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Keywords:

  • Circumcision;
  • Diabetic phimosis;
  • Preputial intussusception;
  • Urethral catheterization;
  • Urethral meatus;
  • Urinary retention

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. CASE REPORT
  5. DISCUSSION
  6. REFERENCES

We present a patient who experienced urinary retention with a comorbid phimosis and redundant prepuce, most likely complications of diabetes mellitus. Additionally, we report a rare complication of difficult catheterization, where the prepuce intussuscepted into the urethral meatus. Attempts to change the catheter with poor visualization of the external meatus secondary to diabetic phimosis resulted in telescoping of the prepuce into the urethra. Circumcision and meatotomy of the external meatus alleviated the acute issue and prevented potential problems with future catheterizations.


INTRODUCTION

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. CASE REPORT
  5. DISCUSSION
  6. REFERENCES

Urethral catheterization is a common practice in long-term nursing facilities, where 5–15% of patients require chronic urinary catheterization (Gammack, 2003). Long-term catheterization is indicated in situations of refractory bladder-outlet obstruction, intractable skin breakdown, neurogenic bladder with retention and palliative care for incontinent patients (Yoshikawa et al., 1996; Cravens and Zweig, 2000; Inelmen et al., 2007). While urethral catheterization has many therapeutic indications, it is not without complications. Adverse effects include chronic renal inflammation, chronic pyelonephritis, nephrolithiasis, cystolithiasis, urethral trauma and bleeding, bladder cancer, allergy, symptomatic urinary tract infection with acute pyelonephritis, bacteremia, sepsis and death (Kunin et al., 1992; Warren, 1992; Warren et al., 1994; Yoshikawa et al., 1996; Cravens and Zweig, 2000; Igawa et al., 2008). Universal bacteriuria occurs within 4 days when using open systems and in 30 days when using closed catheters (Warren, 1992; Cravens and Zweig, 2000). In fact, a single in-and-out catheterization may directly cause bacteriuria in 20% of elderly patients (Yoshikawa et al., 1996). We report a case of an unusual complication of male urethral catheterization, intussusception of the prepuce into the urethral meatus.

CASE REPORT

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. CASE REPORT
  5. DISCUSSION
  6. REFERENCES

A 78 year old male who had diabetes and a history of difficult catheterizations secondary to diabetic phimosis and redundant prepuce was seen in the emergency department due to the inability to change his Foley catheter. The patient was a nursing home resident, and required chronic catheterization for urinary retention. Physical examination revealed a 5-cm circumferential cystic swelling of the distal shaft of the penis and an inability to retract the prepuce and visualize the glans penis and external meatus. Attempts to retract the prepuce revealed intussusception of the prepuce into the urethra and a pinhole meatus. Under anaesthesia the prepuce was detached from the urethral meatus, a dorsal slit was performed, and examination of the glans penis was unremarkable. Circumcision and a meatotomy of the external meatus were performed. A Foley catheter was inserted and clear urine drained from the urinary bladder. The catheter balloon was inflated with sterile water.

DISCUSSION

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. CASE REPORT
  5. DISCUSSION
  6. REFERENCES

Diabetes mellitus has multiple effects on the genitourinary organs. Our patient presented with bladder dysfunction, which is a common complication of diabetes. Diabetic cystopathy is chiefly the result of autonomic neuropathy, which can result in various endpoints, including detrusor hyperreflexia, impaired detrusor contractility and vescico-urethral dyssynergia (Koubaa et al., 2009). In addition, acquired phimosis is strongly associated with impaired glucose tolerance. In a study of patients presenting with acquired phimosis, one-third were found to have a history of diabetes and another 12% were diagnosed with a disorder of glycaemic control (Bromage et al., 2008).

Disorders of the prepuce, including phimosis and redundant prepuce, have been documented to result in difficult male uretheral catheterization (Villanueva and Hemstreet, 2008). Preputial intussusception causes a tight phimosis and a partially buried penis. The resulting urinary outflow obstruction and voiding difficulty promotes further ballooning of the preputial skin, additional redundancy and exacerbation of the bladder-outflow obstruction (Powis and Capps, 1998). Simple circumcision is an effective treatment for preputial intussusception and has been shown to limit the sequelae of bladder-outlet obstruction in the paediatric population (Powis and Capps, 1998).

In the setting of urinary retention complicated by a preputial disorder, choosing the correct catheter is a decision based upon the particular indication, patient preference and practitioner experience. Varieties of catheters include external condom type, transurethral or suprapubic. Condom catheters are primarily used to manage urinary incontinence, where they offer greater comfort and decreased rates of bacteriuria compared to indwelling catheters. However, they are contraindicated in patients with urinary retention and therefore were inappropriate for the patient in this case (Saint et al., 2006).

Overall, transurethral approach is more common than either suprapubic or condom-type catheters, although no particular device has been proven superior in long-term use (Gammack, 2003). Transurethral catheterization can be accomplished via indwelling Foley catheterization or clean intermittent catheterization. Intermittent catheterization is employed to empty the bladder multiple times a day, and is effective for patients with urinary retention due to idiopathic or neurogenic bladder dysfunction (Newman and Willson, 2011). As a result it has become the standard of care for patients with neurogenic lower urinary tract dysfunction (Di Benedetto, 2011). Compared with chronic indwelling catheterization, intermittent catheterization allows for improved self-care and independence. Other benefits include fewer barriers to intimacy and sexual activities and reduced lower urinary tract symptoms between catheterizations (Newman and Willson, 2011). While intermittent catheterization is preferred, indwelling catheterization may be indicated in patients who lack sufficient cognition or hand dexterity for self-catheterization and do not have someone to help with insertion (Wilde et al., 2013). In the case of this patient, an indwelling Foley was chosen because his phimosis posed a difficulty to easily visualize the external urethral meatus and successfully navigate the catheter multiple times each day.

We report a rare complication where insertion of the Foley catheter without visualizing the urethral meatus resulted in intussusception of the prepuce into the distal urethra. When a urethral catheter is difficult to insert due to a preputial disorder, a circumcision should be performed or a suprapubic catheter placed. Either of these would have prevented the complication we present. Suprapubic catheters are indicated in situations where urethral catheter insertion or recatheterization is problematic (Robinson, 2008). However, potential complications of suprapubic catheter placement include a propensity to develop infection, cellulitis, hematoma, leakage or pain at the insertion site, prolapse through the urethra and suprapubic tube revision, as well as risks attributable to any chronic internal catheter, such as urinary tract infection, pyelonephritis and urosepsis (Warren, 1992; Katsumi et al., 2010; Harrison et al., 2011). Thus, a circumcision should be first-line treatment. One previously published case report cites circumferential interposition of the preputial tip into the external urethral meatus associated with a hidden glans penis and phimosis. As with the patient we present, the authors discuss the effectiveness of dissecting the preputial tip off the external meatus and performing a meatoplasty (Ali Khan and Hu, 1984).

To the best of our knowledge this complication of diabetic phimosis and redundant prepuce is not well described in the literature. In situations of a hidden glans penis or phimosis secondary to diabetes, a dorsal slit or circumcision is an effective means to enable urethral catheterization.

WHAT IS KNOWN ABOUT THIS TOPIC

  • Diabetes mellitus has many effects on genitourinary organs, including bladder dysfunction and urinary retention from autonomic neuropathy.
  • Preputial disorders have been strongly associated with poor glycaemic control.
  • Transurethral catheterization is a common practice amongst nursing home patients with urological pathologies. However, disorders of the prepuce may pose a challenge to successful catheter placement.
  • Phimosis is commonly treated with circumcision.

WHAT THIS PAPER ADDS

  • Intussusception of the prepuce as a result of urethral catheterization has never been reported in the literature.
  • Circumcision and meatotomy can be used for appropriate management of this complication.

REFERENCES

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. CASE REPORT
  5. DISCUSSION
  6. REFERENCES
  • Ali Khan S, Hu KN. (1984). Interposition of the prepuce into the external urethral meatus. A case report. International Urology and Nephrology; 16: 129132.
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