CASE REPORT
Unsuccessful Foley Catheterization Had an Unexpected Explanation Junchan Joshua Yune, MD,* Michelle Lightfoot, MD,Þ D. Duane Baldwin, MD,Þ Jeffrey Hardesty, MD,* and Sam Siddighi, MD*
Background: Foley catheterization is a simple procedure routinely performed during many obstetric and gynecologic procedures. Failure to adequately drain the bladder with catheter insertion should prompt further investigation to minimize morbidity to the patient. Case: After repeated attempts to place a Foley catheter during a cesarean section, the urinary bladder did not drain. Postoperatively, it was found that the catheter was positioned inside the left ureter, and cystoscopy confirmed an ectopic ureter inserting into the proximal urethra. Conclusions: This case presents an unusual cause of oliguria in an operative patient requiring Foley catheterization. An ectopic ureteral orifice should be considered in the differential diagnosis of a patient presenting with unexplained oliguria or anuria and failure to decompress the bladder with catheter placement. Key Words: cesarean section, ectopic ureter, Foley catheter (Female Pelvic Med Reconstr Surg 2015;21: e14Ye16)
T
ransurethral Foley catheter placement is a common procedure used in many surgical patients. The benefits of urinary catheterization include the following: decompression of the bladder to provide optimal surgical exposure and minimize the risk of bladder injury, allowance of continuous monitoring of urine output, improved patient comfort, and treatment of urinary retention in postoperative patients. However, urinary catheterization is also associated with a low but significant risk of complications including pain, hematuria, urinary tract infection, and iatrogenic anatomic injury. Foley catheterization in a female patient with normal external genitalia rarely fails to provide adequate drainage of the bladder. If a urethral catheter does not freely drain, other explanations must be considered. One possible scenario is inadvertent deployment of the catheter outside the urinary tract. Other scenarios may include catheter occlusion by clot, debris, bladder tumor, or placement into a bladder diverticulum. In most circumstances, replacement of the Foley catheter will result in bladder drainage. In this report, we present a patient for whom Foley catheter placement into an ectopic ureter resulted in both ureteral and bladder outlet obstruction complicating a cesarean section.
CASE A 26-year-old woman, gravida 6, para 4, presented to the hospital for scheduled primary cesarean delivery at 39 weeks From the Departments of *Female Pelvic Medicine and Reconstructive Surgery, and †Urologic Surgery, Loma Linda University Medical Center, Loma Linda, CA. Reprints: Junchan Joshua Yune, MD, Coleman Pavilion, Room 11105, 11175 Campus St, Loma Linda, CA 92350. E-mail: [email protected]. The authors have declared they have no conflicts of interest. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/SPV.0000000000000111
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for fetal spina bifida. A 16F Foley catheter was placed preoperatively, with an immediate return of 10 mL of clear urine output after catheter insertion. At the time of entry into the peritoneal cavity, the bladder was noted to be distended and resulted in compromised visualization of the operative field. Direct inspection of the Foley and bag revealed clear urine in the tubing and a small amount of urine in the drainage bag. To improve operative visualization, direct needle decompression was used to remove 320 mL of urine from the bladder. This improved visualization, allowing the cesarean section to proceed uneventfully. After delivery and uterine closure, the bladder was again inspected and noted to be distended. The Foley catheter was removed and replaced intraoperatively, again with a small amount of clear urine output obtained. A second needle decompression removed 240 mL of clear yellow urine. The procedure was completed without further incident, and the patient was transferred to the postpartum ward for further recovery. At the ward, the patient was noted to have low urine output of 20 mL over a 2-hour period, so the Foley catheter was removed and replaced with a 24F 2-way catheter with no significant improvement in urine output. The patient continued to experience suprapubic discomfort consistent with bladder distention, and a postpartum renal and bladder ultrasound demonstrated a severely distended bladder and mild right hydronephrosis. Urologic consultation was obtained, and another 16F catheter was placed. There was no resistance to catheter placement, but very little urine output was obtained with the initial insertion. Vaginal palpation demonstrated no catheter in the vagina. Hand irrigation with 10 mL of saline initially demonstrated normal irrigation. However, further attempts at irrigation with 60 mL resulted in a return of only 10 to 20 mL of clear irrigation and caused exacerbation of the patient’s left flank pain. Subsequent noncontrast abdominal and pelvic computed tomography (CT) scan demonstrated the Foley tracking posterior to the distended bladder and up the left ureter with the tip of the catheter located in the midureter (Fig. 1). There was mild bilateral ureteral dilation with diameter measured at 2.2 cm on the left and 1.9 cm on the right; however, there was no significant hydronephrosis. The catheter was subsequently removed, and the patient was able to void spontaneously with immediate resolution of suprapubic and left flank pain. Upon direct questioning, the patient denied any prior episodes of urinary incontinence, retention, straining to void, hematuria, or known anatomic abnormalities. She did have a history of recurrent urinary tract infections, including 1 episode of pyelonephritis before pregnancy. She recalled that she had an epidural anesthesia in the past but had no memory of Foley catheterization or its complication. The remainder of her hospitalization was uneventful, and the patient was discharged on postoperative day 4. She returned to the clinic 4 weeks later for follow-up without any new voiding symptoms. Cystourethroscopy revealed an ectopic capacious left ureter with a large dilated ureteral orifice inserting into the proximal urethra at the 7-o’clock position just distal to
Female Pelvic Medicine & Reconstructive Surgery
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Volume 21, Number 2, March/April 2015
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Female Pelvic Medicine & Reconstructive Surgery
&
Volume 21, Number 2, March/April 2015
Ectopic Ureter Becomes Symptomatic at the Time of Cesarean Section
FIGURE 1. Coronal view of abdominal and pelvic CT scan. The Foley catheter (black arrow) is seen tracking posterior to the distended bladder (B), with Foley balloon (white arrow) located in the mid left ureter.
discomfort. She was offered referral to urology but has declined further evaluation at this time.
the bladder neck (Figs. 2, 3). The ureteral orifice was larger and in line with the urethra explaining the preferential entry of the catheter into the ureter rather than the bladder. In contrast, the bladder neck appeared as a tiny slitlike opening at the 12-o’clock position and could only be entered by angling the scope ventrally. Once the bladder was entered, cystoscopy revealed grossly normal anatomy. However, the right ureteral orifice was difficult to visualize because the examination was limited by the patient’s
Inadvertent placement of the Foley balloon into the ureter is a rare complication of urethral catheterization with only 9 cases reported in the medical literature. Unlike our case, most of these cases were in the setting of chronic indwelling Foley
FIGURE 2. Urethroscopic view 1. On urethroscopy, the bladder neck appeared as a ventral slitlike opening (black arrow). Ectopic left ureteral orifice is seen at the 7-o’clock position (white arrow).
FIGURE 3. Urethroscopic view 2. Upon entering the left ureteral orifice, a capacious space was encountered with connection to the left ureter (arrow).
* 2014 Wolters Kluwer Health, Inc. All rights reserved.
COMMENT
www.fpmrs.net
e15
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Yune et al
Female Pelvic Medicine & Reconstructive Surgery
catheterization in patients with spinal cord injury,1 multiple sclerosis,2 rheumatoid arthritis,3 and history of bladder cancer.4 Inadvertent ureteral catheterization has also been reported in periprocedural5 and perioperative6 settings in patients without a history of chronic catheterization. To our knowledge, this is the first report of ectopic ureter presenting at the time of cesarean section during Foley catheter insertion. There has been 1 reported case of unintended ureteral catheterization in a woman presenting with a urinary tract infection in the postpartum period; however, cystoscopy was not performed to fully characterize the patient’s anatomy.7 Ectopic ureter is diagnosed when the ureteral orifice is located caudal to the normal insertion on the trigone of the bladder. It occurs due to the ureteric bud arising at a more proximal position on the mesonephric duct. Its incidence in autopsy is reported as 1 in 1900 cases, and approximately 10% are bilateral. Other combined genitourinary anomalies such as duplicated collecting system, ureterocele, vesicoureteral reflux, and hydronephrosis can often be found.8 In many instances, an ectopic ureter is not detected because the affected individual is asymptomatic. Approximately one third of cases have the ureteral orifice located on the bladder neck or proximal urethra. Patients with ureteral insertion sites distal to the external sphincter can present with continuous urinary incontinence; this is unique to females with ectopic ureters. Other presenting symptoms may include recurrent urinary tract infections, flank pain due to obstruction, and renal failure.8 Ectopic ureter presenting as oliguria during surgery due to catheterization of the ureter has not been reported in a patient with no previously known abnormalities. The aberrantly placed Foley catheter was easily diagnosed with CT scan. In cases of ureteral trauma, the presence of gross hematuria or urinary extravasation from the ureter should alert the surgeon to the possibility of ureteral disruption or perforation. Once ureteral injury is diagnosed, management requires stent placement, percutaneous nephrostomy, or surgery depending on the type and extent of injury. Because of the absence of both periureteral fluid and gross hematuria, combined with the finding of a large caliber ureter on imaging, the suspicion of ureteral injury was low. Our patient was therefore managed nonoperatively and clinically did well without stent placement. However, long-term management of these patients should include serial renal ultrasounds to detect new hydronephrosis, which could indicate the development of a ureteral stricture. Our case is unique because the patient was asymptomatic and became symptomatic at the time of urinary tract instrumentation. Because of the location and caliber of the ectopic ureteral orifice, the Foley catheter was preferentially inserted
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into the left ureter rather than the bladder. One of the most surprising aspects of this case was the fact that the Foley catheter was easily placed and the balloon was inflated with no resistance; in addition, a small amount of clear yellow urine was obtained at the initial placement, indicating that the catheter remained within the urinary tract. Difficulty with insertion or obtaining blood at the time of placement may alert the practitioner that traumatic catheterization has occurred. When no urine is obtained, there are several different etiologies to consider including placement in a bladder or urethral diverticulum, urethral false passage, urogenital sinus, or several rare anomalies of the lower urinary tract. Oliguria or anuria that presents after initially obtaining good urine output may suggest bladder perforation, ureteral obstruction or injury, catheter occlusion with blood clot or debris, or hypovolemic state. The patient presented in our report adds yet another differential to consider, namely catheter placement into an ectopic ureter.
CONCLUSIONS This case presents an unusual cause of anuria in an operative patient requiring Foley catheterization. An ectopic ureteral orifice should be considered in the differential diagnosis of a patient presenting with unexplained oliguria or anuria and failure to decompress the bladder with catheter placement. REFERENCES 1. Kim MK, Park K. Unusual complication of urethral catheterization: a case report. J Korean Med Sci 2008;23:161Y162. 2. Baker KS, Dane B, Edelstein Y, et al. Ureteral rupture from aberrant foley catheter placement: a case report. J Radiol Case Rep 2013;7:33Y40. 3. Kato H. Incorrect positioning of an indwelling urethral catheter in the ureter. Int J Urol 1997;4:417Y418. 4. Muneer A, Minhas S, Harrison SC. Aberrant foley catheter placement into the proximal right ureter. BJU Int 2002;89:795. 5. Ogan K, Berger RM. Aberrant foley catheter placement into the proximal right ureter. BJU Int 2001;88:124. 6. Hara N, Koike H, Bilim V, et al. Placement of a urethral catheter into the ureter: an unexpected complication after retropubic suspension. Int J Urol 2005;12:217Y219. 7. Shindel AW, Cox MJ, Bullock TL. Unintentional transurethral foley catheterization of the right renal pelvis. Urol Nurs 2008;28:48Y49. 8. Roy Choudhury S, Chadha R, Bagga D, et al. Spectrum of ectopic ureters in children. Pediatr Surg Int 2008;24:819Y823.
* 2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Unsuccessful Foley Catheterization Had an Unexpected Explanation Junchan Joshua Yune, MD,* Michelle Lightfoot, MD,Þ D. Duane Baldwin, MD,Þ Jeffrey Hardesty, MD,* and Sam Siddighi, MD*
Background: Foley catheterization is a simple procedure routinely performed during many obstetric and gynecologic procedures. Failure to adequately drain the bladder with catheter insertion should prompt further investigation to minimize morbidity to the patient. Case: After repeated attempts to place a Foley catheter during a cesarean section, the urinary bladder did not drain. Postoperatively, it was found that the catheter was positioned inside the left ureter, and cystoscopy confirmed an ectopic ureter inserting into the proximal urethra. Conclusions: This case presents an unusual cause of oliguria in an operative patient requiring Foley catheterization. An ectopic ureteral orifice should be considered in the differential diagnosis of a patient presenting with unexplained oliguria or anuria and failure to decompress the bladder with catheter placement. Key Words: cesarean section, ectopic ureter, Foley catheter (Female Pelvic Med Reconstr Surg 2015;21: e14Ye16)
T
ransurethral Foley catheter placement is a common procedure used in many surgical patients. The benefits of urinary catheterization include the following: decompression of the bladder to provide optimal surgical exposure and minimize the risk of bladder injury, allowance of continuous monitoring of urine output, improved patient comfort, and treatment of urinary retention in postoperative patients. However, urinary catheterization is also associated with a low but significant risk of complications including pain, hematuria, urinary tract infection, and iatrogenic anatomic injury. Foley catheterization in a female patient with normal external genitalia rarely fails to provide adequate drainage of the bladder. If a urethral catheter does not freely drain, other explanations must be considered. One possible scenario is inadvertent deployment of the catheter outside the urinary tract. Other scenarios may include catheter occlusion by clot, debris, bladder tumor, or placement into a bladder diverticulum. In most circumstances, replacement of the Foley catheter will result in bladder drainage. In this report, we present a patient for whom Foley catheter placement into an ectopic ureter resulted in both ureteral and bladder outlet obstruction complicating a cesarean section.
CASE A 26-year-old woman, gravida 6, para 4, presented to the hospital for scheduled primary cesarean delivery at 39 weeks From the Departments of *Female Pelvic Medicine and Reconstructive Surgery, and †Urologic Surgery, Loma Linda University Medical Center, Loma Linda, CA. Reprints: Junchan Joshua Yune, MD, Coleman Pavilion, Room 11105, 11175 Campus St, Loma Linda, CA 92350. E-mail: [email protected]. The authors have declared they have no conflicts of interest. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/SPV.0000000000000111
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www.fpmrs.net
for fetal spina bifida. A 16F Foley catheter was placed preoperatively, with an immediate return of 10 mL of clear urine output after catheter insertion. At the time of entry into the peritoneal cavity, the bladder was noted to be distended and resulted in compromised visualization of the operative field. Direct inspection of the Foley and bag revealed clear urine in the tubing and a small amount of urine in the drainage bag. To improve operative visualization, direct needle decompression was used to remove 320 mL of urine from the bladder. This improved visualization, allowing the cesarean section to proceed uneventfully. After delivery and uterine closure, the bladder was again inspected and noted to be distended. The Foley catheter was removed and replaced intraoperatively, again with a small amount of clear urine output obtained. A second needle decompression removed 240 mL of clear yellow urine. The procedure was completed without further incident, and the patient was transferred to the postpartum ward for further recovery. At the ward, the patient was noted to have low urine output of 20 mL over a 2-hour period, so the Foley catheter was removed and replaced with a 24F 2-way catheter with no significant improvement in urine output. The patient continued to experience suprapubic discomfort consistent with bladder distention, and a postpartum renal and bladder ultrasound demonstrated a severely distended bladder and mild right hydronephrosis. Urologic consultation was obtained, and another 16F catheter was placed. There was no resistance to catheter placement, but very little urine output was obtained with the initial insertion. Vaginal palpation demonstrated no catheter in the vagina. Hand irrigation with 10 mL of saline initially demonstrated normal irrigation. However, further attempts at irrigation with 60 mL resulted in a return of only 10 to 20 mL of clear irrigation and caused exacerbation of the patient’s left flank pain. Subsequent noncontrast abdominal and pelvic computed tomography (CT) scan demonstrated the Foley tracking posterior to the distended bladder and up the left ureter with the tip of the catheter located in the midureter (Fig. 1). There was mild bilateral ureteral dilation with diameter measured at 2.2 cm on the left and 1.9 cm on the right; however, there was no significant hydronephrosis. The catheter was subsequently removed, and the patient was able to void spontaneously with immediate resolution of suprapubic and left flank pain. Upon direct questioning, the patient denied any prior episodes of urinary incontinence, retention, straining to void, hematuria, or known anatomic abnormalities. She did have a history of recurrent urinary tract infections, including 1 episode of pyelonephritis before pregnancy. She recalled that she had an epidural anesthesia in the past but had no memory of Foley catheterization or its complication. The remainder of her hospitalization was uneventful, and the patient was discharged on postoperative day 4. She returned to the clinic 4 weeks later for follow-up without any new voiding symptoms. Cystourethroscopy revealed an ectopic capacious left ureter with a large dilated ureteral orifice inserting into the proximal urethra at the 7-o’clock position just distal to
Female Pelvic Medicine & Reconstructive Surgery
&
Volume 21, Number 2, March/April 2015
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Female Pelvic Medicine & Reconstructive Surgery
&
Volume 21, Number 2, March/April 2015
Ectopic Ureter Becomes Symptomatic at the Time of Cesarean Section
FIGURE 1. Coronal view of abdominal and pelvic CT scan. The Foley catheter (black arrow) is seen tracking posterior to the distended bladder (B), with Foley balloon (white arrow) located in the mid left ureter.
discomfort. She was offered referral to urology but has declined further evaluation at this time.
the bladder neck (Figs. 2, 3). The ureteral orifice was larger and in line with the urethra explaining the preferential entry of the catheter into the ureter rather than the bladder. In contrast, the bladder neck appeared as a tiny slitlike opening at the 12-o’clock position and could only be entered by angling the scope ventrally. Once the bladder was entered, cystoscopy revealed grossly normal anatomy. However, the right ureteral orifice was difficult to visualize because the examination was limited by the patient’s
Inadvertent placement of the Foley balloon into the ureter is a rare complication of urethral catheterization with only 9 cases reported in the medical literature. Unlike our case, most of these cases were in the setting of chronic indwelling Foley
FIGURE 2. Urethroscopic view 1. On urethroscopy, the bladder neck appeared as a ventral slitlike opening (black arrow). Ectopic left ureteral orifice is seen at the 7-o’clock position (white arrow).
FIGURE 3. Urethroscopic view 2. Upon entering the left ureteral orifice, a capacious space was encountered with connection to the left ureter (arrow).
* 2014 Wolters Kluwer Health, Inc. All rights reserved.
COMMENT
www.fpmrs.net
e15
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Yune et al
Female Pelvic Medicine & Reconstructive Surgery
catheterization in patients with spinal cord injury,1 multiple sclerosis,2 rheumatoid arthritis,3 and history of bladder cancer.4 Inadvertent ureteral catheterization has also been reported in periprocedural5 and perioperative6 settings in patients without a history of chronic catheterization. To our knowledge, this is the first report of ectopic ureter presenting at the time of cesarean section during Foley catheter insertion. There has been 1 reported case of unintended ureteral catheterization in a woman presenting with a urinary tract infection in the postpartum period; however, cystoscopy was not performed to fully characterize the patient’s anatomy.7 Ectopic ureter is diagnosed when the ureteral orifice is located caudal to the normal insertion on the trigone of the bladder. It occurs due to the ureteric bud arising at a more proximal position on the mesonephric duct. Its incidence in autopsy is reported as 1 in 1900 cases, and approximately 10% are bilateral. Other combined genitourinary anomalies such as duplicated collecting system, ureterocele, vesicoureteral reflux, and hydronephrosis can often be found.8 In many instances, an ectopic ureter is not detected because the affected individual is asymptomatic. Approximately one third of cases have the ureteral orifice located on the bladder neck or proximal urethra. Patients with ureteral insertion sites distal to the external sphincter can present with continuous urinary incontinence; this is unique to females with ectopic ureters. Other presenting symptoms may include recurrent urinary tract infections, flank pain due to obstruction, and renal failure.8 Ectopic ureter presenting as oliguria during surgery due to catheterization of the ureter has not been reported in a patient with no previously known abnormalities. The aberrantly placed Foley catheter was easily diagnosed with CT scan. In cases of ureteral trauma, the presence of gross hematuria or urinary extravasation from the ureter should alert the surgeon to the possibility of ureteral disruption or perforation. Once ureteral injury is diagnosed, management requires stent placement, percutaneous nephrostomy, or surgery depending on the type and extent of injury. Because of the absence of both periureteral fluid and gross hematuria, combined with the finding of a large caliber ureter on imaging, the suspicion of ureteral injury was low. Our patient was therefore managed nonoperatively and clinically did well without stent placement. However, long-term management of these patients should include serial renal ultrasounds to detect new hydronephrosis, which could indicate the development of a ureteral stricture. Our case is unique because the patient was asymptomatic and became symptomatic at the time of urinary tract instrumentation. Because of the location and caliber of the ectopic ureteral orifice, the Foley catheter was preferentially inserted
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into the left ureter rather than the bladder. One of the most surprising aspects of this case was the fact that the Foley catheter was easily placed and the balloon was inflated with no resistance; in addition, a small amount of clear yellow urine was obtained at the initial placement, indicating that the catheter remained within the urinary tract. Difficulty with insertion or obtaining blood at the time of placement may alert the practitioner that traumatic catheterization has occurred. When no urine is obtained, there are several different etiologies to consider including placement in a bladder or urethral diverticulum, urethral false passage, urogenital sinus, or several rare anomalies of the lower urinary tract. Oliguria or anuria that presents after initially obtaining good urine output may suggest bladder perforation, ureteral obstruction or injury, catheter occlusion with blood clot or debris, or hypovolemic state. The patient presented in our report adds yet another differential to consider, namely catheter placement into an ectopic ureter.
CONCLUSIONS This case presents an unusual cause of anuria in an operative patient requiring Foley catheterization. An ectopic ureteral orifice should be considered in the differential diagnosis of a patient presenting with unexplained oliguria or anuria and failure to decompress the bladder with catheter placement. REFERENCES 1. Kim MK, Park K. Unusual complication of urethral catheterization: a case report. J Korean Med Sci 2008;23:161Y162. 2. Baker KS, Dane B, Edelstein Y, et al. Ureteral rupture from aberrant foley catheter placement: a case report. J Radiol Case Rep 2013;7:33Y40. 3. Kato H. Incorrect positioning of an indwelling urethral catheter in the ureter. Int J Urol 1997;4:417Y418. 4. Muneer A, Minhas S, Harrison SC. Aberrant foley catheter placement into the proximal right ureter. BJU Int 2002;89:795. 5. Ogan K, Berger RM. Aberrant foley catheter placement into the proximal right ureter. BJU Int 2001;88:124. 6. Hara N, Koike H, Bilim V, et al. Placement of a urethral catheter into the ureter: an unexpected complication after retropubic suspension. Int J Urol 2005;12:217Y219. 7. Shindel AW, Cox MJ, Bullock TL. Unintentional transurethral foley catheterization of the right renal pelvis. Urol Nurs 2008;28:48Y49. 8. Roy Choudhury S, Chadha R, Bagga D, et al. Spectrum of ectopic ureters in children. Pediatr Surg Int 2008;24:819Y823.
* 2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
