Q. I am a polio quadriplegic and even though I have had normal bladder and bowel control most of my life, an incident that happened to me recently has me scared stiff. A home care RN inflated the balloon to my Foley indwelling catheter in my urethra instead of my bladder. For weeks there was pain, ghastly looking drainage and poor urination. The ER doctor told me what was wrong, and fixed it quickly. When I got home I went on the Internet and found out about penile erosion and am wondering if I have the first stages of it. Those pictures are scary to any male quad.

— Jerry

A. Jerry—you point out an important, and often overlooked, potential danger when changing an indwelling Foley catheter.

A 2010 article in Advances in Urology describes a similar situation — a 56-year-old male C5 incomplete quadriplegic came to the hospital with excessive sweating from dysreflexia after a community health professional changed his indwelling Foley. X-rays showed that the Foley balloon was inflated in his urethra, and his bladder was not draining. The article stresses the importance of making sure the end of the Foley is inserted all the way into the bladder before inflating the balloon. It also explains that some people have tight sphincters or false passages in their urethras, making a precise initial insertion even more crucial.

Rules to Live By
The article points out a red flag to share with anybody changing your Foley: If excessive length of a Foley catheter lies outside the penis (or urethral opening in women), the catheter is not correctly placed. Incorrect positioning of a Foley catheter with balloon inflated in the urethra in can cause bleeding from the urethra and urine retention, and can lead to life-threatening autonomic dysreflexia.

Diedre Bricker, MSN RN CRRN, of Craig Hospital’s SCI Nurse Advice Line, offers some good tips how caregivers should change a Foley and what to watch for to make sure they to it correctly. “In nursing school they teach you to push the Foley in to the urethra until you get urine out of the Foley, then continue to insert the Foley another 1 to 2 inches into the bladder before inflating the balloon.” A great rule of thumb, she says, is to stop immediately if there is any sort of resistance when inflating the Foley balloon with the syringe; there should not be any resistance at all. What some people do to be extra safe is make sure urine is coming out of the end of the Foley, then insert the catheter all the way to the “Y” junction at the end of the catheter before inflating the balloon.

Bricker says if a balloon is accidentally inflated in the urethra, or if an inflated balloon is pulled even part way through the urethra, it is very important to see a urologist to assess the damage and learn about possible remedies. Bricker also stresses that bleeding or passing blood clots are signs of trauma and should be evaluated by a urologist.

Preventing Erosion
To answer your concern about penile erosion, also known as urethral erosion, the sooner it is caught the more easily it can be treated — so it is important to see a urologist as soon as possible if you suspect this might be going on.

According to Bricker — and journal articles — urethral erosion is one of the possible complications of using an indwelling Foley for long-term bladder management. A 2005 article in Spinal Cord Journal points out that urethral erosion also occurs in women that use indwelling catheters — most often from improperly secured extension tubing. The catheter can get inadvertently tugged and pull the Foley balloon against the bladder neck.

Bricker explains the proper technique for securing a Foley catheter is to use a leg strap to secure the extension tubing from the Foley to the upper thigh and make there is enough tubing leading to the Foley to allow it to move freely and avoid any pulling or tugging. Journal articles explain that men need extra extension tubing to allow for penile movement and erections. Bricker says at Craig they also recommend alternating the tubing placement from leg to leg every other day so the bulb inside the bladder and the Foley are not always pulling on one side.

Size Matters
Another important step to help avoid urethral erosion is working with your urologist to make sure you are using the proper size Foley for you. “Although 16 FR is the standard size Foley, everybody has different anatomy, and different people require different size catheters,” says Bricker. “I’ve had patients that would get a lot of blood every time they inserted a catheter, and the reason behind it was they were using a too-large catheter. When they went to a smaller catheter, that solved their problems.” In addition to bleeding, discomfort or autonomic dysreflexia are other indications that the catheter may be too large.

A 2008 article in Ostomy Wound Management is right in step with Bricker and explains the prevailing guideline for Foley catheter size is to use the smallest diameter that will provide good drainage, typically a 14 to 18 FR — unless the catheter user has blood clots or sediment that occlude the lumen (eyelets that urine drains into), in which case a urologist may suggest a larger size. The article further confirms that catheters that are too large can contribute to urethral erosion.

Journal articles also point out the importance of using a Foley catheter made out of a soft material. A 2010 article in Ostomy Wound Management discusses a facility that, as part of creating a latex-free environment, replaced their (softer) latex-containing Foley catheters with silicone catheters that were stiffer. The use of stiffer Foley catheters was associated with urethral erosion in four elderly men. Major catheter manufacturers offer Foley catheters in a variety of soft materials. If there is a concern that the Foley you are using is too stiff, your catheter supplier should be happy to send you samples of different Foley catheter options. However, it is important to discuss any change in a Foley with your urologist.

Exams Are Key
If you suspect your urethra is damaged or suspect you have urethral erosion, it is important to seek help from a urologist versed in physical medicine and rehabilitation as soon as possible. Although the articles I mentioned discussed a few of the different options for dealing with urethral erosion —such as having a caregiver do intermittent catheterization, or switching to a suprapubic catheter (see August 2008 Bladder Matters) — that will be something for you and your urologist to decide together.

If there is urethral erosion, the longer it is undiagnosed, the more damage that can be done. At some point, the problem may require surgery like a urethroplasty (see August 2009 Bladder Matters).

To catch signs of urethral erosion early, Bricker recommends that people using Foleys get a urological exam at least once a year. This can also help identify bladder stones, which occur at higher rates in people using indwelling catheters (see June 2011 Bladder Matters).

So get yourself checked out — hopefully it turns out to be something minor.

Best of luck. Please let us know how it goes.