Bakul M Soni

EK Spees

JP Hughes

MJ Farraye

Paul Mansour

Peter L Hughes

Subramanian Vaidyanathan

English

PubMed

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Burrowing of urinary bladder wall by the tip of a size 22 Fr silicone foley catheter in an adult male patient with multiple sclerosis and suprapubic cystostomy: should caution be exercised in using a size 22 Fr silicone foley catheter for long-term drainage of neuropathic bladder?

BioMed CentralCases Journal
ssOpen AcceCase Report
Burrowing of urinary bladder wall by the tip of a size 22 Fr silicone 
foley catheter in an adult male patient with multiple sclerosis and 
suprapubic cystostomy: should caution be exercised in using a size 
22 Fr silicone foley catheter for long-term drainage of neuropathic 
bladder?
Subramanian Vaidyanathan*1, Peter L Hughes2, Paul Mansour3 and 
Bakul M Soni1
Address: 1Regional Spinal Injuries Centre, District General Hospital, Southport, PR8 6PN, UK, 2Department of Radiology, District General 
Hospital, Southport, PR8 6PN, UK and 3Department of Cellular Pathology, District General Hospital, Southport, PR8 6PN, UK
Email: Subramanian Vaidyanathan* - S.Vaidyanathan@southportandormskirk.nhs.uk; 
Peter L Hughes - Peter.Hughes@southportandormskirk.nhs.uk; Paul Mansour - Paul.Mansour@southportandormskirk.nhs.uk; 
Bakul M Soni - Bakul.Soni@southportandormskirk.nhs.uk
* Corresponding author    
Abstract
Introduction: Silicone Foley catheters tend to become stiffer as size of the catheter increases. Whereas
the tip of a size 12 French silicone, Foley catheter is soft and flexible, a size 24 French silicone, Foley
catheter is distinctly stiff. Chronically inflamed neuropathic bladders are susceptible to perforation by the
tip of a Foley catheter. We report a patient with multiple sclerosis and moderately severe chronic cystitis,
in whom a size 22 French Foley catheter burrowed through the dome of urinary bladder.
Case presentation: A 55-year-old, Caucasian male suffering from multiple sclerosis underwent
suprapubic cystostomy in January 2007. Initially, a size 16 Fr. silicone, Foley, catheter was inserted. During
subsequent catheter changes, silicone Foley catheters of progressively increasing sizes were inserted and
in July 2007, a size 22 Fr. catheter was used in order to prevent blockages and consequent bypassing of
urine. In April 2008, he had an uneventful change of suprapubic catheter; but a week later, this patient
developed profuse bypassing. On examination, suprapubic catheter contained fresh blood; there was
hardly any urine in the leg bag, which was attached to suprapubic catheter. Cystogram showed localised
extravasation of contrast on the superior aspect of urinary bladder around the tip of Foley catheter, which
protruded beyond the dome of urinary bladder. The size 22 Fr. catheter was removed and a size 20 Fr
silicone, Foley, catheter was inserted ensuring that the tip of catheter pointed towards bladder neck. This
patient received gentamicin intravenously and he was prescribed ciprofloxacin for five days. He did not
develop temperature or other features of sepsis. Bypassing stopped completely.
Conclusion: In this patient, bladder biopsy had shown moderately severe chronic inflammation and
congestion. We learn from this case that we should have used a smaller size catheter, which has a softer
texture and changed the catheter at shorter intervals rather than insert a larger bore catheter, and run
the risk of perforation of neuropathic bladder by the tip of a stiff Foley catheter.
Published: 8 July 2008
Cases Journal 2008, 1:25 doi:10.1186/1757-1626-1-25
Received: 18 June 2008
Accepted: 8 July 2008
This article is available from: http://www.casesjournal.com/content/1/1/25
© 2008 Vaidyanathan et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
Cases Journal 2008, 1:25 http://www.casesjournal.com/content/1/1/25Introduction
Rupture of the bladder in persons with multiple sclerosis
can result from a combination of several factors. Outflow
obstruction from neurogenic sphincter disturbance,
chronic bladder infection, direct mechanical trauma from
an indwelling catheter, and potentiation of infection by
corticotrophin may all play a part. Harding and associates
reported bladder rupture in two patients with multiple
sclerosis and both patients had chronically inflamed blad-
ders [1].
Perforation of the urinary bladder associated with long-
term indwelling catheter is a rare and lethal iatrogenic dis-
order. Hughes and associates [2] reported an 80-year-old-
white man, who had Foley catheter drainage of urinary
bladder for more than five years; in this patient, the tip of
Foley catheter eroded through the dome of the bladder.
Pressure necrosis from contraction of urinary bladder on
catheter tip is believed to be the pathogenesis for erosion
of bladder by the tip of a Foley catheter [3]. Spees and
associates [4] reported three unusual situations of bladder
perforation in patients who had a history of long-term uri-
nary bladder catheterization: one in which a fibroid
uterus probably played a role in pressure necrosis of a
bladder with an indwelling catheter, one in which carci-
noma of the prostate and faulty catheter drainage was
present, and one in which pelvic radiation therapy was
followed by bladder perforation. Neuropathic bladder
with chronically inflamed bladder wall is another situa-
tion where the tip of long-dwelling catheter can erode into
the bladder wall. We report a patient with multiple sclero-
sis and moderate active chronic inflammation of vesical
mucosa, in whom the tip of a size 22 French silicone,
Foley catheter burrowed through bladder wall.
Case Report
A Caucasian male, born in 1953, was diagnosed to be suf-
fering from multiple sclerosis in 1992. He was doing inter-
mittent catheterisation about four times a day and wore a
penile sheath during night. But penile sheath would not
stay and he would wet himself, which resulted in macera-
tion of skin over penis, scrotum and buttocks. He was pre-
scribed tolterodine, which made quite a significant
improvement. However, in August 2002, he started using
indwelling urethral catheter. He experienced no trouble
with urine leakage but urethral catheter interfered with his
sexual activity. Flexible cystoscopy showed a contracted
bladder with reddened areas. In March 2003, biopsies
were taken from these areas. Histology showed benign
transitional epithelium and moderately severe chronic
inflammation and congestion. (Figure 1)
In November 2006, he was found to have urethral split
due to the indwelling urethral catheter. Therefore,
suprapubic cystostomy was performed in January 2007.
Initially, a size 16 Fr. Foley, silicone catheter was inserted
for suprapubic drainage. In March 2007, the size of
suprapubic catheter was increased to size 18 Fr. A size 20
Fr. silicone Foley catheter was inserted in May 2007, fol-
lowed by a size 22 Fr. silicone Foley catheter in July 2007.
Subsequently, suprapubic Foley catheter was changed
after intervals of eight weeks, six weeks, four weeks, six
weeks, six weeks, four weeks, six weeks, and then three
weeks. He used to pass lot of sediments in urine and there-
fore, the catheter was changed at frequent intervals in
order to prevent blockage of catheter and consequent
bypassing of urine. He had very vulnerable skin over gen-
italia and any bypassing of urine could lead to maceration
of skin over penis, scrotum and perineum.
The last catheter change was performed on 21 April 2008
when no difficulty was observed either during removal of
old catheter or insertion of a new Foley catheter. There
was no bleeding, and clear urine drained through
suprapubic catheter while the patient was being observed
in the hospital for 30 minutes after change of suprapubic
cystostomy. A week later, the patient rang spinal unit to
say that he was constantly wet, as most of times, he passed
urine per urethra. Urine, which he drained through penis,
was clear; there was no blood. He was advised to take
modified-release oxybutynin 10 mg once daily on the
assumption that he had bladder spasms. X-ray of urinary
bladder was scheduled to look for vesical calculus, and
cystogram was organised to check position of Foley cath-
eter.
Four days later, the patient was examined prior to radio-
logical studies. He was found to be wet from below.
Suprapubic catheter contained fresh blood. There was
Microphotograph of bladder biopsy shows moderately severe chr nic inflammation and congestionFigure 1
Microphotograph of bladder biopsy shows moderately 
severe chronic inflammation and congestion.Page 2 of 4
(page number not for citation purposes)
Cases Journal 2008, 1:25 http://www.casesjournal.com/content/1/1/25hardly any urine in the leg bag, which was attached to
suprapubic catheter. Following injection of 20 ml of Opti-
ray 300 through suprapubic catheter, X-ray was taken.
[Each millilitre of OPTIRAY 300 (ioversol injection 64%)
contains 636 mg of ioversol with 3.6 mg of tromethamine
as a buffer and 0.2 mg of edetate calcium disodium as a
stabilizer. OPTIRAY 300 provides 30% (300 mg/mL)
organically bound iodine.]
Cystogram showed that the tip of Foley catheter had pro-
truded beyond the dome of urinary bladder. (Figure 2)
There was suspicion of extravasation of small amount of
contrast around the tip of Foley catheter. Another 20 ml of
Optiray 300 was injected and X-ray was taken. This X-ray
clearly showed localised extravasation of contrast on the
superior aspect of urinary bladder around the tip of Foley
catheter. (Figure 3)
The size 22 French, silicone, Foley catheter was removed.
A size 20 Fr. silicone, Foley catheter was inserted and it
was ensured that the tip of Foley catheter pointed inferi-
orly towards the scrotum. This patient was given gen-
tamicin 160 mg intravenously and was advised to take by
mouth ciprofloxacin 500 mg twice a day for five days. He
did not develop temperature. The size 20 French, Foley
catheter continued to drain urine satisfactorily; he experi-
enced no further bypassing.
Discussion
Silicone Foley catheters tend to become stiffer as size of
the catheter increases. Whereas the tip of a size 12 Fr. sili-
cone, Foley catheter is very soft and flexible, a size 24 Fr.
silicone, Foley catheter is distinctly stiff. In our enthusi-
asm to prevent blockages and consequent bypassing of
urine, we used a size 22 Fr. Foley, silicone, catheter, which
burrowed through the dome of bladder.
The spectrum of inflammatory changes seen in the
mucosa of neuropathic bladder appears to be related to
the presence or absence of long-term indwelling catheters.
The degree and extent of inflammatory changes in the
bladder mucosa of patients with spinal cord injury, who
have been practising intermittent catheterisation, are
markedly less, as compared to the biopsies taken from the
Following injection of 20 ml of Optiray 300 through suprapu-bic catheter, X-ray was takenigure 2
Following injection of 20 ml of Optiray 300 through suprapu-
bic catheter, X-ray was taken. Cystogram showed that the 
tip of size 22 French Foley catheter had protruded beyond 
the dome of urinary bladder. There was suspicion of extrava-
sation of small amount of contrast around the tip of Foley 
catheter.
Another 20 ml of Optiray 300 was injected and X-ray was takenFigur  3
Another 20 ml of Optiray 300 was injected and X-ray was 
taken. This X-ray clearly demonstrated localised extravasa-
tion of contrast on the superior aspect of urinary bladder 
around the tip of Foley catheter.Page 3 of 4
(page number not for citation purposes)
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neuropathic bladder of spinal cord injury patients with
long-term indwelling catheters [5]. As neuropathic blad-
ders in persons with long-term indwelling catheter show
moderate to severe, acute and chronic inflammatory
changes in vesical mucosa, it is likely that spinal cord
injury patients or those with multiple sclerosis, who
require long-term indwelling catheter drainage, are prob-
ably more susceptible to develop erosion of urinary blad-
der by the tip of a stiff Foley catheter than able-bodied
individuals with healthy bladder, who generally require
indwelling catheters only for a short duration.
In hindsight, we realise that we should have been prudent.
We should have used a smaller size Foley catheter and
changed the catheter at shorter intervals rather than insert-
ing a larger bore catheter and running the risk of perfora-
tion of neuropathic bladder by the tip of a stiff Foley
catheter.
Conclusion
As neuropathic bladders in persons with long-term ind-
welling catheter show moderate to severe, acute and
chronic inflammatory changes in vesical mucosa, it is
likely that spinal cord injury patients or those with multi-
ple sclerosis, who require long-term indwelling catheter
drainage, are at risk of developing perforation of urinary
bladder by the tip of a stiff Foley catheter. In hindsight, we
learn that we should have used a smaller size catheter,
which has a softer texture and changed the catheter at
shorter intervals rather than insert a larger bore catheter,
which is stiff, and run the risk of erosion of neuropathic
bladder by the tip of a stiff Foley catheter.
Patient's perspective
It is more comfortable not to be wet in myself. After the
last change of suprapubic catheter, the size 22, silicone
catheter worked for a short period. But within a week, I
was bypassing. After insertion of a size 20 French, cathe-
ter, I am lot more confident; it seems to drain better. I do
not have bypassing.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
SV suspected problem with suprapubic catheter and per-
formed cystography. PM interpreted bladder biopsy
slides. All authors contributed to the manuscript and
approved the final version.
References
1. Harding AE, Scott J, Jefferson M: Bladder rupture in multiple
sclerosis.  Br Med J 1(6056):270. 1977 January 29;
2. Hughes JP, Gambee J, Edwards C: Perforation of the bladder: a
complication of long-dwelling Foley catheter.  J Urol 1973,
109:237.
3. Farraye MJ, Seaberg D: Indwelling foley catheter causing extra-
peritoneal bladder perforation.  Am J Emerg Med 2000,
18:497-500.
4. Spees EK, O'Mara C, Murphy JB, Michigan S, Newton CG: Unsus-
pected intraperitoneal perforation of the urinary bladder as
an iatrogenic disorder.  Surgery 1981, 89:224-31.
5. Vaidyanathan S, Mansour P, Soni BM, Singh G, Sett P: The method
of bladder drainage in spinal cord injury patients may influ-
ence the histological changes in the mucosa of neuropathic
bladder – a hypothesis.  BMC Urol 2:5. 2002 Apr 30;Page 4 of 4
(page number not for citation purposes)


Crossref

Bladder rupture in multiple sclerosis.

CG: Unsuspected intraperitoneal perforation of the urinary bladder as an iatrogenic disorder. Surgery

Perforation of the bladder: a complication of long-dwelling Foley catheter.

Seaberg D: Indwelling foley catheter causing extraperitoneal bladder perforation.

Sett P: The method of bladder drainage in spinal cord injury patients may influence the histological changes in the mucosa of neuropathic bladder – a hypothesis.

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Burrowing of urinary bladder wall by the tip of a size 22 Fr silicone foley catheter in an adult male patient with multiple sclerosis and suprapubic cystostomy: should caution be exercised in using a size 22 Fr silicone foley catheter for long-term drainage of neuropathic bladder?

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