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Cystoscopy to investigate suprapubic catheter blockage: plugging of the side holes by bladder mucosa

A 53-year-old woman presented with acute urinary retention despite a suprapubic catheter being in place. She had undergone a transperitoneal laparoscopic Burch colposuspension for stress urinary incontinence 21 days previously. The operation was uneventful, and a 10-French Cystofix (B. Braun Melsungen, Melsungen, Germany) suprapubic catheter had been inserted by trocar under laparoscopic visualisation. Voiding trials were started on post-operative day 3, and spontaneous voiding occurred on post-operative day 7. However, because of persistent high post-voiding residual volumes, the catheter was left in place when the patient was discharged on post-operative day 12. Two days after discharge (day 14), she developed acute urinary retention with only small amounts of urine draining through the catheter. Ultrasonography showed a full bladder (about 400 mL of urine) and the catheter in place. Urinalysis was normal. After flushing and irrigating of the catheter, good function seemed to be restored. Four days later (day 18), retention again developed but resolved with catheter irrigation. On post-operative day 21, the same situation recurred. Although there was no difficulty in flushing the catheter, only one-third of the irrigating fluid was recovered. Cystoscopic examination was performed and revealed the catheter penetrating the bladder dome with the curly, free end lying inside the bladder. The catheter was not kinked or knotted, the side holes were not occluded, nor was there any intravesical blood clot. However, as the distending fluid was drained through the catheter, there was progressive plugging of the proximal seven side holes by bladder mucosa, occluding the catheter lumen (Fig. 1A–D). Flow could not be re-established even by manually moving the catheter up and down at the abdominal insertion site. Repeated flushing of the catheter pushed the bladder mucosa out of the proximal to the distal holes one by one, leaving suction marks on the freed mucosa (Fig. 1E and F). On the next attempt at drainage via the suprapubic catheter, the plugging recurred, so we removed the suprapubic catheter. The patient subsequently performed intermittent self-catheterisation until post-operative day 37, by which time she had only low post-voiding residual volumes.