Case 1
A 32-year-old gentleman has arrived in the emergency department following a high-speed road traffic collision. Physical examination reveals blood at the urethral meatus with a palpably distended bladder.
Figure 1: © www.nephropocus.com
1a. What does Figure 1 demonstrate?
1b. What are the next steps in the investigation of this patient?
1c. What other pathologies can be identified on a bladder scanner?
Case 2
The patient has failed urethral catheterisation attempts and subsequently undergoes suprapubic catheter (SPC) insertion.
Figure 2: Suprapubic catheter (SPC) set.
2a. What are the contraindications to suprapubic catheter insertion?
2b. Why should caution be used when considering placing an emergency suprapubic catheter in patients with a pelvic fracture?
Case 3
An SPC is inserted, following which the patient describes severe abdominal pain. Contents from the catheter look faeculant. He undergoes emergency imaging, as shown in Figure 3.
Figure 3: [6].
3a. What does Figure 3 demonstrate?
3b. What are the immediate management options for this patient?
3c. Explain the potential long-term sequelae of the events shown in Figure 3.
3d. How can the risk of the events be reduced?
Answers
1a. Figure 1 is an ultrasound image demonstrating a distended urinary bladder with an estimated volume of approximately 831mls.
1b. This clinical presentation is consistent with urethral trauma and concurrent urinary retention. Following initial stabilisation, a single gentle attempt at urethral catheterisation can be tried. Alternatively, retrograde urethrography (RUG) is the recommended first-line investigation in the early evaluation of suspected male urethral injury, according to the European Association of Urology (EAU) Guidelines [1]. The presence of contrast extravasation outside the urethra confirms an injury. Flexible cystoscopy may be used as an alternative, particularly in female patients, due to their shorter urethral length [1,2].
1c. Whilst bladder scanners are sensitive for detecting intra-abdominal fluid, they are not specific for urinary retention. The overall false positive rate of bladder scanning for urinary retention has been reported to be 9%. Reported false positives include ovarian cysts, renal cysts, ascites and even uterine fibroids [3].
2a. Contraindications to SPC insertion include:
- Known bladder cancer or undiagnosed haematuria (to avoid seeding)
- A nondistended bladder (increases the risk of bowel or vascular injury)
- Coagulopathy, bleeding disorders or patients on anticoagulation treatment
- Abdominal wall sepsis or active skin infection overlying the insertion site
- Osteomyelitis of the pubic bone
- Anatomical or pelvic anatomical abnormalities
- Pregnancy
- Ascites or peritoneal dialysis
- Presence of a suprapubic subcutaneous vascular graft (to avoid graft rupture) [4,5].
2b. Pelvic fractures are associated with bladder injury in approximately 3% of cases, rising to 26.5% in severe injuries, with posterior urethral injuries almost exclusively the result of pelvic fractures. In such cases, urinary diversion may be required to monitor urine output, reduce movement, relieve urinary retention and to prevent urinary extravasation. Following pelvic fractures, the bladder may be displaced by a pelvic haematoma or be underfilled due to shock or concomitant injury, both of which significantly increase the risk of iatrogenic injury to adjacent structures during emergency SPC insertion [2].
3a. Figure 3 is an axial view of a CT pelvis which demonstrates a case of a suprapubic catheter inadvertently inserted into the bowel [6]. Historical bowel injury risk reduced to 0.2% (from approximately 2.5%) following guidance published by the British Association of Urological Surgeons (BAUS) [5].
3b. An injury may be suspected when there is failure in draining the bladder, development of peritonitis or the drainage of bowel content via the catheter. If a bowel injury is suspected, the patient should be resuscitated in an A to E fashion, undergo urgent cross-sectional imaging with a contrast CT, and have early involvement of the general surgical team in view of surgical intervention.
3c. Long term sequelae include the development of enterocutaneous fistulae, adhesions with potential small bowel obstruction, stricture formation and other sequelae resulting from surgical intervention.
3d. The risk of bowel injury can be reduced with adequate bladder distention and if possible, placing the patient in the Trendelenburg position. Adequate bladder distention can be confirmed with suprapubic palpation and ultrasound, which also confirms absence of overlying bowel loops [5]. Additionally, identifying those with a higher risk of bowel injury is vital, for example, patients who have undergone previous abdominal surgery resulting in the development of adhesions. In elective settings, SPC can be inserted under direct cystoscopic visualisation or in some cases via open cystotomy.
References
1. Waterloos M, Campos-Juanatey F, Hallscheidt P, et al. EAU Guidelines on Urological Trauma. EAU Guidelines Office 2026.
https://uroweb.org/guidelines/urological-trauma
2. British Association of Urological Surgeons. British Orthopaedic Association Audit standards for Trauma (BOAST) 14: The management of Urological trauma associated with pelvic fractures. BAUS 2016.
www.baus.org.uk/_userfiles/pages/files/Publications/
BOAST%2014%20Urological%20Injuries.pdf
3. Janardanan S, Moussa AE, James P. False positive bladder scan in ascites with anuria. Clin Case Rep 2019;7(8):1549–50.
4. Poulton T, Leslie SW. Suprapubic Bladder Catheterization. Treasure Island (FL): StatPearls Publishing 2025.
www.ncbi.nlm.nih.gov/books/NBK482179
5. Hall SJ, Harrison S, Harding C, et al. British Association of Urological Surgeons suprapubic catheter practice guidelines – revised. BJU Int 2020;126(4):416–22.
6. Barai KP, Islam S. Suprapubic catheterization complicated by an iatrogenic enterocutaneous fistula: a case report. Cases J 2009;2:9311.
[All links last accessed May 2026].
