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American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
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The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
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American Journal of Medical Sciences and Medicine
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Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
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The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

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Iatrogenic Rectal Perforation During Urethral Foley Catheterization

Mohammed A. M. El Habiel*, Mohammed Hidayathullah Khan, Javereeya Abduljabbar

General Surgery Resident, Tawam Hospital- Al Ain- U.A.E

Abstract: Foley catheterization is a common daily procedure done in our practice. Iatrogenic rectal perforation during urethral Foley catheterization is a very rare complication. There are multiple underlying risk factors that can lead to this devastating complication, including friable rectal tissues due to underlying trauma, radiation. Additionally, the type of Foley catheter and the technique of insertion can lead to this complication. The presentation of the patient is always alarming and can aid in making the diagnosis. The management, always, depends on the whole patient clinical condition, and it ranges from conservative management and changing the catheter under vision, to laparotomy and rectal perforation repair. We are presenting a case report of a comorbid patient suffered this complication in our facility.

Keywords: iatrogenic, rectal perforation, urethral Foley catheterization

Received May 19, 2023; Revised June 20, 2023; Accepted June 29, 2023

Citation: Mohammed A. M. El Habiel, Mohammed Hidayathullah Khan, Javereeya Abduljabbar, Iatrogenic Rectal Perforation During Urethral Foley Catheterization. American Journal of Medical Case Reports, 11 (5). 104-106. January 2023. doi:10.12691/ajmcr-11-5-6

1. Case Report

A 66 –year- old male, known case of Glioblastoma Multiforme was admitted due to decreased urine output. During attempting to catheterize the patient by ER team, frank hematuria with some faecal debris were noted. Thereafter, Urology team was consulted and iatrogenic urethral injury due to urethral catheterization was suspected. A pelvis CT was requested (Figure 1 – Figure 6) and showed: the Foley catheter passing through the membranous urethra and into the rectum. The images obtained after injection of water-soluble contrast through the foley catheter, demonstrate the contrast completely opacifying the rectum, compatible with an urethrorectal fistula. No extravasation of contrast outside of the rectum, or surrounding structures is noted. Flexible Cystoscopy confirmed the membranous urethral injury. Subsequently a catheter was inserted over a guidewire at flexible cystoscopy. The patient was treated conservatively on antibiotics. The patient improved on conservative management, but unfortunately, he passed away later on due to his primary illness.

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

Figure 6.

2. Discussion

Urinary catheterisation is a common practice performed for a wide range of patients due to different medical and surgical reasons; including monitoring of urinary output, urinary retention and for many urology surgical cases [1]. Between 15% and 25% of hospitalized patients may receive short-term indwelling urinary catheters [2,3]. Despite the simplicity of catheterisation as a process, there are several complications reported to be associated with this intervention; including infections, trauma, hypersensitivity reaction, blockage, and fistula formation [4,5].

It has been recorded that genitourinary trauma due to catheterisation occurs in 1.5% of patients [5]. According to another study, the incidence of urethral injury during Foley catheterization is around 3.2 per 1000 patients during hospital admission [6]. The percentage itself is low, but when we take into consideration the high volume of patients that need catheterization, then we can expect the total number of affected patients will be significant. Additionally, the cost burden on the medical field will be high [4].

Rectal perforation is indeed a rare complication of urethral catheter insertion [7,8,9]. We attribute the cause of our patient’s rectal perforation to his previous radiotherapy treatment for his cancer. Radiation proctitis can induce tissue changes of endarteritis, inflammation, and fibrosis [10,11]. This can result in friable and ulcerated tissue, which can be more susceptible to injury, as it might happened to this patient. In some cases, the catheter may have been introduced too far into the bladder and infection may weaken the wall, making it more vulnerable. Additionally, viscous perforation is more likely to occur when the catheter material is not soft [9].

The most common signs and symptoms of the patient with rectal perforation are progressive abdominal pain with penile and/or perineal pain (100%) and, commonly, urethral bleeding (86%) [6]. Timely diagnosis with clinical examination, imaging, and surgical evaluation is critical to the patient recovery.

3. Management

The European Association of Urology Guidelines on Urethral Trauma recommends urethroscopy as the first-line investigation for suspected urethral trauma from catheterization [12].

Laparotomy and repair of the perforation is the standard of care for patients presenting with bowel perforation due to Foley catheterization [9]. In our case, we had a complete alleviation of the symptoms by simply changing the Foley catheter under guidance, and commencing conservative management with antibiotics.

References

[1]   | J. Meddings, M. A. M. Rogers, S. L. Krein, M. G. Fakih, R. N. Olmsted, and S. Saint, “Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review,” Safety, vol. 23, no. 4, pp. 277-289, 2014.
[2]   | Warren JW. Catheter-associated urinary tract infections. Int J Antimicrob Agents. 2001; 17(4): 299-303.
[3]   | Weinstein JW, Mazon D, Pantelick E, Reagan-Cirincione P, Dembry LM, Hierholzer WJ,Jr. A decade of prevalence surveys in a tertiary-care center: Trends in nosocomial infection rates, device utilization, and patient acuity. Infect Control Hosp Epidemiol. 1999; 20(8): 543-548.
[4]   | K. H. Dellimore, A. R. Helyer, and S. E. Franklin, “A scoping review of important urinary catheter induced complications,” Journal of Materials Science: Materials in Medicine, vol. 24, no. 8, pp. 1825-1835, 2013.
[5]   | A. M. Leuck, D. Wright, L. Ellingson, L. Kraemer, M. A. Kuskowski, and J. R. Johnson, “Complications of Foley catheters--is infection the greatest risk?” The Journal of Urology, vol. 187, no. 5, pp. 1662-1666, 2012.
[6]   | Kashfi L, Messer K, Barden R et al.. Incidence and prevention of iatrogenic urethral injuries. J Urol 2008; 179: 2254-7.
[7]   | Kass-Iliyya A, Morgan K, Beck R, Iacovou J. Bowel injury after a routine change of suprapubic catheter. BMJ Case Rep. 2012; 2012:pii: bcr2012006524.
[8]   | Bonasso PC, Lucke-Wold B, Khan U. Small Bowel Obstruction Due to Suprapubic Catheter Placement. Urology Case Rep. 2016; 7: 72-73.
[9]   | Amend G, Morganstern BA, Salami SS, Moreira DM, Yaskiv O, Elsamra S. Acute bladder and small bowel perforation as a complication of Foley catheterization. Urol. 2014; 83: 5-6.
[10]   | M. Venerito, K. Mönkemüller, S. Rickes, and P. Malfertheiner, “Gastrointestinal: radiation proctitis,” Journal of Gastroenterology and Hepatology, vol. 22, no. 5, p. 761-, 2007.
[11]   | F. Ali and K. Y. Hu, “Evaluation and management of chronic radiation proctitis,” Diseases of the Colon and Rectum, vol. 63, no. 3, pp. 285-287, 2020.
[12]   | Martínez-Piñeiro L, Djakovic N, Plas E et al.. EAU guidelines on urethral trauma. Eur Urol 2010; 57: 791-803.