Abstract
Some patients with neurological bladder dysfunction rely on suprapubic catheters (SPCs) for the management of their urinary symptoms. These catheters are usually changed without incident. However, problems can, and do, arise. We present the case of a 56-year-old woman who had a SPC change which was complicated by the catheter perforating the bladder and inflating in the vagina.
Keywords: long-term care, urinary tract infections, catheterisation / catheter care, urological surgery, medical-surgical nursing
Background
Many patients rely on suprapubic catheters (SPCs) for the management of their lower urinary tract dysfunction, especially where other solutions have failed or alternatives are unsuitable. Sometimes SPCs are used as alternatives to avoid complications of long-term urethral catheters. Patients who do benefit from long-term SPCs are those with neurogenic bladder dysfunction such as those with multiple sclerosis or spinal cord injury. Frail patients with bladder outlet obstruction who have been managed with long-term urethral catheters sometimes develop traumatic hypospadias. These patients can also be managed long term with an SPC. Some of the benefits of SPCs include ease of catheter care by patients or their carers, less discomfort in the perineal region and higher patient satisfaction. However, SPCs do carry the same risk of urinary tract infection compared with urethral catheters.1
Usually, after insertion of an SPC by the urologist, the first change of catheter is carried out by the urologist or an experienced nurse practitioner. Subsequent changes are most likely to happen in the community, undertaken by district nurses. The majority of routine catheter changes are without incident but a common complication is the inability to correctly position the replacement catheter. This may result in the need for a further operation for a new catheter siting. We report the case of a supposed successful catheter change which was inadvertently positioned in the vagina.
Case presentation
A 56-year-old woman with a 24-year history of multiple sclerosis and managed with a long-term SPC attended hospital following a complicated silicone SPC change by a district nurse the previous day. After a presumed successful change, the district nurse left and the daughter, who is her trained carer, later realised that the new SPC was not draining and that her mother was in pain. She decided to insert a urethral catheter. During the process, she noted that the tip and balloon of the catheter were in the vagina (figure 1). She completed the urethral catheter insertion and brought the patient to the hospital.
When she was seen the SPC was not draining but the urethral catheter was draining clear urine. She was hoisted on to an examination trolley so that the catheter could be seen while in the lithotomy position. Digital examination (consented and chaperoned) revealed that the catheter had entered the vagina through the base of the bladder, quite close to the urethra. She was already receiving a therapeutic dose of nitrofurantoin.
Treatment
The catheter balloon was deflated and removed and a new catheter inserted. The urethral catheter was spigotted and urine output monitored from the new SPC. After a satisfactory outcome, the urethral catheter was removed and she was discharged. A cystogram was arranged for 10 days’ time to make sure the perforated bladder had healed and the pressure from the balloon (over many hours) had not caused any long-term injury to the bladder that may result in persistent fistula.
Outcome and follow-up
A cystogram performed 14 days later showed no interaction between the bladder and any other structure (figure 2). This indicated that the perforation by the catheter had healed.
Discussion
This situation is something that rarely happens, but there are factors with this patient that may have contributed to the outcome of the SPC change. It is known that older females have a thinner walled bladder which could easily be perforated. In addition, the bladder capacity may be small and further affected by abnormal posturing in patients with neurological disease. Another issue is that the silicone catheters are quite stiff and can easily perforate the bladder if due care is not taken. Despite these factors, the technique of changing an SPC should allow for a safe catheter change without complications. This patient could have been in great pain and distress due to retention if her daughter had not been trained to look after her. If this was a patient with spinal injury at T6 or above, they could have gone into autonomic dysreflexia with possible severe complications.
Complications like these can be avoided by: taking care not to insert the full length of catheter during the change; ensuring that the catheter continues to drain urine for a period after changing; making sure that the patient is not in any discomfort after the procedure is completed.
When a complication like this occurs, it is essential to remove the catheter. It cannot be retracted back into the bladder and left in situ due to the fact that it has been in a non-sterile environment. There is a risk of introducing bacteria from the vagina into the bladder; consequently, the patient will need to be given prophylactic antibiotics in the periprocedure period.
After such an injury to the bladder, it is expected that perforations of 1 cm or less would heal in most patients. The reason for the cystogram is to make sure that there is no leak due to the attendant pressure from the inflated catheter balloon.
Similar cases of bladder perforation following SPC changes have been reported. A case of an SPC perforating the bladder into the colon was reported by Kass-Iliyya et al.2 The patient was well on presentation and was managed conservatively. Witham and Martindale3 reported a case of an SPC change in a male patient that perforated the sigmoid colon with the catheter tip visible per rectum. The patient was unwell and needed to have a laparotomy. This is quite similar to this presentation which would have been more serious had the vagina not been positioned between the bladder and rectum.
Learning points.
Clamp or spigot the catheter prior to changing to allow for an amount of urine to be stored in the bladder. This will help maintain the same alignment of the openings of the anterior abdominal wall and the bladder. Also, it will confirm correct placement by continuous urine drainage via the new catheter.
Avoid inserting the full length of the catheter as this will increase the potential for the catheter to enter the urethra or perforate the bladder.
After every change of catheter, urine output must be monitored from the new suprapubic catheter as this will confirm that it is in the correct position.
After changing catheters, confirm that the patient is comfortable and is not experiencing any unusual pain, discomfort or bleeding. These may suggest that there could be issues that need resolving.
If you are not entirely happy, there is no harm in getting help from more experienced person, rather than compromise patient safety.
Footnotes
Contributors: CE conceived, designed and planned this work, he also did the research, reporting and editing.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Obtained.
References
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