Catheter-associated meatal pressure injury in men: an unrecognised issue

Author: Linda Nazarko

Abstract

Indwelling urinary catheters are commonly inserted in hospital and an estimated 90 000 people living in the community have indwelling urinary catheters. One complication of urethral catheterisation is meatal pressure injury, also known as iatrogenic hypospadias. Both men and women can suffer a meatal pressure injury, but this article examines why these develop in men and how to prevent, recognise and manage these injuries.
 

Key words

Urethral catheters, meatal pressure injuries, iatrogenic hypospadias
 

Introduction

Most urinary catheters are initially inserted in hospital (Shackley et al, 2017), and a significant number of these (19–40%) are inserted without a robust clinical indication (Zhao et al, 2022). In 2008, an estimated 90 000 people living in the community and 34 500 people living in UK care homes were thought to have long-term indwelling urinary catheters (Gage et al, 2017). The main risks of long-term catheterisation include reduction in bladder capacity, infection, pain, bladder stones, kidney damage, tissue damage, hospital attendances associated with blockage and decreased mobility (Feneley et al, 2015; Public Health England, 2016; Gage et al, 2024). Catheter-induced erosion of the urethra and penile skin is rare and there is little awareness of it in the literature (Jindal et al, 2012; Bhat et al, 2020).

Staff may be unaware that catheter-associated meatal injuries can develop and lack the knowledge to identify such injuries. As such, they are unrecognised and under-treated (Munien et al, 2024). Garg and colleagues (2016) commented that clinicians will not identify such injuries unless they look for them. Shenhar and colleagues’ (2020) study of 168 hospitalised men who had indwelling urinary catheters found that 36% of them had developed pressure injuries. Munien and colleagues (2024) studied 169 men who had a catheter in place for at least 4 weeks and found that 10% had pressure injuries.
 

Case history

Mr Evans[1], an 85-year-old man, was admitted to hospital from home with pneumonia. Mr Evans had a history of stroke, elevated cholesterol levels, vascular dementia and chronic kidney disease. He lived at home with his wife and had a four-times-a-day package of care and support. Mr Evans had his catheter changed by the community nurse every 12 weeks, and no problems had been reported with the catheter.

On admission Mr Evans’ catheter blocked and he was checked by a registered nurse. He was noted to have erosion to the middle third of the penile shaft – a grade 3 catheter-associated meatal injury (Figure 1). Mr Evans’ dementia was moderately severe, so he was unable to tell staff how long he had had this problem for.

He was seen urgently by urology, the urethral catheter removed, and a suprapubic catheter inserted. Mr Evans lacked capacity to consent to surgical repair of his urethra, but the consultant urologist believed that Mr Evans was at high risk of infection if such repair was not carried out. Mr Evans’ wife and family agreed that surgery was the best option, a best interests meeting took place, and it was decided to proceed with surgery. It was unclear why Mr Evans had originally been catheterised.

About 4 months after the surgery, a trial without catheter was carried out and Mr Evans was able to empty his bladder fully.

Figure 1. Erosion to middle third of the penile shaft – a grade 3 catheter-associated meatal injury.
 


 

What are meatal injuries?

A number of different terms are used to describe meatal injuries, including iatrogenic hypospadias, penile cleft, ulceration of penis, broken urethra and penile erosion (Thakkar et al, 2022). Iatrogenic hypospadias is described as a preventable injury to the ventral male urethra, produced by the downward pressure of an indwelling urethral catheter (Andrews et al, 1998).

Becker and colleagues (2018) classified iatrogenic hypospadias into four types. Munien and colleagues (2024) built on this and other work, including that of Shenhar et al (2020), to develop one term – catheter-associated meatal injuries – and a grading system for both male and female pressure injuries.

Male catheter-associated meatal injuries are divided into four grades, defined by the most proximal anatomical extent of the pressure injury (Figure 2).
 

Figure 2. Classification of catheter-associated meatal injuries. Based on Munien et al (2024).


 

Risk factors

Frail older men are most likely to develop a catheter-associated meatal injury. Men who developed a catheter-associated meatal injury had poor mobility, and many had cardiac failure. The longer an indwelling urethral catheter was in place the more likely the man was to develop an injury (Shenhar et al, 2020; Munien et al, 2024). Men who have impaired sensation as a result of neurological or other diseases and those who have impaired cognition are at increased risk of catheter-associated meatal injury as they are either unable to feel or unable to interpret pain associated with tissue damage. Urinary catheters that are not properly secured and fixed increase the risk of tissue damage (Cipa-Tatum et al, 2011).

Table 1 illustrates the risks and what can be done to reduce them.
 

Table 1. Identifying and reducing the risk factors for developing catheter-associated meatal injury

Risk factor	Action
Prolonged catheterisation	Avoid catheterisation Remove indwelling urinary catheter if possible
Use of a large catheter (increases pressure on tissues)	Use smallest possible catheter if catheter is necessary
Use of large catheter bags, e.g. 1 litre leg bag (increases traction on meatal tissue and can cause tissue damage)	Use catheter valves if possible Use small, 500 ml urine bags and empty when they are two thirds full
Improperly secured catheter leg bags (increases traction on meatal tissue)	Ensure two straps are used to secure leg bags Ensure straps are properly applied
Improperly secured night drainage bags (increases traction on meatal tissue)	Ensure catheter stand is used and the bag is properly secured
Lack of fixation (catheter can be tugged causing damage to delicate meatal tissue)	Use fixation device

Preventing catheter-associated meatal injury

Catheter-associated meatal injury is thought to be preventable and so its development is an indicator of poor-quality care (Gokhan et al, 2007).

Providing routine high-quality care can reduce the risks of catheter-associated meatal injury and early identification of tissue damage can prevent the progression of tissue damage, pain and complications.
Long-term urethral catheterisation can cause harm and affect health and wellbeing. Complications of indwelling urinary catheters cost the NHS between £1.0 billion and £2.5 billion and account for 2100 deaths per year (Feneley et al, 2015). Around 50–70% of people with long-term catheters experience problems such as bladder pain, catheter leakage, blockage and urinary tract infection (Youssef et al, 2023). Prolonged urethral catheterisation is a major risk factor for catheter-associated meatal injury (Shenhar et al, 2020; Munien et al, 2024). Inappropriate urinary catheterisation is common – 19–40% are inserted without a robust clinical indication (Zhao et al, 2022). Avoiding unnecessary catheterisation and removing indwelling catheters when they are no longer clinically indicated is vitally important.
 

Catheter characteristics

Large catheters can increase the risk of tissue damage. Catheter size is measured using the Charriere scale which grades the outer circumference of the catheter. It is important to select the smallest possible catheter to minimise urethral dilation — a size 12 or 14 French gauge is normally suitable. Using the smallest possible catheter reduces the risks of trauma, bladder spasm and leakage (Reid et al, 2021).

There is limited evidence about whether silicone, coated latex or hydrogel coated silicone catheters are most suitable for long-term use (Reid et al, 2021). A Cochrane review concluded that it was not possible to recommend any particular type of catheter material, although the authors commented that there was limited evidence that hydrogel-coated catheters were better tolerated in men (Jahn et al, 2012).

Most men who require long-term catheters are older men, some of whom may have problems with mobility, dexterity, bladder sensation or cognition. The decision about the type of bladder drainage required should be based on an assessment of the man’s physical and cognitive abilities and the level of care and assistance available.
 
Catheter valves reduce tissue trauma and damage (Simpson, 2017; Tremayne, 2020). A reasonable bladder capacity is required if the person is to use a catheter valve. If bladder capacity is low, for example less than 350-400ml, the person may leak urine. Catheter valves are not normally used if a person does not have bladder sensation because the person may forget to empty the bladder. If the bladder becomes overfull this can cause backflow of urine to the kidneys and renal damage. It is important to check that the individual is able to use the valve to empty the catheter and if the person wishes to have a valve. 

Leg bags are normally used for people who are up and about during the day (Figure 3). They are strapped to the leg using two straps. Leg bags are available in three sizes: 350 ml, 500 ml and 750 ml. Sometimes caregivers or men with catheters ask for the 750 ml capacity bag because it will need emptying less often. However, in this situation, bigger is not better. The greater the capacity of the leg bag the more pressure it is likely to place on delicate tissues as it fills up, especially if the bag is not well supported. Generally a 500 ml capacity bag is suitable, and this should be emptied when it is two thirds full.

At night the leg bag is attached to a night drainage bag. This enables the person to have a good night’s sleep without having to wake to empty the catheter bag. If a person is bed bound or is only able to sit out in a chair, a night drainage bag is normally used to collect urine.

Figure 3. Leg bag attached to a urethral catheter.

It is important to ensure that catheter drainage bags are properly supported: night drainage bags should be supported on a catheter stand, while leg bags should be supported with two straps of a sleeve. Inadequate support can lead to traction on the catheter which can cause tissue damage. Fixing or securing urinary catheters helps prevent trauma and tissue damage. Yates (2018) outlines the advantages and disadvantages of different devices for individuals. Cipa-Tatum and colleagues (2011) described a case of a 63-year-old man who was admitted with a grade 4 catheter-associated meatal injury. The authors then audited practice in their 100-bed hospital and found that 34 people had indwelling urethral catheters but only 18 of those catheters were secured with a fixation device. They commented that there was a low level of compliance with this easy and effective practice, concluding that ‘negative outcomes associated with urethral and meatal erosions can be prevented by properly securing the indwelling catheter’.
 

Treatment of catheter-associated meatal injury

Whenever possible the man who has developed a catheter-associated meatal injury should be managed without a urinary catheter. If this is not possible a suprapubic catheter is often used. Conservative methods are used if tissue damage is confined to the meatus. If there is more severe damage, reconstructive surgery is carried out unless the man is too frail or declines surgery (Andrews et al, 1998; Bhat et al, 2020).
 

Discussion

Indwelling urinary catheters may be inserted routinely in hospital without a proper appreciation of how this catheter might impact on a person’s life. Indwelling urinary catheters can be forgotten and long-term catheters can lead to tissue damage in vulnerable older men. This may cause pain and discomfort, increase anxiety and make a person fearful of moving around.
People living at home or in care homes are often cared for by healthcare assistants, who may have had little education about how to care for people with indwelling catheters. Clinicians and healthcare assistants may be unaware of catheter-associated meatal injury and as a result this may be under-recognised and undertreated.
We need to educate caregivers, nursing and medical staff to think holistically and to understand the potential impact of procedures such as urinary catheterisation which are often considered to be simple. We also need to raise awareness of catheter-associated meatal injury so that it can, whenever possible, be prevented, and be promptly treated when it occurs.  
 

Key points

• Over 124 000 people living in community settings have indwelling urinary catheters, and 19–40% of these have been inserted without a robust clinical indication.
• Around 50–70% of people with long-term catheters experience complications including pain and blockage.
• Evidence suggests that careful catheter care can reduce the risks of tissue damage.
• Caregivers and clinicians may be unable to recognise catheter-associated meatal injury, so improved education is essential.

References

Andrews HO, Nauth-Misir R, Shah PJ (1998) Iatrogenic hypospadias--a preventable injury? Spinal Cord. 36(3):177-80. doi: 10.1038/sj.sc.3100508

Becker B, Witte M, Gross AJ, Netsch C (2018) Iatrogenic hypospadias classification: A new way to classify hypospadias caused by long-term catheterization. Int J Urol. 25:980-981. doi: 10.1111/iju.13791

Bhat AL, Bhat M, Khandelwal N et al (2020) Catheter-induced urethral injury and tubularized urethral plate urethroplasty in such iatrogenic hypospadias. Afr J Urol. 26:17. doi: 10.1186/s12301-020-00030-z

Cipa-Tatum J, Kelly-Signs M, Afsari K (2011) Urethral erosion: a case for prevention. J Wound Ostomy Continence Nurs. 38(5):581–583. doi: 10.1097/WON.0b013e31822b3280

Feneley RC, Hopley IB, Wells PN (2015) Urinary catheters: history, current status, adverse events and research agenda. J Med Eng Technol. 39(8):459-70. doi: 10.3109/03091902.2015.1085600

Gage H, Avery M, Flannery C, Williams P, Fader M (2017) Community prevalence of long-term urinary catheters use in England. Neurourol Urodyn. 36(2):293-296. doi: 10.1002/nau.22961

Gage H, Williams P, Avery M, Murphy C, Fader M (2024) Long-term catheter management in the community: a population-based analysis of user characteristics, service utilisation and costs in England. Prim Health Care Res Dev. 25:e13. doi: 10.1017/S1463423624000021

Garg G, Baghele V, Chawla N, Gogia A, Kakar A (2016) Unusual complication of prolonged indwelling urinary catheter - iatrogenic hypospadias. J Family Med Prim Care. 5(2):493-494. doi: 10.4103/2249-4863.192335

Gokhan G, Kahraman T, Kemal K, Semih A (2006) Complete tear of ventral penile skin and penile urethra: a rare infective complication of chronic urethral catheterization. Int Urol Nephrol. 38(3-4):613-4. doi: 10.1007/s11255-006-6674-3

Jahn P, Beutner K, Langer G (2012) Types of indwelling urinary catheters for long-term bladder drainage in adults. Cochrane Database Syst Rev. 10(10):CD004997. doi: 10.1002/14651858.CD004997.pub3

Jindal T, Kamal MR, Mandal SN, Karmakar D (2012) Catheter-induced urethral erosion. Urol Nurs. 32(2):100-101

Munien K, Ravichandran K, Flynn H, Shugg N, Flynn D, Chambers J, Desai D (2024) Catheter-associated meatal pressure injuries (CAMPI) in patients with long-term urethral catheters-a cross-sectional study of 200 patients. Transl Androl Urol. 13(1):42-52. doi: 10.21037/tau-23-445

Public Health England (2016) English surveillance programme for antimicrobial utilisation and resistance (ESPAUR). Annual Report 2016. Public Health England, London

Reid S, Brocksom J, Hamid R et al (2021) British Association of Urological Surgeons (BAUS) and Nurses (BAUN) consensus document: management of the complications of long-term indwelling catheters. BJU Int. 128(6):667-677. doi: 10.1111/bju.15406

Shackley DC, Whytock C, Parry G et al (2017) Variation in the prevalence of urinary catheters: a profile of National Health Service patients in England. BMJ Open. 7(6):e013842. doi: 10.1136/bmjopen-2016-013842

Shenhar C, Mansvetov M, Baniel J, Golan S, Aharony S (2020) Catheter-associated meatal pressure injury in hospitalized males. Neurourol Urodyn. 39(5):1456-1463. doi: 10.1002/nau.24372

Simpson P (2017) Long-term urethral catheterisation: guidelines for community nurses. Br J Nurs. 26(9):S22-S26. doi: 10.12968/bjon.2017.26.9.S22

Thakkar Y, Saha S, Singhal M, Agarwal A (2022) Iatrogenic hypospadias: a curse of the care. Clin Surg. 7:3567

Tremayne P (2020). Managing complications associated with the use of indwelling urinary catheters. Nurs Stand. 35(11):37-42. doi: 10.7748/ns.2020.e11599

Yates A (2018) Catheter securing and fixation devices: their role in preventing complications. Br J Nurs. 27(6):290-294. doi: 10.12968/bjon.2018.27.6.290

Youssef N, Shepherd A, Best C et al (2023) The quality of life of patients living with a urinary catheter and its associated factors: a cross-sectional study in Egypt. Healthcare (Basel). 11(16):2266. doi: 10.3390/healthcare11162266

Zhao T, Du G, Zhou X (2022) Inappropriate urinary catheterisation: a review of the prevalence, risk factors and measures to reduce incidence. Br J Nurs. 31(9):S4-S13. doi: 10.12968/bjon.2022.31.9.S4