Images in Clinical Urology Acute Bladder and Small Bowel Perforation as a Complication of Foley Catheterization Gregory Amend, Bradley A. Morganstern, Simpa S. Salami, Daniel M. Moreira, Oksana Yaskiv, and Sammy Elsamra The complications of chronic urethral catheterization are well documented in the medical published data. Chronic urethral catheterization has been demonstrated to cause inflammatory changes within the bladder wall, promoting perforation and small bowel fistualization. In this report, we document the clinical course of a patient who presented with acute perforation of the bladder and small bowel as a result of Foley catheterization. To our knowledge, this is the first documented acute perforation of the bladder and the small bowel during Foley catheterization. UROLOGY 83: e5ee6, 2014. 2014 Elsevier Inc. output for 1 day after replacement of his Foley catheter. Examination of the abdomen demonstrated a nontender, distended, and tympanitic abdomen without signs of peritoneal inflammation. Analysis of turbid brown Foley catheter fluid revealed numerous bacteria. Computed tomography showed the Foley catheter exiting the bladder via an enterovesical fistula (Fig. 1) and entering an adjacent loop of small bowel (Fig. 2), causing obstruction. The patient acutely decompensated, becoming hypotensive and hypoxic, and was rushed to the operating room, in which a primary repair of the bladder and small bowel resection were performed. Histology of the bladder and bowel demonstrated acute ulcerative inflammation and acute transmural inflammation, respectively (Fig. 3). Postoperatively, the patient was treated for gram negative and/ or positive sepsis and eventually discharged stable. Previous published data on complicated urethral catheterization discuss chronic inflammatory changes that allow the Foley to erode through the bladder wall and/or fistualize with the lumen of the small bowel.1-8 We report the first acute perforation of the bladder and the small bowel during Foley catheterization. References
Figure 1. Computed tomography with intravenous contrast, coronal section. Foley catheter (arrow) is shown traveling through an enterovesical fistula. Dilated bowel indicative of obstruction is present.
A
65-year-old man with a history of prostate cancer, status after external beam radiation 12 years ago, and indwelling catheter in place for 2 years presented with nausea, abdominal distension, and decreased urinary
Financial Disclosure: The authors declare that they have no relevant financial interests. From the North Shore-LIJ Hofstra School of Medicine, The Smith Institute for Urology, NY; and the Department of Pathology and Laboratory Medicine, North ShoreLIJ Hofstra School of Medicine, NY Reprint requests: Bradley A. Morganstern, M.D., North Shore-LIJ Hofstra School of Medicine, The Smith Institute for Urology, 450 Lakeville Road, Suite M41, New Hyde Park, NY 11042. E-mail: [email protected] Submitted: October 10, 2013, accepted (with revisions): November 20, 2013
ª 2014 Elsevier Inc. All Rights Reserved
1. Cano-Valderrama O, Dominguez-Serrano I, Esteban Collazo F, et al. Enterovesical fistula caused by an indwelling bladder catheter. Cir Esp. 2012;90:535-537. 2. Hawary A, Clarke L, Taylor A, et al. Enterovesical fistula: a rare complication of urethral catheterization. Adv Urol 2009:591204. 3. Okuda H, Tei N, Shimizu K, et al. Experitoneal bladder perforation due to in-dwelling urethral catheter successfully treated by urethral drainage: a case report. Hinyokika Kiyo. 2008;54:501-504. 4. Farraye MJ, Seaberg D. Indwelling foley catheter causing extraperitoneal bladder perforation. Am J Emerg Med. 2000;18:497-500. 5. Arun N, Kekre NS, Nath V, et al. Indwelling catheter causing perforation of the bladder. Br J Urol. 1997;80:675-676. 6. Baba K, Yajima M, Takahashi H, et al. Ileovesical fistula caused by long-term indwelling of urethral catheter: a case report. Hinyokika Kiyo. 1995;41:235-237. 7. White SA, Thompson MM, Boyle JR, et al. Extraperitoneal bladder perforation caused by an indwelling urinary catheter. Br J Surg. 1994;81:1212. 8. Magee GD, Marshall SG, Wilson BG, et al. Perforation of the urinary bladder due to prolonged use of an indwelling catheter. Ulster Med J. 1991;60:237-239.
0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2013.11.022
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Figure 2. Computed tomography with intravenous contrast, coronal section. Foley catheter (arrow) is shown extending approximately 8 cm into the lumen of the small bowel, locally obstructing the passage of gastrointestinal contents.
Figure 3. Hematoxylin and eosin stains: intraoperative bladder (A) and small bowel (B) biopsies. Bladder mucosa demonstrates acute ulcerative and exudative processes superimposed on chronic inflammatory changes. These findings suggest that the bladder wall had been chronically compromised as a result of the indwelling Foley catheter, rendering the tissue susceptible to acute perforation. Histology of the intestinal wall reveals primarily acute changes, which are consistent with acute perforation and fresh enterovesical fistula tract formation.
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UROLOGY 83 (3), 2014
Figure 1. Computed tomography with intravenous contrast, coronal section. Foley catheter (arrow) is shown traveling through an enterovesical fistula. Dilated bowel indicative of obstruction is present.
A
65-year-old man with a history of prostate cancer, status after external beam radiation 12 years ago, and indwelling catheter in place for 2 years presented with nausea, abdominal distension, and decreased urinary
Financial Disclosure: The authors declare that they have no relevant financial interests. From the North Shore-LIJ Hofstra School of Medicine, The Smith Institute for Urology, NY; and the Department of Pathology and Laboratory Medicine, North ShoreLIJ Hofstra School of Medicine, NY Reprint requests: Bradley A. Morganstern, M.D., North Shore-LIJ Hofstra School of Medicine, The Smith Institute for Urology, 450 Lakeville Road, Suite M41, New Hyde Park, NY 11042. E-mail: [email protected] Submitted: October 10, 2013, accepted (with revisions): November 20, 2013
ª 2014 Elsevier Inc. All Rights Reserved
1. Cano-Valderrama O, Dominguez-Serrano I, Esteban Collazo F, et al. Enterovesical fistula caused by an indwelling bladder catheter. Cir Esp. 2012;90:535-537. 2. Hawary A, Clarke L, Taylor A, et al. Enterovesical fistula: a rare complication of urethral catheterization. Adv Urol 2009:591204. 3. Okuda H, Tei N, Shimizu K, et al. Experitoneal bladder perforation due to in-dwelling urethral catheter successfully treated by urethral drainage: a case report. Hinyokika Kiyo. 2008;54:501-504. 4. Farraye MJ, Seaberg D. Indwelling foley catheter causing extraperitoneal bladder perforation. Am J Emerg Med. 2000;18:497-500. 5. Arun N, Kekre NS, Nath V, et al. Indwelling catheter causing perforation of the bladder. Br J Urol. 1997;80:675-676. 6. Baba K, Yajima M, Takahashi H, et al. Ileovesical fistula caused by long-term indwelling of urethral catheter: a case report. Hinyokika Kiyo. 1995;41:235-237. 7. White SA, Thompson MM, Boyle JR, et al. Extraperitoneal bladder perforation caused by an indwelling urinary catheter. Br J Surg. 1994;81:1212. 8. Magee GD, Marshall SG, Wilson BG, et al. Perforation of the urinary bladder due to prolonged use of an indwelling catheter. Ulster Med J. 1991;60:237-239.
0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2013.11.022
e5
Figure 2. Computed tomography with intravenous contrast, coronal section. Foley catheter (arrow) is shown extending approximately 8 cm into the lumen of the small bowel, locally obstructing the passage of gastrointestinal contents.
Figure 3. Hematoxylin and eosin stains: intraoperative bladder (A) and small bowel (B) biopsies. Bladder mucosa demonstrates acute ulcerative and exudative processes superimposed on chronic inflammatory changes. These findings suggest that the bladder wall had been chronically compromised as a result of the indwelling Foley catheter, rendering the tissue susceptible to acute perforation. Histology of the intestinal wall reveals primarily acute changes, which are consistent with acute perforation and fresh enterovesical fistula tract formation.
e6
UROLOGY 83 (3), 2014
