A male tetraplegic patient attended accident and emergency with a blocked
catheter; on removing the
catheter, he passed bloody urine. After three unsuccessful attempts were made to insert a
catheter by nursing staff, a junior doctor inserted a three-way Foley
catheter with a 30-mL balloon but inflated the balloon with 10 mL of water to commence the bladder irrigation. The
creatinine level was mostly 19 µmol/L (range: 0-135 µmol/L) but increased to 46 µmol/L on day 7. Computerized tomography urogram revealed that the bilateral
hydronephrosis with hydroureter was extended down to urinary bladder, the bladder was distended, prostatic urethra was dilated and filled with urine, and although the balloon of Foley
catheter was not seen in the bladder, the tip of the
catheter was seen lying in the urethra. Following the re-catheterization, the
creatinine level decreased to 21 µmol/L. A follow-up ultrasound scan revealed no evidence of
hydronephrosis in both kidneys. Flexible cystoscopy revealed inflamed bladder mucosa,
catheter reaction, and tiny stones. There was no
bladder tumor. This case report concludes that the cause of bilateral
hydronephrosis, hydroureter, and distended bladder was inadequate drainage of urinary bladder as the Foley balloon that was under-filled slipped into the urethra resulting in an obstruction to urine flow. Urethral catheterization in tetraplegic patients should be performed by senior, experienced staff in order to avoid
trauma and incorrect positioning. Tetraplegic subjects with decreased muscle mass have low
creatinine level. Increase in
creatinine level (>1.5 times the basal level) indicates
acute kidney injury, although peak
creatinine level may still be within laboratory reference range. While scanning the urinary tract of
spinal cord injury patients with indwelling
urinary catheter, if Foley balloon is not seen within the bladder, urethra should be scanned to locate the Foley balloon.