Penile gangrene caused by inflation of balloon of indwelling urethral catheter in urethra in a spinal cord-injured patient

Case report

A 51-year-old, single male was admitted to our hospital with complaints of bleeding from the penile body and urinary incontinence for two weeks. He had submitted to long-stage catheterization, on account of neurogenic dysfunctional voiding. After the last change two weeks previously, instigated by leaking of urine at the side of the catheter, he inflated the balloon with 50 cc water. He heard a popping sound, and saw his penis severely bleeding. This he managed to arrest by compression. He presented two weeks afterwards.

He had undergone surgery in 2015 for spinal stenosis at the L4 level with a cauda equina syndrome. Clean intermittent self-catheterization was recommended postoperatively because of voiding difficulty and overflow incontinence. Since he was unable to perform intermittent self-catheterization, an indwelling urethral catheter was preferred, though this was changed by the patient himself. He had no history of any other systemic illness.

Examination on admission revealed mild mental retardation and very poor self-care. In particular, there was no penile body and subcutaneous penile tissues were completely necrotic. The genitals were wet due to constant urine leakage, and the urethra was impossible to identify (Figure 1(a)). However, there was no tenderness, oedema, induration, or crepitation around the lesion.

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Figure 1.

Intraoperative images of the patient. (a) Severed penis with necrotic corpus cavernosum and corpus spongiosum. (b) Penoscrotal region after the debridement of the necrotic tissues. (c) Formation of granulation tissue. (d) Postoperative 1st month follow-up.

Routine haematological and biochemical investigations were within the normal limits and the serum prostate-specific antigen level was 1.4 ng/ml. Considering that the proximal part of the urethral catheter may have remained in the patient as a foreign body and that there may be urine extravasation due to injury in the urethra (also due to bladder dysfunction), a non-contrast computed tomography (CT) scan was performed. CT scan revealed air throughout the penis, which is suspicious for necrotizing infection with normal kidneys and bladder (Figure 2).

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Figure 2.

Computed tomography (CT) images of the patient. (a) Axial view of emphysema in penile tissue. (b) Sagittal view emphysema in penile tissue. (c and d) Normal CT images of the kidneys.

A suprapubic cystostomy was inserted and all necrotic tissues within the penile shaft were debrided under spinal anaesthesia. Buck's fascia and the prostatic urethra could then be identified (Figure 1(b)). Flexible cystourethroscopy showed the prostatic urethra, bladder neck and ureteral orifices to be normal.

Over the following two weeks, no regression of the urinary leakage from the prostatic urethra was observed. Considering the patient's social, mental and marital status, the bladder neck was primarily sutured with 3.0 Vicryl under spinal anaesthesia (Figure 1(c)), leaving the patient with a long-term suprapubic cystostomy tube. At the end of one month, granulation tissue had filled the space without any urinary leakage (Figure 1(d)).

Discussion

Pressure necrosis of the penis may occur from outside, by compression of a condom or penile prosthesis, or from inside by foreign bodies or inflation of the balloon of a urethral catheter^1,2 within the urethra. This may occur due to spasm of the urethral sphincter, trauma to the urethra resulting in urethral false passage, or blockage by a large prostate or bladder tumor. ³ The golden rule is always only to inflate the balloon when the distal inflation channel abuts on the glans and urine is seen flowing freely down the catheter.

In case of serious urethral trauma due to pressure necrosis, urinary diversion and debridement are mandatory. Closure of the bladder neck may keep the urethra dry and allow quicker tissue recovery.

In our case, the patient was changing the catheter by himself, which he did not have the full capacity to do. Intermittent self-catheterization is, in this sort of situation, safer, as catheters used do not have to have an inflatable balloon. Any indwelling catheterization should be performed by a well-experienced healthcare professional by a fully sterile method, and likewise any catheter change.