Treatment injury case study
August 2011 – Issue 36
Sharing information to enhance patient safety
EVENT: Urinary catheterisation
INJURY: Urethral damage
Case Study
Lee, a 68-year-old man, was sent by his GP to the emergency department with
acute urinary retention.
Lee had a complicated urological history, having developed
a urethral stricture many years previously, probably as a
result of having contracted a sexually transmitted infection.
The stricture had been dilated a number of times and Lee’s
condition had been stable for a few years.
In the months prior to developing urinary retention, he had
been having increasing difficulty with his urine flow. It was
not clear if this was due to a recurrence of the stricture. Lee’s
GP also suspected benign prostatic hypertrophy.
Key points
• Urethral strictures most commonly arise
owing to instrumentation of the urinary
tract, but can also be caused by infections,
particularly gonorrhoeal urethritis
• It’s important to obtain a history from
the patient prior to catheterisation and to
consider the possibility of stricture disease
• If there is a chance that a stricture is
present and the catheter does not advance
readily, do not persist with attempts to
catheterise
• If expert help is not available, a Bonanno
type suprapubic catheter should be used
• In patients without stricture disease, if a
14 French catheter does not advance with
gentle insertion, a larger catheter may be
better. A smaller one is likely to curl up in
the urethra
• Repeated forceful attempts to catheterise
can result in the catheter perforating the
urethral wall, creating a false passage
• Consider the possibility of postobstructive diuresis – monitor at-risk
patients for two or three hours after relief
of the obstruction.
When Lee was seen at the emergency department by one
of the junior medical staff he was noted to have a distended
bladder. An attempt was made to insert a 14 French
indwelling urinary catheter. Inserting the catheter proved
extremely difficult and 100ml of blood-stained urine passed in
the process.
The catheter was removed and another attempt was made
using a smaller 12 French catheter. After much effort, the
doctor was unable to insert this catheter either, so a urology
opinion was sought.
When seen by the urology registrar, there was frank blood
draining from the urethral meatus. Urethroscopy was carried
out using a flexible cystoscope. This revealed a false passage
in the penile urethra, most likely caused by the unsuccessful
catheterisation attempts. There was also a bulbar urethral
stricture proximal to this.
The stricture was dilated under direct vision using a balloon
dilator. A catheter was successfully inserted into the bladder
using a guide wire and further treatment was planned for the
stricture.
A treatment injury claim was lodged for damage to the
urethra as a result of catheterisation. ACC sought external
clinical advice from a urologist who advised that, given Lee’s
complex history, it had been unwise for the junior medical
staff to persist with catheterisation after the first attempt
failed. In his opinion urological input should have been
sought sooner. ACC accepted the claim for urethral injury but
excluded Lee’s underlying urethral stricture from cover.
Expert Commentary
Andre Westenberg FRACS
Urethral stricture disease is a relatively common urological
problem. A scar in the urethra blocks the bladder outlet and
results in poor flow and secondary bladder irritability. This
may lead to urinary retention and, in rare cases, fistulation
with the development of a ‘watering can’ perineum (where it
becomes riddled with multiple fistulae).
We know that strictures have been part of the human
condition since ancient times. Silver urethral dilators have
Case study
been found buried with pharaohs in their tombs. The need for
these devices was no doubt due to the prevalence of strictures
caused by sexually transmitted infections, particularly
gonorrhoea.
Gentle urethral catheterisation should be attempted as a first
step. If a 14 French catheter does not advance, it is often better
to try a larger catheter such as an 18 French rather than a smaller
one, as a 12 French catheter is likely to just curl up in the urethra.
Whilst gonorrhoeal urethritis is still an important cause of
urethral strictures, it is rare. These days, strictures are most
often caused by previous instrumentation of the urinary tract,
with an incidence of up to five percent after trans-urethral
prostate resection. Even relatively trivial urethral trauma, such
as an apparently straightforward urethral catheterisation, can
result in severe stricture disease.
It is important to obtain a history and to consider the possibility
of stricture disease. If there is a chance of stricture and the
catheter does not advance readily, attempts to catheterise
should be abandoned.
BXO (balanitis xerotica obliterans), an inflammatory condition
of the prepuce and glans, is increasingly recognised as a cause of
urethral strictures, and while on occasion strictures are referred
to as idiopathic, some specialists believe that ‘idiopathic’
strictures most likely arise from forgotten perineal trauma.
In older men, urethral strictures can co-exist with benign
prostatic obstruction. Both conditions lead to similar symptoms
and they can be difficult to separate on clinical examination only.
Stricture should be considered as a possible cause of symptoms
in those patients who have a history of transurethral surgery,
pelvic trauma or previous catheterisation. Strictures rarely
resolve unless patients have a formal urethroplasty. Those
patients presenting with obstructive symptoms, who have a
history of urethral stricture disease, are likely to have reformed
their strictures.
Strictures can be diagnosed by the shape of the urinary flow rate
curve or by cystoscopy. Most urologists try incising the stricture
under anaesthetic as a first step, but the rate of recurrence is
unfortunately high.
In young, otherwise healthy patients, a formal urethroplasty
gives the best chance of long-term success. In older patients
with vascular insufficiency, where there may be problems with
graft uptake or healing, long-term self-dilation with a urethral
catheter is often advised. Temporary thermoalloy expandable
stents to hold the stricture open after urethrotomy may be
useful in some.
Acute urinary retention is exceedingly uncomfortable and can
be distressing, not only for the patient but also for the clinician
attempting to relieve the obstruction.
How ACC can help your patients following treatment injury
Many patients may not require assistance following their treatment injury.
If expert help is not available, a Bonanno type suprapubic
catheter should be used. This is a very safe way to relieve
obstruction in those with an obviously palpable bladder.
Insert the catheter one centimetre above the symphysis
pubis and advance it directly backwards, perpendicular to the
abdominal wall, to reduce the incidence of bowel injury. This
is a safe technique, even in obese patients. A more acute angle
downwards runs the risk of missing the bladder. A bladder scan
can be useful in a larger patient in order to confirm that the
bladder is full.
Repeated forceful attempts to catheterise can result in the
catheter perforating the urethral wall and creating a false
passage. This not only is uncomfortable but can result in
significant bleeding and further stricturing. It can sometimes
make it difficult to find the true urethral lumen at future
cystoscopy.
It is important to consider the possibility of post-obstructive
diuresis. If the patient has been in retention for any length of
time, they may have physiological renal changes that decrease
the ability of the kidneys to concentrate urine. Relief of the
obstruction can lead to a fierce diuresis and elderly patients in
particular can become significantly dehydrated with electrolyte
disturbances. It is important to monitor these patients for two or
three hours after the relief of the obstruction to ensure they do
not need intravenous support.
References
Mundy AR, Andrich DE. Urethral Strictures. BJU Int 2011; 107(1):6-26
Jordan GH, Schlossberg SM. Surgery of the penis and urethra. Chpt 33 in: Wein AJ,
et al, eds. Campbell-Walsh Urology vol 1, 9th ed. Philadelphia, Pa: WB Saunders
Co; 2007:1054-75
Claims information
Between 1 July 2005 and 30 June 2011, ACC received 149 claims related to urinary
catheterisation. Of these, 129 were accepted.
Of the accepted claims, the most common injuries were damage to the urethra and
bladder.
The most common reason for declining a claim was that there was no physical
injury.
However, for those who need help and have an accepted ACC claim, a
range of assistance is available, depending on the specific nature of the
injury and the person’s circumstances. Help may include things like:
About this case study
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•
This case study is based on information amalgamated from a number of
claims. The name given to the patient is therefore not a real one.
•
contributions towards treatment costs
weekly compensation for lost income (if there’s an inability to
work because of the injury)
help at home, with things like housekeeping and childcare.
No help can be given until a claim is accepted, so it’s important to
lodge a claim for a treatment injury as soon as possible after the
incident, with relevant clinical information attached. This will ensure
ACC is able to investigate, make a decision and, if covered, help your
patient with their recovery.
ACC6026 August 2011 ©ACC 2011
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The case studies are produced by ACC’s Treatment
Injury Centre, to provide health professionals with:
•
•
an overview of the factors leading to treatment injury
expert commentary on how similar injuries might be avoided in
the future.
The case studies are not intended as a guide to treatment injury cover.
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