醫源性尿管水球位置異常導致腎後急性腎損傷及陰莖壞疽：病例報告及文獻綜述

呂孟軒¹、王紹全^1,2

¹中山醫學大學附設醫院 泌尿科；²中山醫學大學 醫學系

Iatrogenic Intraurethral Balloon Malposition Leading to Post-renal Acute Kidney Injury and Penile Gangrene: A Case Report and Literature Review

Meng-Hsuan Lu¹, Shao-Chuan Wang^1,2

¹Department of Urology, Chung Shan Medical University Hospital;

²School of Medicine, Chung Shan Medical University

Background: Iatrogenic urethral injury (IUI) from malpositioned Foley catheters is a preventable, potentially lethal complication. While typically associated with strictures, inadvertent balloon inflation within the penile urethra can trigger a catastrophic sequence of post-renal acute kidney injury (AKI) and ischemic penile gangrene. Critically, this case underscores how iatrogenic trauma can serve as the "final insult" in fragile patients, transitioning manageable illness into irreversible multi-organ failure.

Case Presentation: A 62-year-old male with stroke, hypertension, and diabetes was admitted to the ICU for pneumonia. On October 9, the Foley catheter was replaced to monitor urine output. Subsequently, urine output plummeted from 3000 mL/day to near-anuria (5 mL/day) by October 12, coinciding with AKI (creatinine 0.87 to 3.23 mg/dL; eGFR 94.5 to 20.8 mL/min/1.73m²). A palpable penile mass was noted, which resolved upon balloon deflation but recurred following re-inflation; the catheter remained in place. On October 16, urology was consulted; bedside ultrasonography confirmed intraurethral balloon malposition within the penile urethra. Although emergent suprapubic cystostomy restored renal function, the prolonged mechanical compression led to progressive penile erythema and ulcerative necrosis. Due to profound pancytopenia, formal debridement was deferred for a conservative staged strategy. Despite intensive care, the patient succumbed to septic shock and heart failure on October 23.

Discussion: This case illustrates a "dual-insult" mechanism: complete urinary obstruction and mechanical vascular occlusion. A critical diagnostic clue—the "disappearing penile mass" during deflation—was pathognomonic for intraurethral balloon malposition but was misinterpreted. The 4-day diagnostic delay allowed AKI to transition from functional to structural damage. Management of the subsequent gangrene presented a therapeutic conflict; while aggressive necrosectomy is standard for source control, the patient’s pancytopenia necessitated a staged debridement strategy, prioritizing urinary diversion and topical antimicrobials while awaiting hematological stabilization. In vulnerable populations, the window for intervention is exceptionally narrow once ischemia progresses.

Conclusion: Iatrogenic Foley trauma is a significant clinical complication requiring heightened vigilance. Sudden-onset anuria in previously polyuric patients should prompt immediate evaluation for mechanical obstruction or malposition via Point-of-Care Ultrasound (POCUS). Standardized techniques, including confirmation of urine return and early urological involvement, are essential to prevent ischemic necrosis and fatal outcomes in patients with marginal physiological reserve.