Article Title
stringlengths 10
300
| Question Content
stringclasses 29
values | Answer Content
stringlengths 1
977
⌀ | Answer ID
int64 43
65.3k
| Article ID
int64 21.2k
209k
| text_content
stringlengths 148
280k
⌀ |
|---|---|---|---|---|---|
Thalassemia in black americans.
|
What is the age of studied population ?
|
59 years
| 40,794
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
What is the outcome of the study ?
|
The suprapubic catheter was removed surgically and replaced with a functioning catheter; the patient was discharged with urology outpatient follow-up.
| 40,795
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
What is the studied population ?
|
A 59-year-old man with a history of schizophrenia, diabetes, hypertension, antibiotic-resistant urinary tract infection, urethral stricture requiring suprapubic catheter, and vesiculo-cutaneous fistula.
| 40,796
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
What is the number of the studied population ?
|
1
| 40,797
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
What is the study design of this article ?
|
Case report
| 40,798
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
What is the condition of the studied population ?
|
The patient had a nonfunctioning suprapubic catheter encased by bladder calculi, leading to urinary retention and catheter obstruction.
| 40,799
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
What is the studied or evaluated intervention ?
|
Open cystolitholapaxy (surgical removal of bladder stones) and removal and replacement of the suprapubic catheter.
| 40,800
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
What is the studied indication ?
|
Suprapubic catheter dysfunction leading to acute urinary retention.
| 40,801
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
What are the comparators ?
|
Urethral catheterization (as a comparative discussion point in the article).
| 40,802
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
What did improve quality of live ?
|
Removal of the obstructed catheter and surgical intervention to eliminate the bladder stone.
| 40,803
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
Any adverse events or complications reported ?
|
No adverse events or complications were reported post-procedure; the patient tolerated the procedure well.
| 40,804
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
What are the primary outcomes ?
|
Removal of the encrusted suprapubic catheter and resolution of urinary retention.
| 40,805
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
What are the secondary outcomes ?
|
Not explicitly mentioned in the context.
| 40,806
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
Was the magnitude of the treatment effect observed clinically significant ?
|
Yes; the patient was successfully treated with surgical intervention and discharged, indicating a clinically significant improvement.
| 40,807
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
Has a statistical analysis of the data been provided and is it appropriate ?
|
No statistical analysis was provided, as the study is a single case report.
| 40,808
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
What is the target device ?
|
Suprapubic catheter
| 40,809
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
Was the device used for the same intended use (e.g., methods of deployment, application, etc.) ?
|
Yes; the suprapubic catheter was used for its intended purpose of managing chronic urinary retention.
| 40,810
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
Was the data generated from a patient group that is representative of the intended treatment population e.g., age, sex, etc.) and clinical condition (i.e., disease, including state and severity) ?
|
No; the data is from a single patient case and may not be representative of the broader intended treatment population.
| 40,811
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
Was the data Bench Simulation ?
|
No
| 40,812
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
Do the reports or collations of data contain sufficient information to be able to undertake a rational and objective assessment ?
|
Yes; the report provides detailed clinical information allowing for a rational and objective assessment.
| 40,813
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
Thalassemia in black americans.
|
Do the outcome measures reported reflect the intended performance of the device ?
|
Yes; the outcomes related to catheter functionality and resolution of urinary retention reflect the intended performance of the suprapubic catheter.
| 40,814
| 182,191
|
Introduction
Suprapubic catheterization is relatively common in the management
of patients with distal urethral obstruction or chronic urinary retention
due to bladder dysfunction. It is an effective and well tolerated proce-
dure, carries lower rates of infections and higher satisfaction levels
among patients in comparison to urethral catheterization [ 1-3]. How-
ever, there are associated complications that can arise with this tech-nique, especially without appropriate follow up care.
Acute urinary retention is an emergent condition that requires im-
mediate attention. Frequently, patients present to the emergency de-
partment (ED) in need of assistance due to urinary catheter
malfunction. Causes of catheter dysfunction include balloon irritation,
altered mental status, infection, fecal impaction, tube obstruction, im-
proper sizing, improper positioning of the catheter and others [ 4]. This
case report describes a man diagnosed with a bladder stone encasinghis suprapubic catheter that was removed surgically and replaced
with a functioning catheter.
2. Case report
A 59- year-old man with a history of schizophrenia, diabetes, hyper-
tension, antibiotic resistant urinary tract infection, urethra stricture re-
quiring suprapubic catheter, and vesiculo-cutaneous fistula presented
to the ED with a nonfunctioning suprapubic catheter. Due to his baselinecognitive impairment the patient resided in a group home and had anassigned guardian to make his medical decisions. The patient reportedthat his urinary catheter had not functioned properly for about a
month and that it stopped draining completely two hours prior to
his arrival. He did not know when his provider had last exchanged
the catheter.
On his arrival, his heart rate was 101 beats per minute. His blood
pressure, oxygen saturation, temperature and respiratory rate were
within normal limits. He was alert and at his mental status baseline
with normal heart and lung sounds. His abdomen was mildly distended
and mildly tender to palpation in the suprapubic region without re-
bound or guarding. At the site of the suprapubic catheter, clear yellow
urine was leaking around the site of the catheter with mild excoriation
of the super ficial soft tissue surrounding the stoma. There was no urine
draining from the catheter. As mentioned, the patient had alongstanding history of vesiculo-cutaneous fistulas which were visible
on examination in the perineum with excoriation of the surroundingskin. Due to urinary obstruction and retention, the emergency provider
attempted to flush the catheter but met resistance.
Serum laboratory testing showed no leukocytosis, no acute kidney
injury and were overall reassuring. Urinalysis was not obtained in the
ED as urine was not collected. A CT scan of the abdomen and pelvis
with IV contrast demonstrated a suprapubic catheter in place with ex-
tensive circumferential calci fication around the balloon and the distal
tip (Fig. 1 A,B). There were multiple bladder stones measuring greater
than two centimeters and urethral stones.
The urology service was consulted, and the patient was seen in the
ED. The urology team knew the patient; he was intermittently lost to
follow-up and likely had maintained his suprapubic catheter for several
months. They also could not flush the catheter and found the balloon of
the catheter to be ruptured. Thus, they could not remove the suprapubic
tube. The urology team counseled the patient on options and his guard-
ian gave consent. He then underwent open cystolitholapaxy given theAmerican Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
∗Corresponding author at: Department of Emergency Medicine, George Washington
University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037,
United States.
E-mail addresses: [email protected] (N. Sullivan), [email protected]
(A. Pourmand).
https://doi.org/10.1016/j.ajem.2022.03.0310735-6757/© 2022 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajeminability to access his bladder via his urethra as well as size of the stones.
During the procedure, surgeons removed the stone intact along with the
suprapubic tube. The stone had occluded the catheter preventing drain-
age and causing urinary retention ( Fig. 2 ). The patient tolerated the pro-
cedure well. Patient subsequently was discharged with urologyoutpatient follow up.3. Discussion
This report describes a rare finding of a suprapubic catheter
enveloped by a bladder stone that caused the tube to occlude. This
case illustrates the possibility of further complication when chronic
indwelling catheters are not exchanged on schedule particularly in
patients at increased risk of bladder calculi. It encourages providers tohave a high index of suspicion for the possibility of catheter encrusta-
tion in cases of acute or subacute retention in a patient with a chronic
indwelling catheter.
Compared to urethral catheterization, suprapubic catheterization
presents a greater risk of blockage and insertion failures; insertion of a
suprapubic catheter requires specialized training and the procedure
carries a 1 –3% risk of bowel injury. However, they have lower rates of
urinary tract infection, scrotal infection, urethral damage, and scrotalerosion and patient discomfort [ 1,5]. A scoping review suggests urethral
catheters may be associated with a higher rate of upper urinary tractcomplications as well [ 6]. In this case, the patient's history of extensive
urethral stricture made suprapubic catherization a superior option. Acommon but less severe complication of suprapubic catheters appears
to be skin irritation secondary to leakage at the insertion site [ 6].
Overgranulation may also occur [ 1]. Both of these complications were
present in our patient and may have been exacerbated by the fact that
urine leaked around the obstructed catheter as the patient retained
urine.
Bladder calculi are most often associated with patients with spinal
cord injury but may occur in other circumstances as well [ 7-9]. In this
patient population, urinary tract infections and indwelling cathetersare associated with increased risk of bladder calculi [ 7]. Historically,
there has been con flicting evidence whether long term catheters
themselves cause bladder calculi formation [ 9-12 ]. The mechanism for
encrustation has been attributed to the formation of bio films on
catheters [ 13]. Research suggests that any increase in bladder calculi
formation is indiscriminate of the type of catheter [ 1,6]. One study
showed the annual risk of calculi formation may be as high as 16% in
those patients who previously formed one stone. While there does not
appear to be an exact consensus on the recommended frequency of
catheter changes, more frequent catheter changes in patients with
recurrent bladder calculi decrease the risk of encrustation [ 8,13].
While our patient did not have a spinal injury, he had several risk factors
for encrustation including recurrent urinary tract infections, chronic
indwelling catheter, infrequent changes and prior history of calculi
formation. He had missed several appointments for reevaluation and
catheter exchange. Furthermore, as some urine was able to leak around
the catheter, his caretakers did not quickly recognize his retention.
4. Conclusion
Occlusion of the distal catheter secondary to encrustation is a rare
complication of suprapubic catheter dysfunction. Providers should
have a higher index of suspicion particularly in patients with urinary
catheters that have been in place for greater than a month, in patients
with a history of bladder stones and in those with inconsistent follow
up to care. Immediate surgical intervention is indicated for acute reten-
tion with a non-functioning catheter that cannot be addressed in the ED.
Conflict of interest
The authors do not have a financial interest or relationship to
disclose regarding this research project.
Financial support
This is a non-funded study, with no compensation or honoraria for
conducting the study.
Fig. 1. A. and B shows the excised urinary catheter with a distal tip that is encased in a large
bladder stone (arrow).
Fig. 2. The stone had occluded the catheter preventing drainage.N. Sullivan, R. AlRemeithi and A. Pourmand American Journal of Emergency Medicine 56 (2022) 395.e5 –395.e7
395.e6Credit authorship contribution statement
Natalie Sullivan: Conceptualization, Writing –original draft, Writ-
ing–review & editing. Rashed Alremeithi: Writing –original draft,
Writing –review & editing. Ali Pourmand: Conceptualization, Supervi-
sion, Writing –original draft, Writing –review & editing.
|
End of preview. Expand
in Data Studio
No dataset card yet
- Downloads last month
- 2