Management of Catheter-Related Urethral Injuries in Male Children.

INTRODUCTION: Management of urethral trauma lacks clarity in the paediatric population. There is no clear guidance for management and follow-up of these patients which can lead to missing the long-term sequelae of the primary injury. Catheter-associated urethral injuries are less likely to cause a complete transaction of the urethra. This is due to the mechanism, typically caused by creating a false passage or inflating the balloon in the urethra. In partial urethral injuries, the European Association of Urology (EAU) guidelines suggest follow-up after one-two weeks of bladder drainage or a urethrogram.  The purpose of this study was to review literature related to the management and follow-up of catheter-induced urethral injuries, subsequently comparing this to a case series in a single paediatric tertiary centre. The aim was to propose a unique algorithm to safely and effectively guide clinicians for this presentation.

RESULTS: In our case series, 11 of 12 required initial bladder drainage. The data demonstrated an inconsistent approach to investigations throughout their admissions. Most cases had a successful trial without catheter (TWOC) or ability to resume continuous intermittent catheterisation. One patient needed a vesicostomy. We had a single bulbar urethral stricture, which wouldn't permit an 8fr catheter. This was managed using cystoscopy and serial urethral dilations. Our cohort is likely an underrepresentation of the actual number of catheter-related injuries in our institute. Some injuries are managed by the parent team without referring to paediatric urologists if spontaneous micturition occurs or if they manage to catheterise after an initial traumatic attempt.  Conclusion: Catheter-related urethral injuries are common but underreported. They are less likely to have long-term sequelae than other mechanisms of trauma. The majority of cases do well following a period of initial bladder drainage. Current practise varies even in one institute as there are no clear management and follow-up guidance in current literature. Our proposed algorithm is a useful tool and decreases the incidence of missing long-term sequelae. Management algorithm: Post urethral injury, a child who is passing urine with conservative management is likely to have good long-term function. They would require re-assessment after discharge. In clinic they would require urinary flow assessment and post-void residuals. If not toilet trained, parental impression of whether their child's stream is interrupted or if they strain during urination would be assessed. Back-pressure changes would be considered on ultrasound scan (USS). If the assessment indicates concern, then a micturating cystourethrogram (MCUG) assessment for children younger than one or a cystoscopic assessment for children older than one would be recommended. Post urethral injury, if a child is unable to pass urine conservatively, then an urgent urological assessment would be appropriate. An attempt at catheterisation would be made. If unsuccessful, the patient would be assessed for theatre. If unfit for it, an ultrasound-guided suprapubic (SP) catheter would be advised. If the patient is fit, then a cystoscopic and wire-guided catheter would be preferred. Later, if they passed a TWOC, they would be managed as per the algorithm described above. If they failed the TWOC, MCUG would be proceeded to. Catheter management and regular follow-up, or for a definitive intervention would be planned for.