Bulbous urethral stricture: a rare and grave complication of suprapubic catheterisation

Abstract

We report a very rare complication of bulbous urethral stricture following suprapubic catheterisation (SPC). A 67-year-old paraplegic man underwent SPC for urethral trauma. During SPC, the catheter slipped across the bladder neck into the bulbous urethra where the balloon was inflated. Follow-up retrograde urethrograms showed the gradual evolution of stricture at the same site. This report highlights yet another pitfall of the SPC procedure. We also describe the ways to avoid this complication.

Background

Suprapubic catheterisation (SPC) is a useful procedure that provides bladder drainage when urethral access is not possible in conditions like urethral disruption, severe urethral stricture disease or inaccessible urethra owing to traumatic catheterisation.^{1 2} The complication rate of this procedure is minimal; however, complications such as bleeding, infection, obstruction, stone encrustations³ and perforation of bladder or other intra-abdominal structures has been described.⁴ We present a case of bulbous stricture formation following SPC, a complication that has not been described before.

Case presentation

A 67-year-old paraplegic man was on urethral catheter for 6 months with regular change of catheter. He presented with bleeding per urethra following urethral trauma during catheter change and a trocar SPC was done by an inexperienced local physician. Next day, he came with complaints of suprapubic pain and pericatheter urine leak. Examination revealed that all the urine was leaking by the side of catheter while the suprapubic catheter was not draining urine. A firm, round, non-tender swelling was palpable in the perineum. Ultrasonography (USG) abdomen failed to demonstrate the balloon of the Foley catheter within the bladder. Retrograde urethrogram (RUG) showed inflated balloon of the catheter in mid-bulbous urethra (figure 1A). The Foley balloon was deflated and catheter pulled back into the bladder and this was confirmed by USG. To assess the effect of misplaced SPC, RUG was performed that revealed a large cavity at place of inflated balloon (figure 1B). After 1 month, a repeat RUG showed reduction in the size of the cavity by nearly 50% (figure 1C). The SPC was changed and the patient observed for another 1 month, following which RUG showed a stricture corresponding to the same site in mid-bulbous urethra (figure 1D).

Figure 1.

Serial retrograde urethrograms. (A) Foley catheter balloon seen inflated in mid-bulbous urethra. (B) Dilated bulbous urethra (with extravasation) in the region of inflated Foley balloon. (C) After 1 month, showing reduction in size of cavity. (D) Stricture seen at the same site.

Treatment

Patient underwent ventral onlay buccal mucosal graft urethroplasty for bulbar urethral stricture.

Outcome and follow-up

Patient is doing well at 6-month follow-up. He is voiding but mostly performs clean intermittent catheterisation.

Discussion

SPC is one of the commonest urological procedures being performed in outpatient settings and is considered safe and simple even in inexperienced hands. Although, various complications have been reported, bulbous urethral stricture following SPC is very rare and to the best of our knowledge has not been reported in the literature. In this case, though there is remote possibility that stricture could have developed at the site of initial urethral injury, follow-up RUGs showed evolution of stricture corresponding to the location where the catheter balloon was inflated. One possible explanation for inadvertent entry of catheter into the urethra was because of a wide open bladder neck and small capacity bladder in paraplegics.⁵

This complication highlights yet another cause of stricture formation in the urethra. It re-emphasises the importance of following the practice guidelines. Also, we suggest that a trained and experienced health professional be involved in this procedure.^{1 2}

Learning points.

• In such patients who are at risk, following measures should be kept in mind while doing suprapubic catheterisation (SPC):

  • The catheter should drain clear urine immediately that should be observed for at least 1 h.⁶
  • The balloon of the catheter should inflate without much resistance.
  • The catheter should be pulled out maximally and tucked with abdominal wall after inflating the Foley balloon.⁶
  • Flush the catheter with sterile water, and look at the urethral meatus for leak of water.⁶
  • While changing the catheter in an already established SPC tract, the catheter need not be inserted completely. Usually with judgement an estimate can be made on how much to insert the catheter.