WHEN IS A URETHRAL CATHETER NOT A UROLOGIST’S BEST FRIEND?
Aviva E. Weinberg, M.D.; Christopher S. Elliott, M.D.: Stanford, CA
Introduction: Chronic indwelling urinary catheters are commonly used for bladder management in spinal cord injury (SCI) patients who are not candidates for intermittent catheterization or other surgical forms of urinary diversion. The prolonged use of indwelling urethral catheters is associated with a variety of complications, ranging from urinary tract infections (UTIs), hematuria, bladder calculi periurethral abscess, fistula formation, catheter encrustation as well as urethral and bladder neck erosion. While urethral and bladder neck erosions have been previously described in women with longstanding urethral catheters, damage to other surrounding structures is rare. Herein, we present a case of urethral erosion with associated pelvic osteomyelitis and adductor abscess in a female SCI patient.
Results: Our patient was a 56-year old female SCI patient with morbid obesity (BMI 51), poorly controlled diabetes mellitus (HbA1c 9.7), and paraplegia secondary to spinal osteomyelitis with epidural abscess, whose neurogenic bladder had been managed by indwelling urethral catheter for 12 months. She was admitted to the county hospital for IV antibiotic therapy for a diagnosis of Strep anginosus bacteremia. A CT abdomen/pelvis was obtained to localize a source for her bacteremia. This scan demonstrated osteomyelitis of the pubic symphysis and a pelvic abscess just posterior to the pubis that extended inferiorly to involve the right adductor muscles. The patient described a history of urethral catheter exchanges on a monthly basis complicated by recurrent UTIs, urinary incontinence around the catheter and significant bladder spasm. A complete pelvic exam and subsequent cystoscopy was performed demonstrating catheter erosion through the dorsal urethral plate and bladder neck. In addition, the patient had visible erosion into the pubic bone, with purulent drainage from an anterior abscess cavity. The patient was gravitationally stress incontinent. We initially offered the patient a bladder neck closure with suprapubic tube to divert her urinary stream. In preparation for this procedure, her catheter was removed to allow for maximal drainage of the abscess, a PICC line was placed for an 8-week prescribed course of IV antibiotic treatment of her osteomyelitis, and she was placed on tight insulin regimen to optimize her diabetes prior to surgery.
A follow-up CT obtained after 1-month of antibiotic therapy however demonstrated progression of her osteomyelitis, with worsened bony destruction and significant enlargement of the abductor abscess. Given failure of antibiotic therapy to control her infection we felt that bladder neck closure was doomed to failure in the face of gross infection. A decision to proceed with ileal conduit urinary diversion in conjunction with pubic bone debridement and abscess drainage with an orthopedic surgeon was made.
Discussion: Few studies have addressed the issue of catheter-induced urethral/bladder neck erosions and its attendant complications in female SCI patients. The vast majority of reported cases of catheter-associated urethral damage are focused on the male SCI populace and primarily describe techniques of male urethral reconstruction. Over 50% of patients with longstanding indwelling urethral catheters are said to suffer urethral erosion or a totally incompetent or patulous urethra 2-4 years after insertion. Chronic indwelling urethral catheters typically lead to urethral erosion by means of pressure necrosis. In women with chronic catheters, the erosive process often first manifests by urinary leakage around the catheter within a patulous urethra. Progressive erosion is often then exacerbated by a vicious cycle of catheter upsizing and balloon over-inflation with the intention to minimize this urinary leakage. Surgical options for the management of urethral and bladder neck erosion in women consist of pubovaginal sling with Martius flap, trans-vaginal versus trans-abdominal bladder neck closure or urinary diversion (ileal conduit vs continent technique). The type of reconstruction is dependent on a host of factors (degree of urethral damage, patient body habitus, personal preferences and supportive care). Urethral erosion with resultant pubic symphysis osteomyelitis has been described only once to date. This is the first case to describe concomitant female urethral erosion, pubic osteomyelitis and associated pelvic abscess in the setting of a chronic indwelling urethral catheter.
Conclusions: Urethral catheters should be considered a last resort of therapy for long-term bladder drainage, especially in women with neurogenic bladders. Pressure-necrosis from chronic indwelling urethral catheterization is a significant threat to the female urethra, requiring often increasingly complex forms of surgical reconstruction to render the patient dry. Urinary incontinence around a chronically dwelling urethral catheter should be considered a red flag to the possibility of an urethral erosion. Urologists should take a lead role in educating patients, caregivers, and spinal cord clinicians in avoiding chronic urethral catheterization in SCI women, and highlight alternative means of bladder management in this vulnerable population.