Trauma to the urethra can occur during catheterization. A false lumen can be created if excessive force is applied during insertion, especially in patients with underlying urethral stricture or prostatic enlargement. This usually occurs at the level of the proximal bulbous urethra. Signs of false lumen include bleeding, pain, and lack of urine output. This complication can be avoided by using either a large catheter (20 French or larger) or a Coudé-tipped catheter in order to pass an obstruction while using less force. Prolonged suprapubic or transurethral drainage can correct most false lumens, but surgical intervention may be required.
The urethra can also be damaged by inflation of the retention balloon within the urethra. Pain or resistance encountered during balloon inflation may indicate that the balloon is located within the urethra. Forceful removal of the catheter with the balloon fully or partially inflated will also cause urethral damage and edema. Prompt recatheterization is indicated in this situation to avoid subsequent urethral obstruction.
The erosion of the glans penis and necrosis of the urethra that can develop in patients with long-term catheterization can be avoided by properly anchoring the catheter so as to lessen any tension that is exerted on the meatus or urethra. Patients with penile prostheses are at particular risk for urethral necrosis and erosion as a result of urethral compression. Scarring at the site of urethral necrosis can lead to stricture formation. This is much more common in male patients and often presents as difficulty in catheterization. Diagnosis is made by retrograde urethrogram, and treatment frequently requires cystoscopic repair.
Damage to the bladder as a result of catheterization can range from mild bladder wall irritation to bladder perforation. Chronic indwelling catheters produce histologic changes to the bladder wall. Polypoid cystitis, a benign inflammatory reaction, develops after approximately 30 days but is readily reversible upon catheter removal. Squamous cell carcinoma can also develop as a result of long-term catheterization, however, and should be considered in patients who have hematuria with long-term indwelling catheters.
Perforation of the bladder can also result from catheterization. Long-term indwelling catheters can erode through the bladder wall and perforate the bladder. Catheters may also be passed through the bladder wall during catheterization. Although this is uncommon, its risk is increased if the bladder wall is distended or inflamed. Patients with bladder perforations typically have decreased urine output, pyuria, hematuria, and peritoneal signs. Diagnosis is best made by cystogram, and urologic consultation is required for definitive treatment. Many patients respond well to conservative treatment consisting of bladder drainage and decompression, but operative repair is often required.
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