A hard mass discovered in the corpus spongiosum after difficult urethral catheterization: two case reports.
Key Words: Male urethral catheterization, complication, corpus spongiosum, mass, urethral trauma.
Urethral catheterization is one of the most common procedures in everyday medical practice (Buddha, 2005). However, a difficult catheterization could cause problems for both practitioner and patient. Various strategies have been proposed to overcome this problem. These strategies can include using a larger-size indwelling catheter in the case of benign prostatic hyperplasia, changing to a straight catheter (Robinson catheter), and/or injection of greater quantity of anesthetic jelly into the urethra (Villanueva & Hemstreet, III, 2008). Nevertheless, unexpected complications may arise. Most of these complications are related to urethral injuries (Lang, Nguyen, Zhang, & Smith, 2012; Willette & Coffield, 2012), although unexpected ureteral injuries have also been reported (Hale, Baugh, & Womack, 2012). Two unreported complications of urethral catheterization and its management are presented below.
A 56-year-old male presented to the emergency room with urinary retention. The patient had a long history of prostatic obstructive symptoms. Despite adequate medical therapy for benign prostate hyperplasia with tamsulosin hydrochloride (Flomax[R]) and finasteride (Propecia[R]), obstructive urinary symptoms continued, leading to acute urinary retention. After multiple failed attempts of urethral catheterization by the general practitioner (GP), even with injection of 20 cc of anesthetic jelly into the urethra, the on-call urologist was consulted to examine the patient.
On physical examination, the urologist noted blood on the patient's external urethral mea tus. Due to the prior unsuccessful traumatic urinary catheterizations and the patient's discomfort, the urologist inserted a suprapubic catheter without any additional patient examination. In a follow-up cystoscopy by the same urologist, the urethral mucosa was completely normal. However, the urethra was compressed and pushed upward. Upon physical examination, a hard lobulated mass in the proximal urethra was palpated. In contrast to normal corpus spongiosums, which are soft and compressible in nature, the palpated mass was stony hard, resembling a malignant lesion. Multiple percutaneous biopsies were then taken from the superficial and deep tissues of the mass using a prostate biopsy-needle.
Results of clinical interactions. The pathology report revealed nonspecific inflammation without any evidence of malignancy. The patient subsequently developed an urethrocutaneous fistula post-biopsy. Closure of the fistula was accomplished with conservative management. The patient was managed with continuous drainage via the suprapubic catheter and a course of broad-spectrum antibiotics. During follow up for the fistula closure, gradual resolution of the mass was noted. Within 6 weeks, the mass disappeared completely. Afterward, an open prostatectomy was performed with the patient regaining his voiding abilities.
The etiology of the mass was not clearly defined in this case. Use of a wait-and-see strategy later revealed the mass was not malignant via pathology report and spontaneous resolution. Though the mass was apparently benign and inflammatory in nature, the etiology remained undiagnosed.
As a result of the findings in the above case, the urologist decided to palpate future patients' entire urethral length before attempting urethral catheterization or insertion of a suprapubic catheter. Prior to this, patients presenting with urinary retention had been catheterized without palpation of the penile, scrotal, and perineal urethra.
The second patient was an 87-year-old man who presented with obstructive urinary symptoms. The same urologist saw this patient as noted in the previous case. Clinical assessment revealed a normal digital examination. Because of the urologist's previous experience, the patient's entire urethral length from the external penile meatus up to the perineal urethra was palpated. The urethral examination was completely normal.
The urologist referred the patient to the emergency room to be catheterized by the GP. This attempt was unsuccessful. The urologist was again consulted and attempted to catheterize the patient injecting 20 cc anesthetic lidocaine jelly into the meatus.
Results of clinical interactions. After injection of the anesthetic jelly, the urologist noted the jelly immediately oozing from the patient's meatus. A mass similar to the first case report patient was observed directly after instillation of the jelly in the proximal part of corpus spongiosum. Urethral catheterization by the urologist was unsuccessful.
The patient was then managed with a suprapubic catheter drainage and antibiotics were initiated. The mass spontaneously resolved within one month.
The mass developed after an unsuccessful and traumatic urethral catheterization using 20 cc of anesthetic jelly. Injection of 20 cc of anesthetic jelly may have had a direct relationship to the subsequent development of the urethral mass.
In both case report patients, traumatic catheterization appeared to have injured the urethra resulting in a breakage in the corpus spongiosum. In further attempts to catheterize the patients, using 20 cc of anesthetic jelly injected through the urethra, all or at least some jelly was pushed into corpus spongiosum producing a lobulated, firm mass in the corpus spongiosum (see Figures 1-3).
In the first case, the urologist had not previously examined the patient. Therefore, there may have been some confusion on the urologist's part in palpating the hard and lobulated mass as he focused on the mass as the etiology of urinary retention. Consulting on the second case report patient from the onset with the same presentation assisted him to diagnose the suspected problem, and possibly sparing the patient from additional invasive studies.
Although urethral urinary catheterization is a simple and common procedure, it may lead to unexpected complications. Gentle urethral injection of anesthetic jelly can decrease the patient's pain and discomfort. But more importantly, decreasing the volume of anesthetic jelly to 10 cc with gradual instead of rapid instillation could prevent excess anesthetic jelly leakage into the corpus spongiosnm. This complication resolved uneventfully in both cases, possibly avoiding sepsis, permanent urethrocutaneous fistula, Fournier gangrene, or jelly embolism (Mallikarjuna, Vijayakumar, Patil, & Shivswamy, 2012).
In this author's opinion, it is advisable to palpate the patient's entire penis and perineal urethra before attempting urethral catheterization. Additionally, gradual instillation of 10 cc of anesthetic jelly during catheterization of an injured urethra may prevent leakage of jelly into the corpus spongiosum. However, in an uninjured urethra, slow instillation of 20 cc anesthetic jelly might help the clinician in more difficult cases.
Familiarity with a newly developed mass in the corpus spongiosum after a difficult catheterization aids the clinician in reassuring the patient of the self-limiting nature of the lesion. Additionally, further risky and unnecessary diagnostic and surgical interventions may be prevented.
Acknowledgement: The author is grateful to Mr. Hasan Mirzaie Motlagh, operating room technician, for drawing the figures.
Buddha, S. (2005). Complication of urethral catheterization. Lancet, 365(9462), 909.
Hale, N., Baugh, D., & Womack, G. (2012). Mid-ureteral rupture: A rare complication of urethral catheterization. Urology, 5, 65-66.
Lang, E.K., Nguyen, Q.D., Zhang, K., & Smith, M.H. (2012). Missed iatrogenic partial disruption of the male urethra, caused by catheterization. International Brazilian Journal of Urology, 38(3), 426-427.
Mallikarjuna, M.N., Vijayakumar, A., Patil, V.S., & Shivswamy, B.S. (2012). Fournier's gangrene: Current practices. ISRN Surgery, 942437, 1-8.
Villanueva, C., & Hemstreet, G.P. III. (2008). Difficult male urethral catheterization: A review of different approaches. International Brazilian Journal of Urology, 34(4), 401-412.
Willette, P.A. & Coffield, S. (2012). Current trends in the management of difficult urinary catheterizations. Western Journal of Emergency Medicine, 13(6), 472-478.
Hamed Akhavizadegan, MD, is an Assistant Professor in Urology, Baharloo Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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|Title Annotation:||Case Study|
|Date:||Jul 1, 2013|
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