Case of the Month from the University of Amsterdam UMC, the Netherlands: ureteric injury by a Foley catheter, an unusual complication in pregnancy

Abstract

A 34-year old woman, multigravida, with no urological medical history, presented at 38 weeks of pregnancy with urinary retention during induced labour. Delivery was induced due to gestational diabetes. Her previous two pregnancies were delivered vaginally, without complications. A bladder Foley catheter was placed by the midwife, who reported that placement was difficult and insertion was met with some resistance. There was immediate efflux of 600 mL urine. Initially, the catheter was productive. However, during the subsequent hours, urinary production decreased. The patient had received epidural anaesthesia for pain relief but, despite this, she experienced urgency for micturition. The catheter was removed and a new Foley catheter was placed. This was again reported to be a challenging procedure, with notable deep insertion of the catheter. The patient underwent a caesarean section because of very slow progression of labour and a healthy baby was born. During surgery, a full bladder was observed and a urologist was consulted. Inspection of the urinary tract was challenging because of a very enlarged uterus in combination with the caesarean incision in the lower abdomen. Dorsally on the right side of the uterus, a round non-pulsating elastic lesion and a strand going distally were palpated. When the catheter balloon was deflated, the round lesion disappeared. Differential diagnosis included perforation of the bladder, with the catheter placed in the retroperitoneal space. Placement of the Foley catheter in the right ureter was considered, but rejected. The catheter was removed and a new one was placed with balloon intravesically. During the following hours, the patient experienced worsening abdominal pain and ultrasonography showed fluid abdominally and retroperitoneally. Serum haemoglobin was stable, decreasing the likelihood of haemorrhaging. Contrast CT of the abdomen was obtained, which showed a defect of 3 cm in the proximal right ureter with leakage of contrast fluid outside of the urinary system. A substantial amount of free fluid was present in the retroperitoneal space. No contrast leakage around the bladder was seen. These findings indicated that the catheter had been inserted into the right ureter and the insertion itself or the inflation of the balloon caused damage. Findings are shown in Fig. 1. This explains the symptoms of a feeling of full bladder and minimal urine production despite a catheter being in situ.