INTRODUCTION

Urethral catheterisation is one of the most commonly performed procedures in health care settings worldwide, with more than 5 million urethral catheterisations done in the United States in the year 2000 alone.¹ The two most common complications related to foley’s catheters, particularly in males, are anterior urethral injuries which can lead to long term sequelae, such as urethral strictures, and retention of the catheter balloon in the urethra.²  Bladder perforation following urethral catheterisation is a rare  complication and can be life threatening,³  so when it occurs it is a surgical emergency that needs urgent surgical intervention to prevent mortality.

CASE PRESENTATION

A 63-year-old male who presented to the emergency unit of Lily Hospitals Limited, Warri, Delta State, Nigeria with complaints of bilateral flank pains of 1 day duration which developed following passage of urethral catheter a day prior to onset of symptoms. The pain was said to be dull aching, does not radiate to any part of the body, not worse at any time of the day with no known aggravating or relieving factors. There was an associated history of anorexia, vomiting but no associated fever, abdominal distension, diarrhoea or haematuria.

He has been on management for chronic kidney disease and recurrent urinary tract infection. He had open left nephrolithotomy in 2018 and left double J stent removal in 2020. There was no positive history of hypertension, diabetes or drug allergy.  There was no family history of kidney diseases, hypertension or diabetes.

Physical examination revealed a patient in painful distress, pale, bilateral flank and epigastric tenderness with foley’s catheter draining amber coloured urine. Investigations done revealed- Serum electrolytes, urea and creatinine revealing deranged values for potassium of 6.3mmol/L (3.5-5.3mmol/l) urea of 117mg/dl (5-20mg/dl) and creatinine of 8.5mg/dl (0.5-1.5mg/dl). Urinalysis showed protein of two pluses and leukocytes of two pluses. Urine microscopy, culture and sensitivity revealed growth of klebsiella sensitive to levofloxacin, gentamycin, azithromycin. Full blood count revealed haemoglobin of 9.5g/dL (11.5-16.5g/dl) and white blood count of 15,800 x 10⁹ /l (4-11 x 10⁹ /l). Abdominopelvic ultrasound scan revealed fluid collection at both paracolic gutters. Peritoneal aspiration of the fluid under ultrasound guidance revealed amber coloured fluid, laboratory assessment of the creatinine content of the peritoneal fluid revealed a value of 93.5mg/dl which was far higher than the blood level. A diagnosis of intraperitoneal fluid collection was made and he was worked up for exploratory laparotomy to determine the cause of the collection.

He was transfused with two units of packed cells, placed on parenteral levofloxacin and had a session of haemodialysis. Post dialysis serum electrolytes, urea and creatinine revealed potassium of 4.4mmol/l (3.5-5.3mmol/l), urea of 62mg/dl (5-20mg/dl) and creatinine of 3.6mg/dl (0.5-1.5mg/dl). He subsequently had exploratory laparotomy with findings of urine collections at both paracolic gutters measuring 270 millilitres, foley’s catheter balloon within the peritoneal cavity with the catheter passing through a posterior bladder wall perforation measuring about 1 centimetre in length (Figure 1). The urine collection was drained, bladder perforation was repaired in two layers followed by urethral catheterisation, then the peritoneal cavity was copiously lavaged with normal saline and drains were placed at the right paracolic gutter and perivesical regions. He had two units of blood transfused post operatively, the serum electrolytes, urea and creatinine done after surgery was better than the result gotten before the surgery. There was complete resolution of the flank pains and the patient was discharged home seven days after surgery with the urethral catheter. Urethral catheter was removed a week after discharge.