D) followed by a stapled side-to-side anastomosis, which was reinforced with Lembert sutures. Concurrently, a 1 cm bladder injury at the dome toward the posterior wall was identified. The bladder wall was noted to be extremely fragile, and this could be caused by her history of pelvic radiation and the chronic indwelling catheter. The defect was closed in two layers using figure-of-eight and simple interrupted sutures with Vicryl 2-0, and no leakage was seen after a 150 mL saline leak test. Omental patch was our first option; however, it failed due to short omentum. As a result, the repair was further reinforced with a peritoneal patch harvested from the right side and fixed with PDS 2-0 suture. The resected bowel was sent to histopathology and revealed a focal area of transmural inflammation, which was in keeping with perforated small bowel.

Figure 2.

(A) A picture of the small bowel fixed to the bladder. (B) A better visualization of small bowel perforation after removal of the Foley’s catheter. (C) Small bowel perforation after disconnecting from the urinary bladder, showing the perforation clearly with an unhealthy bowel segment. The suspicion is that the balloon was inflated in the small bowel, causing more severe injury as seen. (D) The resected segment of small bowel (site of perforation).

Initial improvement was observed in the patient, leading to a transfer from the intensive care unit (ICU) to the ward after 24 h. However, her condition deteriorated on her third postoperative day. She was readmitted to the ICU with profound septic shock and coagulopathy secondary to disseminated intravascular coagulation. Antibiotics were broadened to meropenem and vancomycin. Blood culture grew Gram-negative bacilli, and urine culture grew Klebsiella, Pneumoniae, and Enterobacter cloacae. She was placed on maximum vasopressor support, but her condition worsened, marked by a drop in blood pressure to 68/46 mmHg, O₂ saturation to 85%, and difficulty speaking. She was intubated but suffered a cardiac arrest and could not be revived, succumbing to refractory septic shock and multi-organ failure.

Discussion

There are several indications of Foley’s catheter insertion, mainly for drainage of acute urinary retention or incomplete bladder emptying[2]. It is also used in different settings, like in critically ill patients or during a lengthy procedure for monitoring urine output[1]. Despite clear indications to insert Foley’s catheter, 21–31% of patients are inappropriately catheterized. As a result, this poses a risk of complications for the patient. About 80% of nosocomial urinary tract infections are contributed by the Foley’s catheter[11]. Another consequence of Foley’s catheter insertion is urethral trauma, which can result in the development of urethral stricture or false passage[2]. Uncommon complications that may occur include iatrogenic hypospadias, urethral diverticula, ischemic necrosis of the penis, and urinary bladder perforation[12]. The best measures to avoid Foley’s catheter complications are to raise awareness and knowledge of the indications and proper technique of catheterization, restrict its unnecessary use, and limit its time as much as possible[13].

Despite being a simple procedure, Foley’s catheter can cause morbidity to the patient. Although very rare, bladder perforation is possible after Foley’s catheter insertion or, in some cases, spontaneously in chronic catheterization. The most indicative signs of bladder perforation include gross hematuria, lower abdominal pain, and difficulty voiding[3]. In our case, her ED presentation was thought to be due to a urinary tract infection. This highlights the importance of proper investigation for early recognition, especially when factors that alter bladder sensitivity or architecture are present, which may predispose to bladder injury. For instance, inflammation, infection, diabetes, alcoholism, chronic catheterization, old age, and chemoradiotherapy are all factors that may affect bladder integrity^[3,14^]. In addition, the healthcare provider’s level of training could be a possible risk factor for bladder perforation[15]. In our patient, prior radiotherapy, advanced age, long-term catheterization, as well as the healthcare provider’s expertise may have further contributed to the development of the bladder injury.

Bowel injury caused by Foley’s catheter insertion is extremely rare. Only a few cases have been reported in the literature. To our knowledge, this is the first case to describe such a presentation in a patient without a pre-existing enterovesical fistula. One case was published by Amend et al, who reported a case of small bowel obstruction after exchanging the indwelling Foley’s catheter, where it was found exiting the bladder through an enterovesical fistula[8]. In such instances, patients are usually managed surgically; however, one case reported rectal perforation secondary to Foley’s catheter insertion that was successfully managed conservatively[9]. The possible contributing factor for bowel perforation in our case is adhesions to the bladder dome secondary to radiotherapy to the pelvis. However, more cases are needed to determine the associated factors that could lead to such an event. Therefore, this case report sheds light on the importance of having a rationale behind catheterizing a patient, as well as careful and proper insertion of a Foley’s catheter to avoid such unfortunate events.

Conclusion

In conclusion, although Foley’s catheterization is typically a safe procedure, rare complications such as bladder perforation with possible bowel involvement can carry serious consequences. Careful assessment of patient-specific risk factors, adherence to proper indications, and thorough training in insertion technique may help minimize these events and improve clinical outcomes.

Ethical approval

Ethical approval is not required for case reports in our institution, as long there is no violation to patient’s anonymity.

Consent

The patient passed away before taking informed consent for publication of this case report and accompanying images. Multiple attempts were made to reach out to the family using the registered phone number in her medical record file, but it was disconnected. To protect her anonymity, we have not used any identifier that could lead to the patient or her family.

Sources of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

H.M.: Study concept, data collection and analysis, writing the paper. A.W.: Data collection and analysis, writing the paper. O.B.A.: Paper review and editing. A.A.: Supervision. R.A.: Supervision. A.A.: Supervision.

Conflicts of interest disclosure

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Research registration unique identifying number

Not applicable.

Guarantor

Dr. Ali AlZahar.

Provenance and peer review

Not commissioned; externally peer-reviewed.

Data Availablity statement

No datasets were generated or analyzed during the study.