Penile erosion in spinal cord injury – an important lesson

Managing External Urinary Catheters

This narrative review explores the use of external urinary catheters. These devices are available in various types and materials for male and female patients. The indications for the use of external urinary catheters include managing incontinence linked to overactive bladder and neurogenic lower urinary tract dysfunction. Contraindications to the use of external urinary catheters include urinary obstruction. Proper skin care and proactive infection control measures are necessary to prevent complications. The collection of a urine specimen for culture requires a standardized technique to prevent contamination. Clinician-led patient education on catheter management plays a important role in ensuring patient comfort and safety.

Catheter-induced urethral injury and tubularized urethral plate urethroplasty in such iatrogenic hypospadias

Background

Catheter-induced urethral erosion can involve meatus, glans and any extent of penile shaft. These injuries cause a lot of psychological, social and sexual trauma to the patient. Though the use of condom drainage system can render this spinal cord injury patient effectively dry, but can lead to penile or urethral complications. Many of these patients are kept on indwelling catheter. Long duration catheterization, poor catheter care in such paraplegic patients and other morbid patients may lead to urethral erosions. We conducted a prospective study of catheter-induced urethral injury from July 2014 to February 2016 in our tertiary care centre. The demographics, past history of illness, catheter material, and duration of catheterization, securing of catheter, local examination findings and associated comorbidities were recorded. Factors leading to urethral erosion were evaluated. And patients, who were fit and were willing for surgery, underwent tubularized urethral plate urethroplasty after 4–6-week supra-pubic diversion. The objective of the study was to evaluate factors of urethral erosion, and the results tubularized urethral plate urethroplasty in iatrogenic hypospadias.

Results

We had twelve patients of catheter associated urethral injury in the study period. Age of the patients varied from 34 to 95 years with a mean of 61.25 years. Duration of catheterization ranged from 6 to 24 months with a mean duration 10.9 months. Catheters used were silicon coated, not secured to abdomen and had comorbid condition of neurological or cardiac origin in all patients. Long duration of catheter, poor quality of catheter and poor catheter care such moribund with poor body resistance patients were the main causative factor for urethral erosion. Urethral injuries varied from erosion of distal 2 cm to entire ventral urethra till penoscrotal junction with or without penile torque. Six of these patients underwent tubularized urethral plate urethroplasty with good cosmetic and functional postoperative outcome.

Conclusion

Patients of spinal cord injury, patients with comorbid condition like diabetes mellitus and ischaemic heart disease, poor catheter care and long duration catheterization are likely to have severe urethral injury. Extent of injury may vary from meatal erosion to erosion of entire ventral urethra till penoscrotal junction leading to iatrogenic hypospadias. These patients either may be put on clean intermittent catheterization or supra-pubic catheterization. Results of tubularized urethral plate urethroplasty in such iatrogenic hypospadias are very good.

Catheter-associated meatal pressure injury in hospitalized males

AIMS

To assess the prevalence of catheter-associated meatal pressure injury in acute hospitalized males, to determine risk factors for its formation and to propose a grading system for meatal pressure injury severity.

METHODS

In this cross-sectional study, we screened all adult males concurrently hospitalized at a tertiary medical center for indwelling urethral catheters and for meatal pressure injury. We proposed a system to grade meatal pressure injury severity and used logistic-regression modeling to calculate odds ratios (ORs) of possible risk factors.

RESULTS

A number of 168/751 (22.4%) hospitalized males with indwelling urethral catheters were included. Median age was 70.5 (inter-quartile range [IQR]: 57.0-80.3) years, median time from catheterization 5.5 (IQR: 2-11) days. A total of 61 (36%) had meatal pressure injury, as early as the first day after catheterization. Grade III injuries (<2 cm ulcer) developed in 22 (13%) patients, earliest noted on the second catheter day, and grade IV injuries (≥2 cm) in 7 (4%) patients, as early as 5 days post catheterization. In a multivariable analysis, catheter fixation (OR: 0.26 [95% CI: 0.10-0.70]; P = .008) was associated with reduced risk of meatal pressure injury, while catheter presence over 14 days (OR: 1.46 [95% CI: 1.01-1.08]; P = .005) and other skin ulcers (OR: 2.45 [95% CI: 1.05-5.71]; P = .038) were associated with a higher risk of meatal pressure injury.

CONCLUSIONS

Meatal pressure injury is a common complication of indwelling catheters in hospitalized males, beginning days after catheterization. Meatal pressure injury was associated with prolonged catheter presence, other pressure injuries, and lack of catheter fixation. Prospective studies are needed to establish evidence-based guidelines.

Penile Erosion in a Paraplegic Man With Indwelling Urinary Catheter and Scrotal Edema

The chronic use of urinary indwelling catheters is a common practice in the setting of long-term patient care and is associated with numerous complications. More awareness about urogenital trauma from urinary catheterization is needed, as it is as common as symptomatic urinary tract infections. There are a number of preventable measures that can be taken to decrease the risk of mechanical trauma to the urethra and glans penis caused by chronic catheterization. We present a case of a 27-year old paraplegic male needing a chronic indwelling catheter that acquired ventral penile erosion while being cared for in the ICU setting.

Longitudinal cleavage of the penis in chronic spinal cord injury: two case reports

CONTEXT

Penile cleavage is a rare complication of spinal cord injury (SCI) in patients with a chronic indwelling catheter. We report two cases of chronic SCI who developed penile urethral cleavage after prolonged use of an indwelling catheter for bladder management.

FINDINGS

A 25-year-old wheelchair mobile male with T7 American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade A paraplegia developed a 4 × 1.5 cm ventral urethral cleavage after using an indwelling catheter for four months with inadequate care. He had an associated urinary tract infection and undiagnosed diabetes mellitus. A suprapubic catheter was inserted and surgical repair recommended after resolution of UTI and adequate control of his diabetes mellitus. After initial treatment he was lost to follow-up. The second patient was a 15-year-old male with AIS grade B tetraplegia who presented with a 2.5 cm cleavage on the ventral aspect of penis for the preceding three months. He had been using an indwelling catheter for bladder management for the previous 18 months. He had modified Ashworth scale grade III spasticity in lower limbs resistant to conservative management. There was no history of trauma, infection or diabetes mellitus. The patient was advised penile urethral repair surgery but was lost to follow-up.

CONCLUSION

Penile cleavage is a rare complication of neurogenic bladder in SCI patients. Patients and care givers should be trained in proper bladder management techniques during the hospital stay, counseled regarding the need for regular follow up, and be taught identification and prevention of common complications.

Hypospadias in spinal cord injury: association with indwelling catheter drainage and disturbance of behavior: a report of three cases

STUDY DESIGN

Case series.

OBJECTIVE

To present three cases of paraplegic patients with hypospadias and psychiatric comorbidities.

SETTING

Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey.

CASES

Three spinal cord injured male patients with hypospadias are presented. All three patients had a history of psychiatric disorders that is thought to be a precipitating factor.

CONCLUSION

This is the first report in the literature of three cases of hypospadias associated with indwelling catheter drainage and behavioral disturbance.

[Specific features of urethral diseases in spinal cord injury patients]

This article discusses all of the urethral diseases observed in patients with neurogenic bladder. The frequency of these disorders has decreased considerably with progress in intermittent catheterization and bladder retraining. However, urologists may occasionally be required to manage an urethral diverticulum, or an ulcer of the urethra over an indwelling catheter and must be familiar with the specific features in this setting.