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Traumatic Urinary Catheter Insertion: A Case Presentation
Jonathan M. Yaghoubian, MS DO and Jason Grabert, MD FACEP FAAEM
Chief Complaint
Altered Mental Status & Gross Hematuria
HPI
83-year-old minimally verbal male presented with altered mental status and confusion. He was recently discharged from the emergency department (ED) after a fall and has been residing in a rehabilitation facility. The patient was found to be septic with positive blood cultures from the prior ED visit. A urinary catheter was placed in the ED. Gross hematuria was noted. The patient was subsequently admitted for further work-up and management of sepsis and hematuria.
Pertinent Physical Exam
Well-developed, well-nourished, white male in no acute distress. Responded to painful stimuli only. Abdomen was soft, but bladder felt distended. Testes were descended without masses. Severe amount of scrotal and penile edema. No perineal crepitus noted. Urinary catheter was not draining. Gross hematuria was noted. Rectal examination revealed a large amount of stool in the rectal vault. Prostate was smooth. Good sphincter tones were noted.
Pertinent Laboratory Data
Blood cultures grew gram positive cocci in clusters in 1 of 2 bottles. Urinalysis demonstrated red urine, bloody in appearance, large bilirubin, large blood, positive for nitrites, moderate leukocyte esterase, 50+ red blood cells, 50+ white blood cells.
Radiographic Images
CT abdomen/pelvis without contrast was ordered to determine the source of hematuria.
Discussion
The image above depicts a (1) traumatic urinary catheter insertion which is (2) not optimally placed. The catheter is inflated in the posterior urethra with the tip of the catheter in perineal fluid collection. There is free air noted in the perineum as well as the left buttocks. The free air and fluid collection are likely from the traumatic catheter insertion. It seems that the catheter was placed in the ED and caused traumatic rupture of the urethra. Urology was consulted and the catheter was redirected into the bladder. The catheter needed to be in place for at least a month to allow for healing. The patient was at increased risk for Fournier’s gangrene and/or abscess formation as a result of this catheter insertion.
With the recent availability of ultrasound in the ED, a point of care study can be performed by the ED physician to confirm placement of an urinarycatheter within the bladder. The provider should be able to readily visualize the balloon within the bladder.
Pearls
1. Care must be taken when inserting an urinarycatheter particularly in male, altered patients, as they are not able to convey discomfort as an alert and oriented patient. 2. When in doubt, confirmatory imaging, such as, point of care ultrasound or computed tomography may be used.
Disclaimer
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
