Catheterisation-related urethral injury in a patient with chronic liver disease: a diagnostic dilemma

Introduction

The incidence of urethral injury during catheterisation is 0.67%. Injury to the urethra has consequences such as the need for prolonged hospitalisation and the requirement for cystoscopy or suprapubic catheter placement. Long-term complications such as urethral stenosis and the requirement for urethral dilation or urethroplasty are also well known.^1,2 We present a case with injury to the urethra during catheter placement in a patient with chronic liver disease and subsequent multiple episodes of severe per urethral bleeding. Superselective embolisation with glue was performed in the pudendal artery after the failure of treatment with medication and mechanical compression.

Case report

A 54-year-old male patient with chronic liver disease (CLD) due to non-alcoholic steatohepatitis (NASH) was admitted to the hospital for management of CLD. On admission his Child–Turcotte–Pugh (CTP) score was 11 and the model for end-stage liver disease (MELD) score was 30. Prothrombin time (PT) was 31.7 and international normalised ratio (INR) was 2.75. The patient also gave a history of severe bleeding per urethra after an attempt at catheterisation in another hospital where he was admitted 5 days earlier. Bleeding was managed conservatively and the patient was referred to our institute for further management. Two days after admission the patient complained of severe bleeding per urethra.

On examination the patient was found to have profuse bleeding per urethra which was refractory to conservative measures such as perineal compression. Contrast-enhanced computed tomography angiography (CTA) of the pelvis was performed which showed active extravasation of contrast with pooling in the corpus spongiosum in arterial phase (Figure 1a and b) supplied by branches of the right internal pudendal artery (Figure 1c, arrow). In view of the history of per urethral bleed after Foley catheterisation, a diagnosis of arterial injury with active bleed was made. After consultation with an interventional radiologist the decision for embolisation was taken. Digital subtraction angiography was performed and selective right internal iliac artery angiogram demonstrated active extravasation with pooling of contrast (ruptured aneurysm) supplied by the right internal pudendal artery (Figure 2a). Superselective angiogram of the right internal pudendal artery using a 2.7 Fr Progreat microcatheter (Terumo, Japan) close to the bleeding site revealed better visualisation of active extravasation site (Figure 2b and c) and contrast agent flowed out directly from the urethral meatus. As the patient had cirrhosis-induced coagulopathy, embolisation was done using N-butyl cyanoacrylate (glue/NBCA) (endocryl) and lipoidol (lipoidol ultra fluid; Guerbet, USA) in a ratio of 1:3. Post-embolisation angiogram (Figure 2d) showed obliteration of the distal right internal pudendal artery without evidence of active extravasation of contrast and maintained flow within the rest of the penis. Left internal iliac artery angiogram also taken with superselective cannulation of the left internal pudendal artery showed no abnormal blush or extravasation (Figure 2d). Post-procedure CTA showed glue cast in spongiosum with no blush or extravasation of contrast (Figure 2f).

Figure 1.

Computed tomography angiography (CTA) of pelvis images: (a) CTA axial section shows linear hyperdense extravasation of contrast in corpus spongiosum adjacent to penile bulbar urethra (white arrow). (b) CTA axial section shows spongiosal branches of the internal pudendal artery was the origin of the aneurismal sac with bleed/extravasation (open arrow). (c) Coronal section maximum intensity projection (MIP) image shows spongiosal branch of internal pudendal artery showing active extravasation with pooling (s/o ruptured aneurysm (black arrow).

Figure 2.

Digital subtraction angiography images: (a) Right internal iliac artery angiogram showing pooling and extravasation of contrast (arrow) supplied by branch of the right internal pudendal artery. (b) Superselective cannulation of the right internal pudendal artery done close to bleeding site reveals spongiosal branch outpouching and extravasation (arrowhead). (c) Fluoroscopy image shows adequate filling of aneurysm sac with glue cast (white arrow). (d) Post-embolisation angiographic run showing complete obliteration of spongiosal branches by glue cast. (e) Selective left internal iliac angiogram showing no blush/extravasation of contrast. (f) Post-procedure computed tomography angiography (CTA) of pelvis axial section shows linear dense hyperdense glue cast with no extravasation of contrast in corpus spongiosum adjacent to penile-bulbar urethra region (open black arrow).

After the interventional therapy, the urethral meatus showed no blood, and the temperature and colour of the penis indicated no abnormality. During the follow-up of 2 weeks, the patient’s erectile function was unremarkable.

Discussion

Patients with liver disease are at high risk of bleeding due to coagulopathy. In patients with liver disease, INR and PT may not be useful in assessing haemorrhagic risk. ³ In this case the bleeding was due to the injury to the urethral artery but due to the liver disease the suspicion was more towards the ongoing coagulopathy. During the literature search we came across previous studies revealing the effects of iatrogenic urethral injuries in the form of urethral stenosis and urethral stricture formation. ⁴ A study by Davis et al. ¹ noted that patients with catheter-related injuries to the urethra have to stay 9.4 additional days in the hospital. Catheter-related injury to the urethra may need cystoscopic or suprapubic placement of the catheter which will further lead to extra costs. Catheter-related urethral injuries are preventable and they are also an unwanted source of increased morbidity to the patients. ⁵ We did not come across any such case in the literature, in which multiple blood transfusions and angioembolisation of the internal pudendal artery was carried out to control the source of haemorrhage from the urethra in an isolated urethral injury. Transarterial embolisation of the distal internal pudendal arteries is the treatment of choice for high-flow priapism and is a useful alternative to surgery. ⁶ The active bleeding site was superselectively embolised with N-butyl cyanoacrylate (glue/NBCA) liquid agent in our case because of certain properties of NBCA-like permanent quick embolisation, a lower rate of recanalisation and easy to penetrate in small vessels. Kondo et al. had reported a patient with high-flow priapism due to urethral trauma caused by a misplaced Foley catheter and was managed with superselective arterial embolisation of the bilateral internal pudendal arteries using metallic microcoils. ⁷ However, it is very difficult to place a coil distally in the tortuous vessel up to the site of bleeding; this may increase the chances of procedure failure especially in the coagulopathy patient.

Conclusion

A surgical cause of bleeding may be missed especially in patients with coagulopathy if the index of suspicion is not high. Transcatheter superselective glue embolisation is a safe and effective treatment for traumatic urethral bleeding even in patients with coagulopathy.