Analgesia & Resuscitation : Current ResearchISSN: 2324-903X

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Case Report, Analg Resusc Curr Res Vol: 6 Issue: 2

One, Two, Three, Four, Five and Six: The Parturient with Six Urinary Catheters during the Peripartum Period

Nnamani NP* and Diane Allen

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical center, Dallas, USA

*Corresponding Author : Nwamaka P Nnamani
Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical center, Dallas, USA
Tel: 2146486400 E-mail: [email protected]

Received: October 19, 2017 Accepted: November 03, 2017 Published: November 08, 2017

Citation: Nnamani NP, Allen D (2017) One, Two, Three, Four, Five and Six: The Parturient with Six Urinary Catheters during the Per Partum Period. Analg Resusc: Curr Res 6:2. doi:10.4172/2324-903X.1000148

Abstract

Foley catheter placement is one of the most common medical procedures performed for patients across all age ranges and diagnoses. We present the case of a patient who required six urinary catheters during her brief peripartum stay secondary to urethral perforation. This case illustrates how a routine and simple task performed in numerous laboring patients can result in an unexpected morbidity during the peripartum period.

Keywords: Urinary catheters; Peripartum period; Obstetrics

Introduction

Foley catheter placement is one of the most common medical procedures performed for patients across all age ranges and diagnoses. They are inserted in more than 5 million patients in acute and extended care facilities across the United States every year [1]. In the majority of cases, urinary catheterization is carried out without any problems. However, on rare occasions there can be serious complications. We present the case of a patient who required six urinary catheters during her brief peripartum stay secondary to urethral perforation.

Case Report

26-year-old female G1P0 at 38w1d gestation age with a history of cholelithiasis during the pregnancy presented with premature rupture of membranes, so labor was induced. An epidural was placed during labor, along with a Foley catheter. The Foley catheter remained in her bladder and was patent for 12 hours draining 1200mls of clear yellow urine, however when the patient advanced to the second stage of labor and started pushing, the catheter was removed. A cesarean delivery was deemed necessary due to failure to progress and chorioamnionitis, so a second Foley was placed in the operating room. This catheter drained 20mL of bloody urine initially on placement but subsequently no further drainage was evident. The surgical team noted bladder distention that was interfering with the visualization of the uterus so the Foley catheter was again removed and a third catheter placed. The placement encountered some resistance but this was attributed to fetal positioning. This catheter drained 5mL of dark bloody fluid initially but no urine. After delivery of the baby, the bladder was still distended, so a different nurse removed the third catheter and placed a fourth, again resistance was noted and no urine was evident. After closure of the abdominal incision, a cystoscopy was performed which revealed mild irritation and inflammation at the Ureter Vesicular Junction (UVJ) with excoriations and edema in the periurethral area. Intravesicular exam showed minimal clots, but there was no obvious sign of a lesion.

Overnight, the patient continued to have palpable bladder distention and no urine output so she underwent a CT urography which showed the urinary catheter entering the urethra and exiting the posterior urethra wall with the balloon of the Foley catheter inflated in the vesicouterine space. She was taken to the OR where a fifth catheter was placed and ultrasound showed that it was located in a false track outside the urethra so it was removed. The team placed a red rubber catheter, which followed the false track, and then another urinary catheter was successfully placed into the bladder with drainage of urine. This catheter remained in place for one week to allow healing of the iatrogenic urethra opening. The patient was evaluated a week later in the outpatient clinic and the Foley catheter was removed and she passed an active bladder test with no further voiding problems.

Discussion

Urethral injury in female patients is rare and usually limited to major trauma. Pelvic fracture is the most common injury that can damage the urethra, but stab wounds to the buttocks can also damage the urinary tract especially if it is near the perineum [2]. Foley catheter placement is rarely associated with urinary tract trauma, but this practice is necessary in many different patient populations, especially in parturient patients with neuraxial anesthesia. While a spinal or epidural is not necessarily an indication for bladder catheterization [3], women in the peripartum period are at risk for urinary retention, which can interfere with the second stage of labor [4]. Similarly, having continuous urine monitoring provides vital information to the surgery team particularly during a cesarean delivery. This allows the anesthesia team to immediately communicate to the surgeons if there has been bladder damage, which may be evident as hematuria and reduction in urine output. Foley catheter placement can be difficult in patients with prostatic hyperplasia, or neurogenic bladder with frequent intermittent catheterization due to a narrowed urethra [5]. There are several case reports of bladder perforation with long term indwelling Foley catheters in patients who are malnourished and so may have weakened connective tissue or an extrinsic mass leading to ulceration of the catheter through the bladder [6]. This usually requires surgical repair but has been treated with urinary drainage alone [7]. However, we could find no reports of traumatic Foley insertion in a laboring patient requiring multiple catheters.

In this case, the pressure from a fetus low in the pelvis likely was obstructing the urethra. She had no history of frequent catheterization but did have a Foley catheter placed in the early stage of her labor so there may have been some edema present. Once the second catheter met resistance, it was advanced and may have created the false passage into the vesicovaginal space. The third catheter was placed while the pressure of the infant was still present so it followed that track as well. The resultant edema may have prohibited the perforation from being seen on cystoscopy. Furthermore, her main symptom was low urine output, and any pain would have been obscured by regional anesthesia. The following day, once a red rubber catheter had been advanced into the false track, a new catheter could then follow the urethra into the bladder and remained in place long enough to allow the perforation to heal. She is at risk for urethral strictures in the future, as well as detrusor muscle malfunction because of significant bladder distention, but thus far she is doing well. This case illustrates how a routine and simple task performed in numerous laboring patients can result in an unexpected morbidity during the peripartum period.

References

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