Catheter Problems – OSCE Case

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Introduction

You are called by ward staff who cannot insert a urethral catheter for a 70 year old man in acute urinary retention. They mention a “tight foreskin.”

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History

Handover from ward staff

β€œWe are unable to retract the foreskin to clean prior to catheterisation”

History of presenting complaint

Have you always been unable to retract your foreskin?

β€œI used to be able to retract it some years ago but not anymore”

Have you been having difficulties passing urine?

β€œNot as such but it does balloon up at times”

Have you had any previous episodes of redness or skin changes on the penis before?

β€œI have had a few episodes of redness, itchiness and soreness”

Other components of history

Past medical history

  • Do you have any other medical conditions?

Ask about:

  • Diabetes mellitus
  • Penile lesions
  • Previous catheterisations

β€œMy GP has given me a clean bill of health recently. I’ve never noticed any changes to the skin around the penis apart from when it is itchy and sore.”

Medication history/allergies

  • Do you take any regular medications or have any allergies?

Ask about:

  • Anticoagulation
  • Immunosuppression

“I am on no medications and have no allergies.”

Social history

  • Have you ever smoked? How many cigarettes per day? For how long?

I have never smoked.”

  • Poor glycemic control can lead to recurrent balanitis
  • It is important to know about anticoagulation or bleeding disorders should you need to put in a suprapubic catheter or perform an emergency dorsal slit procedure.
  • In addition, outpatient circumcision may need some planning around ceasing anticoagulation peri-operatively.
  • Patients with HIV and associated immunodeficiency have historically presented with penile lesions (SCC, Kaposi’s Sarcoma etc).5

Clinical examination

It is important to perform a complete examination of the external genitalia. In addition, an abdominal examination may be performed to assess for any masses or palpable lymphadenopathy.

Specific things to assess on examination:

  • The appearance of the external genitalia, including the glans and meatus
  • Retraction of the foreskin

Examination findings

  • Normal appearances of the external genitalia
  • No scars to suggest previous surgery or suprapubic catheterisation
  • On attempted retraction of the foreskin- no visible retraction off glans with pouting of the foreskin
  • Unable to visualise glans or meatus

Diagnosis

Phimosis

PhimosisΒ is a tight foreskin that cannot be retracted behind the coronal sulcus to expose the glans. In children, this may be due toΒ adhesions between the foreskin and the glans. These adhesions typically breakdown by 5-7 years old, and 99% are retractile by 17 years old.2

In adults, phimosis may develop due to scarring from infections/inflammation of the glans.


Management

Phimosis warrantsΒ manual retraction of the foreskin. First, attempt to gently introduce an instillagel nozzle to find the urethral meatus. Then, insert a catheter by feel to identify the meatus.

If this is unsuccessful, the following actions may be taken:

  • Insertion of a suprapubic catheter to drain the bladder, with delayed management of phimosis until it is safe to do so
  • Emergency dorsal slit procedure to expose the meatus
  • Elective circumcision

Patients with phimosis can be circumcised to prevent recurrent episodes.

Indications for elective circumcision in adults are as follows:3

  • Symptomatic
  • Pathological phimosis (i.e. secondary to infection/inflammation)
  • Penile cancer- either to expose the lesion or as part of biopsy/surgical excision

Indications for elective circumcision in children are as follows:3

  • Recurrent balanitis
  • Balanitis xerotica obliterans (BXO) / lichen sclerosis
  • Urinary tract infection (UTI) with structural abnormality (e.g. posterior urethral valves, neuropathic bladder, vesicoureteric reflux)
  • Recurrent UTIs

Other outpatient management options for children include topical steroids for four weeks.


Complications

Complications of phimosis include:

  • Paraphimosis: if the foreskin is retracted and unable to return to the anatomical position
  • Recurrent balanitis, balanoposthitisΒ 

There is a higher risk of penile squamous cell carcinoma in uncircumcised males due to a higher incidence of inflammatory episodes to the glans/prepuce.1,4


Reviewer

Miss Hannah Wells

Consultant Urologist


Editor

Hannah Thomas


References

  1. RΓΌbben I, RΓΌbben H. Phimose [Phimosis]. Published in 2012. Available from: [LINK]
  2. Yang, C., Liu, X., and Wei, G.H. (2009) Foreskin development in 10 421 Chinese boys aged 0-18 years.World J. Pediatr.5, 312–315
  3. Royal College of Surgeons. Commissioning guide: Foreskin conditions. Published in 2016. Available from: [LINK]
  4. Douglawi A, Masterson TA. Updates on the epidemiology and risk factors for penile cancer. Published in 2017. Available from: [LINK]
  5. Anderson D, Politch JA, Pudney J. HIV infection and immune defense of the penis. Published in 2011. Available from: [LINK]

Β 

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