Catheters and Urinary Diversion
Placement of a urinary catheter is often indicated in the care of a trauma patient for monitoring resuscitation and fluid status, as well as logistical reasons in a critically ill, bed-bound patient. It is recommended by the American Urological Association guidelines in many renal and GU injuries such as bladder rupture or straddle injury to the urethra (Grade C evidence, considered “low” quality).32 In patients with diagnosed or suspected renal and GU trauma, however, this is slightly more complicated.
A common question in the ED is whether to attempt placement of a Foley catheter in patients when there is even the remote possibility of a urethral injury. The question is particularly pertinent in the initial evaluation and resuscitation: Will catheterization make a patient worse, potentially turning a partial tear into a complete perforation? A retrospective study of 46 patients with urethral and bladder trauma seen at the University of California Los Angeles Medical Center found that blind Foley placement was attempted in 91% of patients. They could find no evidence that this attempt worsened the initial injury, including patients with blood at the meatus.87 In a sweeping review article on the history of urethral trauma, Mundy and Andrich argued that, in the modern era of urinary catheters and antibiotics, a blind attempt at Foley catheterization (with the caveat that adequate confirmation of bladder placement is vital) is unlikely to cause additional harm and is a reasonable approach in a trauma patient that requires one.29 Despite these studies, blind catheter placement is best avoided, if possible. If it is attempted, it should be noted that successful passage of a Foley catheter does not exclude the possibility of a small or incomplete perforation of the urethra.33 In a trauma patient, the inability to easily pass a Foley catheter mandates stopping for urethral imaging and either passing a Foley over a guidewire or a suprapubic catheter.22,29