Experitoneal bladder perforation due to in-dwelling urethral catheter successfully treated by urethral drainage: a case report

Perforation of the bladder related to long-term indwelling urethral catheter is a rare and serious complication. A 85-year-old man with an indwelling urethral catheter presented severe hematuria, abdominal pain with rebound tenderness and muscular tension over the suprapubic area after the exchange of the urethral catheter. Computed tomography and cystogram revealed experitoneal bladder perforation due to indwelling catheter. Three weeks after the indwelling urethral catheter had been placed, the perforation was closed. In most cases, laparotomy and suprapubic cystostomy are performed. We describe the case of experitoneal bladder perforation successfully treated by urethral drainage.     

Delayed bowel perforation following suprapubic catheter insertion

Background

Complications of suprapubic catheter insertion are rare but can be significant. We describe an unusual complication of a delayed bowel perforation following suprapubic catheter insertion.

Case presentation

A gentleman presented with features of peritonitis and feculent discharge along a suprapubic catheter two months after insertion of the catheter.

Conclusion

Bowel perforation is the most feared complication of suprapubic catheter insertion especially in patients with lower abdominal scar. The risk may be reduced with the use of ultrasound scan guidance.     

Early-onset complete spontaneous migration of contraceptive intrauterine device to the bladder in a post C-section patient: A case report

Introduction and importanceSpontaneous migration of a contraceptive intrauterine device (IUD) to the bladder is very rare. It usually takes years for the IUD to migrate completely from the uterine cavity to the bladder. We report a case of early-onset complete spontaneous migration of contraceptive IUD to the bladder in a post C-section patient.Case presentationA 30-year-old woman presented with suprapubic pain and dysuria three weeks prior to hospitalization. She had C-section three months prior and underwent copper IUD insertion two months after the surgery. One week after IUD insertion, radiography showed that the IUD remained in the uterus, but the patient felt suprapubic pain and dysuria. Computed tomography (CT) three weeks after IUD insertions showed IUD migration to the bladder with its tips embedded in the uterine wall. Cystoscopy was performed one week later and the IUD was completely inside the bladder. By then, the IUD was removed completely via forceps with no complication.Clinical discussionThe exact pathophysiology of spontaneous IUD migration is unknown, but migration always starts with uterine perforation. In our case, uterine perforation was probably caused by immediate traumatic perforation. CT is the preferred radiological examination. IUD removal was performed one month after IUD insertion showing complete migration of the IUD, though CT one week prior suggested that the tips of the IUD remained embedded.ConclusionIn cases of early-onset complete spontaneous migration of contraceptive IUD to the bladder, CT is the preferred radiological examination, and delaying removal procedure may be beneficial.     

Laparoscopic management of cecal injury from a misplaced percutaneous suprapubic cystostomy

Iatrogenic bowel injury is a recognized complication of percutaneous suprapubic cystostomy. In the present report, we describe a case of misplacement of suprapubic catheter into cecum, in which laparoscopic technique was used successfully to identify and treat this condition. A 72-year-old woman with severe multiple sclerosis underwent her fourth change of suprapubic catheter 3 months after initial insertion. At the time of catheter change, the urologist performed a cystoscopy via the suprapubic tract and found feculent material in the presumed bladder. A diagnosis of colovesical fistula was made, and patient was referred to the acute surgical service. Cystogram via suprapubic catheter showed passage of contrast straight into colon in the region of cecum with no evidence of a fistula. Computed tomography of abdomen and pelvis confirmed the position of the catheter in the cecum. At laparoscopy, the cecum was seen to move when tension was applied to the suprapubic catheter, confirming the catheter tip and balloon in the lower pole of cecum. Laparoscopic transection of the cecum above the point of entry of the catheter was performed using an Endo GIA linear stapler. Under laparoscopic visualization, a new suprapubic catheter was inserted into the bladder. Intraoperative bleeding was minimal and the postoperative course was uneventful.     

Experience sharing of conservative treatment after a 90-year-old male replacing the suprapubic bladder catheter enters the small intestine: A rare case report

IntroductionThe treatment of intestinal perforation caused by the SBC enters the small intestine in elderly patients is a challenge for urologists. The report is to share our experience of conservative treatment after a 90-year-old male with the suprapubic bladder catheter enters the small intestine.Presentation of caseBecause of the device was obstructed, a 90-year-old male went to our hospital with his family and requested to replace the SBC. When the fistula tube was replaced, it entered the intestine through the intestinal injury site instead of entering the bladder. During the hospitalization, the patient was given supportive treatments and the SBC was dynamically monitored daily and it was intermittently withdrawn out during this period. After the drainage volume was less than 10 mL for three consecutive days and the intestinal fistula was healing gradually, the catheter was taken out.DiscussionAccording to our experience, the common complications in the process include failure to pull out the SBC, abnormal position of the SBC, and poor drainage of the SBC. However, the drainage tube placing into the small intestine through the original hole of the suprapubic bladder fistula during the replacement process is quite rare. When elderly patients have traumatic small bowel perforation, the diagnosis and treatment of intestinal perforation in elderly patients was particularly important.ConclusionThe conservative treatment of intestinal perforation is suitable for elderly patients who are unsuitable or unwilling to undergo a surgical operation. Of course, it should be in accordance with the patient's condition to make the right choice of treatment.     

Safe percutaneous suprapubic catheterisation

INTRODUCTION

We describe our technique of percutaneous suprapubic catheter insertion with special reference to steps that help to avoid common complications of haematuria and catheter misplacement.

METHODS

The procedure is performed using a stainless steel reusable trocar under local infiltrative anaesthesia, usually at the bedside. After clinical confirmation of a full bladder, the trocar is advanced into the bladder through a skin incision. Once the bladder is entered, the obturator is removed and the assistant inserts a Foley catheter followed by rapid balloon inflation. Slight traction is applied to the catheter for about five minutes. Patients with previous lower abdominal surgery, an inadequately distended bladder or acute pelvic trauma do not undergo suprapubic catheterisation using this method.

RESULTS

The procedure was performed in 72 men (mean age: 42.4 years, range: 18–78 years) with urinary retention with a palpable bladder. The average duration of the procedure was less than five minutes. No complications were noted in any of the patients.

CONCLUSIONS

Trocar suprapubic catheter insertion is a safe and effective bedside procedure for emergency bladder drainage and can be performed by resident surgeons. The common complications associated with the procedure can be avoided with a few careful steps.     

Abdominal visceral perforation by buried peritoneal dialysis catheters: Cause or coincidence?

Delayed visceral organ perforations after PD catheter insertions are extremely rare. We report two patients who presented with asymptomatic visceral perforation from their buried PD catheters. Five months after a laparoscopic buried PD catheter insertion in a 92‐year‐old man PD was initiated; bile and bowel contents were noted in the PD effluent. He subsequently expired (from pneumonia) to autopsy revealed the PD catheter within the small bowel. Despite this perforation, there was no evidence of peritonitis, inflammation, nor any bowel content within the peritoneal cavity. A second case was observed 2.5 months after an uncomplicated laparoscopic buried PD catheter insertion in a 60‐year‐old woman. PD was attempted; the patient had an immediate urge to void. MRI revealed the presence of the PD catheter within her bladder. She underwent PD catheter revision the next day with repair of bladder perforation and ultimately successfully initiated PD . Since the perforations did not occur at the time of catheter placement, we believe that the catheter eroded into a viscus, perhaps related to the lack of a fluid at the catheter ‐ viscus interface. The diagnosis of delayed visceral organ perforation following buried PD catheter insertion may be delayed because the catheter is not immediately used.     

Suprapubic catheterization complicated by bowel perforation

Inadvertent bowel injury can occur when utilizing trocar cystotomy technique for the placement of a suprapubic catheter. The authors present a patient who had a suprapubic catheter placed through a stab incision at the time of vaginal pelvic reconstruction for procidentia. Her presentation did not include the typical signs of peritonitis, but was characterized by low urine output and regression of bowel function due to ileus and third-spacing in the peritoneal cavity. The potential risk factors for bowel injury in this patient are enumerated and techniques to minimize the risk of bowel perforation are discussed. The risk of bowel injury is reduced by choosing a catheter introducer that minimizes impedance while piercing tissues, and by using a rigid cystoscope for visualization of the suprapubic trocar during entry into the bladder.     

Preventable long-term complications of suprapubic cystostomy after spinal cord injury: Root cause analysis in a representative case report

Background

Although complications related to suprapubic cystostomies are well documented, there is scarcity of literature on safety issues involved in long-term care of suprapubic cystostomy in spinal cord injury patients.

Case Presentation

A 23-year-old female patient with tetraplegia underwent suprapubic cystostomy. During the next decade, this patient developed several catheter-related complications, as listed below: (1) Suprapubic catheter came out requiring reoperation. (2) The suprapubic catheter migrated to urethra through a patulous bladder neck, which led to leakage of urine per urethra. (3) Following change of catheter, the balloon of suprapubic catheter was found to be lying under the skin on two separate occasions. (4) Subsequently, this patient developed persistent, seropurulent discharge from suprapubic cystostomy site as well as from under-surface of pubis. (5) Repeated misplacement of catheter outside the bladder led to chronic leakage of urine along suprapubic tract, which in turn predisposed to inflammation and infection of suprapubic tract, abdominal wall fat, osteomyelitis of pubis, and abscess at the insertion of adductor longus muscle

Conclusion

Suprapubic catheter should be anchored securely to prevent migration of the tip of catheter into urethra and accidental dislodgment of catheter. While changing the suprapubic catheter, correct placement of Foley catheter inside the urinary bladder must be ensured. In case of difficulty, it is advisable to perform exchange of catheter over a guide wire. Ultrasound examination of urinary bladder is useful to check the position of the balloon of Foley catheter.     

Chronic perforation of the urinary bladder by self-inserted foreign body

We report on a 14-year-old girl with pyelonephritis, secondary to a foreign body, in her urinary bladder. A self-inserted pencil led to stone formation and bladder perforation at two sites. Eighteen months after insertion, the pencil was removed by suprapubic cystotomy.     

A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL COMPARING SUPRAPUBIC WITH URETHRAL CATHETERIZATION IN RECTAL SURGERY

Background : Bladder drainage is necessary for several days following rectal surgery. Urethral catheterization has long been known to be associated with significant morbidity. Therefore a prospective randomized trial was performed to determine if this morbidity could be decreased by suprapubic catheterization. Methods : One hundred and thirty-seven patients undergoing rectal surgery were prospectively randomized to either suprapubic or urethral catheterization. Results : After exclusions, 108 patients were analysed. Of the 49 patients with suprapubic catheters there was 14% morbidity, and of the 59 patients with urethral catheters there was 32% morbidity. Significant bacteriuria was halved with suprapubic catheterization. Patient acceptability of suprapubic catheterization was high, and there was no increased morbidity in any of the areas studied. Conclusions : This study suggests that suprapubic catheterization has advantages over urethral catheterization with decreased bacteriuria, and greater patient acceptability. However, the significance of decreased bacteriuria is not clear and therefore we can only say suprapubic catheter drainage is comparable to urethral catheter drainage.     

Simplified percutaneous large bore suprapubic cystostomy for acute urinary retention—A cost saving procedure

Introduction and objectivesCommercial cystostomy kits/trocars are not always readily available in regions with insufficient funding. Open suprapubic cystostomy procedures are yet prevalent. This paper presents a simplified percutaneous suprapubic cystostomy technique that utilizes specially selected surgical blades in the place of commercial trocars.Subjects and methodsEighty-nine male patients with acute urinary retention underwent puncturing of the visibly and palpably distended bladder with surgical blade size 20 (7 mm diameter), 21 or 22 (9 mm diameter) to allow resistance-free placement of Foley catheter size 18 Fr (maximum diameter of 6 mm) or size 20 (maximum diameter of 6.7 mm) respectively under local anesthesia along the mid abdominal line in a sagittal direction – two finger breadths above the pubic symphysis. The main outcome measures were to determine the success rate and the encountered complications.ResultsSuccessful bladder puncture and insertion of the Foley catheter of choice was possible in all cases. There was no mortality and no adjacent visceral injury. There were two cases of catheter blockage with clots that were easily flushed out.ConclusionsEmergency cystostomy can be safely achieved through direct puncture of the visibly and palpably distended bladder with appropriately selected surgical blades that will subsequently allow resistance-free placement of sizable Foley catheters.     

Suprapubic catheter insertion using an ultrasound-guided technique and literature review

What's known on the subject? and What does the study add? The conventional ‘blind’ technique for suprapubic catheter (SPC) insertion relies on adequate filling of the bladder to displace bowel away from the site of needle puncture. However, in a small percentage of patients this fails to happen, which can occasionally lead to life‐threatening bowel injury. Recently published British Association of Urological Surgeons (BAUS) guidelines have recommended that ultrasonography (US) may be helpful to identify bowel loops and recommends its usage whenever possible. This paper describes the technique of US‐guided needle puncture and SPC insertion to reduce the likelihood of bowel injury. The paper addresses training, equipment and logistical issues associated with this advice. We have reviewed the available publications on the outcomes from this technique and also present our experience. Suprapubic catheter (SPC) insertion is a common method of bladder drainage in contemporary urological practice. The procedure involves insertion of a sharp trocar into the bladder percutaneously, usually by palpation, percussion or cystoscopy for guidance. Although generally considered a safe procedure, the risk of bowel injury is estimated at up to 2.4% with a mortality rate of 1.8%. Recently published British Association of Urological Surgeons (BAUS) guidelines have recommended that ultrasonography (US) may be helpful to identify bowel loops and recommends its usage whenever possible. The present paper describes the use of US for SPC insertion and discusses the implications of this advice. This paper is designed to support and supplement practical techniques learnt on a course and in clinical practice.     

Bulbocavernosus muscle responses after suprapubic stimulation: analysis and measurement of suprapubic bulbocavernosus reflex latency

Our objective was to describe pelvic floor responses with measurement of reflex latency after suprapubic mechanical stimulation. Twenty-one patients without neurological disease were studied. They were 14 women and seven men. The mean age was 51 (SD = 14.2). Motor responses were recorded with a needle electrode inserted in the left bulbocavernosus muscle. Stimulation was delivered with an electromechanical hammer, tapping directly on the suprapubic area. A polyphasic muscular response was always easily elicited in all patients. The man latency was 67.5 milliseconds (SD = 14.7). The reproducibility between the first and second mechanical responses was good with no statistical difference (r=0.966;P = 0.0001). In three patients who underwent cystometry, no rise in detrusor pressure was observed during mechanical stimulation of the suprapubic area. Our study clearly demonstrates a suprapubic bulbocavernosus reflex (SBR). Tapping the suprapubic area is a strong stimulus, reflexively mediated, used in the management of neurogenic bladder to determine a bladder contraction. However, the reflex consisting of pelvic floor muscle contraction after suprapubic stimulation was not specifically studied in humans. Many arguments can be put forth for a polysynaptic reflex (polyphasic response, habituation and short latency of the reflex, mean latency in the habitual values of R2 responses after electrical stimulation of the dorsal nerve of the penis). We hypothesize that the true stimulus is the stimulation of the bladder wall tensoreceptors, the integration level of the SBR is the sacral segments and the efferent limb the pudendal nerve, and afferent pathways could be conducted by pelvic nerve fibers. Competition between a preponderant (or exaggerated) SBR and a bladder contraction after suprapubic tapping may constitute an equivalent of detrusor-sphincter dyssynergia in some suprasacral bladders.     

Assessing the effectiveness of different urinary catheters in emptying the bladder: an application of transvaginal ultrasound

The effectiveness of different types of urinary catheters in completely draining the bladder has not been tested. Transvaginal ultrasound, which is able to measure bladder volumes in women from 2 to 175 ml, provides a means of measuring any fluid volume remaining in the bladder following catheter drainage. Using transvaginal ultrasound, the post-catheterisation bladder volumes were measured in 26 female patients; 14 underwent urethral catheterisation using either a 14F short plastic female catheter or a Foley catheter of the same size (balloon not inflated); 12 had an indwelling 12F suprapublic catheter following bladder neck surgery. The mean post-catheterisation bladder volumes after using the short plastic female and Foley catheters were less than 1 ml and 77 ml respectively. A short plastic catheter should be used in women to collect the residual urine volume by urethral catheterisation. A Foley catheter is relatively ineffective in this task. A 12F suprapubic catheter was found to drain the bladder relatively well. The mean post-catheterisation bladder volume was 35 ml. Prior to removing a suprapubic catheter post-operatively, it is recommended that the residual urine volume (measured using the suprapubic catheter) be checked by measuring the post-catheterisation bladder volume (using either a short plastic catheter or transvaginal ultrasound).     

Prospective randomised trial of two devices for suprapubic catheterisation in general surgical patients.

Compared with urethral catheterisation, suprapubic catheterisation is associated with a reduced incidence of urinary infection and urethral stricture and it facilitates a controlled trial of micturition. A prospective comparison of two types of suprapubic catheter was performed in 70 patients, using a specially designed catheter mounted on a trocar for insertion (Suprapubic Ingram Trocar), and a disposable trocar and cannula (Add-a-Cath) and standard Foley catheter. A suprapubic catheter was inserted successfully in 63 patients. Overall there was a low incidence of urinary tract infection (4.3%) and the only significant catheter-related problem was suprapubic leakage of urine, which was self-limiting in all but one patient. Although there is little objective difference between the systems tested, we prefer the Add-a-Cath system for its simplicity and economy. This trial provides further support for the more frequent use of suprapubic catheters in general surgical practice.     

Intentional urethral closure with a TVT (tension-free vaginal tape) for intractable urinary incontinence: a preliminary report of three cases

Bladder neck and urethral closure with urinary diversion is offered as a last resort to patients with intractable urinary incontinence. Various techniques have been described to achieve bladder neck and urethral closure. Most of these are associated with either operative morbidity or long-term complications. A modification of the conventional tension-free vaginal tape (TVT) procedure is described. As the name suggests, during the conventional TVT procedure, the tape is inserted relatively without tension in such a manner that the urethra retains its function and post-operative voiding is possible. In the cases described in this short series, the aim was to achieve urethral and bladder neck closure with minimal operative morbidity. This was achieved by inserting the TVT exactly as in a conventional TVT procedure, but the tape was inserted under greater tension than is normally used to ensure continence. A long-term suprapubic catheter was used for urinary diversion. This procedure is simple to perform, is associated with low operative morbidity [Agostini et al., Eur J Obstet Gynecol Reprod Biol, 124(2):237–239, 2006] and results in functional urethral closure. Results suggest that it may be a useful alternative to other bladder neck and urethral closure procedures in selected patients.     

Catheterization: Possible complications and their prevention and treatment

Abstract:   Intermittent catheterization (IC) is a more preferable method for bladder drainage than indwelling urethral or suprapubic catheterization. Several complications with IC have been described, however, including urinary tract infection, genital infection, urethral bleeding, urethritis, urethral stricture, and bladder stones. To prevent these complications, patients should be well instructed on the technique and the risks of IC. Indwelling catheterization should be used only exceptionally, under close control and the catheter should be changed with adequate frequency.     

Combined vesicovaginal and rectovaginal fistulas associated with a vaginal foreign body

Long-duration intravaginal foreign bodies are a rare entity, but may cause serious complications to the bladder or rectum. We describe a 22-year-old woman who presented with a calcified pelvic mass caused by a long-duration intravaginal foreign body complicated by perforation into the bladder and rectum. The vesicovaginal and rectovaginal fistulas were simultaneously repaired by suprapubic approach after retrieval of the foreign body during the same procedure.     

Suprapubic double-lumen catheter for measuring bladder pressure and filling bladder

A suprapubic double-lumen catheter for both measuring the bladder pressure and filling the bladder is described. This catheter is considered useful for the urodynamic evaluation of the lower urinary tract. Urodynamic evaluation at voiding can be easily performed repeatedly.