Indwelling urethral catheter-associated urethral erosion is a rare complication. Urethral erosion can be partial thickness or full-thickness involving meatus, glans and penile shaft. We had such twelve cases of urethral erosion, and 50% (five patients with spinal pathology and one with diabetes and coronary artery) of them had undergone surgical intervention. Most of the cases reported in the literature are of spinal cord injury, but in our series 4 cases were of spinal cord injury, 1 with cauda equina syndrome, 2 cases of diabetes and cerebrovascular accident, 3 with diabetes and cardiovascular disease and one with diabetes and benign hyperplasia of prostate.
Mean duration of catheterization, before injury was detected, was 10.9 months (range 6–24 months) with most of the patients and their attendants often unaware of the damage but the injury came to light when urethral catheterization became a problem for a variety of reasons. Distal urethral erosion was noticed in one of the patient with catheter in situ presented to us as vesical calculus and bladder irritation symptoms. Majority of these patients have underlying neurological dysfunction [10, 15, 16]. Impaired penile sensation is not a pre-requisite for this condition but may aggravate the injury . In the study, five patients had one or more comorbidities. Additionally two patients had coronary artery disease, and two had diabetes mellitus. These are important factors in erosion of urethra with indwelling catheter. Additionally, the presence of periurethral infection is another contributing factor. Fixing the catheter on thigh with leg bag will not allow free movement of catheter, so the indwelling catheter acts as a bowstring when the patients have erections and may be an important factor in urethral erosion. Securing the catheter abdominal wall prevents pressure on the ventral surface which helps in prevention ventral urethral erosion. This is more common because of weak ventral support of corpus spongiosum to urethra and strong support of thick corpora cavernosum on dorsal aspect. Of course, discarding indwelling urethral catheter is the best way to prevent erosion of urethra. Intermittent catheterization is preferable to indwelling urinary catheter drainage. Supra-pubic cystostomy for the patients requiring the long-term catheterization will help in preventing catheter-induced erosion of urethra.
Mary et al. reported role of catheter material and securing the catheter in urethral trophic ulcers and use of soft silicone catheters and securing the catheter on abdominal wall reduces the incidence of urethral complications. Indwelling catheter-associated urethral erosions have been proposed to cause trophic ulcers due to neurogenic and vasculogenic deficiency . In the study, silicon-coated catheters had been used instead of soft silicon catheter and catheters were not secured, thus increasing the chances of urethral erosion. Four of the patients had anticlockwise torque; this could be because of the fixation of spongiosum to corpora to one side on the direction of catheter traction (Fig. 2).
Elderly patients with comorbidities are poor candidates for surgical reconstruction of urethra. Secrest et al. studied 17 patients with neurogenic bladder who underwent urethral reconstruction. Of those, 11 with spinal cord injury required reoperation and all eventually required urinary diversion . Andrews et al. repaired six cases out of sixteen cases of iatrogenic hypospadias. They reported successful outcome in all these patients without any complication .
In our study, age, diabetes, coronary artery disease, neurological diseases like cerebrovascular accidents and cauda equina syndrome, spinal cord injury, etc., were risk factors for urethral erosion following long-term indwelling catheterization.
We reconstructed six cases with satisfactory outcome. Urethroplasty is needed to do clean intermittent catheterization in cases of lower motor neuron bladder. The results from repair were very gratifying as the penis returned to its normal appearance. Tubularization of laid open urethra is feasible in most of the cases, but if there is extensive scarring and the urethral plate was insufficient for primary closure, then a substitution urethroplasty is recommended. A dartos or tunica vaginalis flap can be developed and placed over to support the neourethra. Graft tissue is harvested depending on tissue availability either excess penile skin, non-hair bearing skin and Buccal mucosa. Inner preputial flap urethroplasty can be done if prepuce skin is available. Urethral erosion is a preventable complication of indwelling catheter. Patients and their attendants should be counseled and educated about the complications of catheterization and about their prevention. Patients with neurogenic bladders could be best put on self-calibration. Patients requiring long-term catheterization should be counseled for supra-pubic diversion of urine . Recurrence of stricture is not a problem in the spinal cord patients because these patients are put on clean intermittent catheterization. Four of patients put on CIC did not have any recurrence, but one patient with spontaneous voiding has meatal stenosis. Limitation of the study is of 12 patients only, so statistically significant conclusions cannot be derived. Since our study duration is short, longer follow-ups are required to ascertain long-term complications of the reconstructive surgery such as stricture, diverticulum, urethrocutaneous fistula.