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Case Report
Urethral Complications of Urinary
Catheterization Presenting as Primary
Scrotal Masses: Sonographic Diagnosis
H. Richard Parvey, MD, Bhargavi K. Patel, MD
Department of Radiology, Veterans Administration Medical Center, 915 North Grand Boulevard, 114-JC,
St. Louis, Missouri 63106
Received 15 July 1997; accepted 29 October 1997
ABSTRACT: We report on 2 debilitated male patients
who had penile urethral complications of transurethral catheter drainage. One patient had a urethral diverticulum, and the other had a Foley catheter misplaced through a urethral perforation. Both lesions
mimicked primary intrascrotal masses on physical examination and were therefore evaluated by scrotal sonography. The correct diagnosis of each lesion required careful examination of the mass and its
anatomic relationship to the adjacent urethra. Penile
urethral complications of catheterization in debilitated
patients must be included in the differential diagnosis
of scrotal cystic masses. These cases also emphasize
the necessity of a thorough sonographic examination
that extends beyond the specific area of presumed
clinical interest. © 1998 John Wiley & Sons, Inc.* J
Clin Ultrasound 26:261–264, 1998.
Keywords: scrotum; urethra; urinary catheterization;
diagnostic pitfalls; ultrasonography
crotal sonography is an established method
for evaluating abnormalities that arise in the
testis or epididymis. Adjacent extrascrotal lesions, such as urethral abscesses or diverticula,
may extend across fascial planes1 and also present as scrotal lesions.2 Consequently, the correct
nature and origin of such an abnormality may not
be recognized. We describe 2 patients in whom
urethral lesions initially appeared to lie in the
scrotum on both clinical and sonographic examinations.
Correspondence to: H. R. Parvey
*This article is a U.S. Government work and, as such, is in the
public domain in the United States of America.
© 1998 John Wiley & Sons, Inc.
VOL. 26, NO. 5, JUNE 1998
CCC 0091-2751/98/050261-04
A 45-year-old man had undergone multiple urethral catheterizations since becoming a paraplegic after a gunshot wound 18 years earlier. He
was admitted to the hospital because of fever,
lower abdominal pain, and scrotal enlargement
that continued over several weeks despite oral antibiotic therapy. A urine culture done 3 weeks earlier grew Citrobacter freundii. On admission, the
patient had an external condom catheter, scrotal
erythema, and a tender and enlarged right hemiscrotum. There was no perineal mass, tenderness,
or fluctuation. A repeat urine culture showed no
bacterial or other growth. The patient was given
intravenous antibiotics for a presumed urinary
tract infection, and 5 days later, a right hydrocele
was drained. However, he suffered continued
postoperative fever, leukocytosis, and scrotal pain
and swelling. On reexamination, the phallus was
normal, but there was still marked right hemiscrotal enlargement and tenderness. Scrotal sonography was then performed to rule out a residual hydrocele or abscess. Sonography showed a
large complex cystic mass immediately above the
left testis (Figure 1A). Closer examination, however, revealed that this mass extended directly
from the bulbous penile urethra (Figure 1B and
C). A subsequent retrograde urethrogram showed
extension of contrast medium into a lobulated
spherical diverticulum arising from the bulbous
urethra; no other extravasation was observed.
Cystoscopy showed moderate trabeculation of the
bladder and dilatation of the bulbar and midpenile urethra but failed to identify the neck of the
diverticulum clearly.
FIGURE 1. Posterior penile urethral diverticulum. (A) Longitudinal sonogram shows a cystic mass (M) superior to the left testis (T) and the head
of the left epididymis (white arrow). (B) Transverse sonogram near the base of the penis shows a narrow channel (black arrows) extending directly
from the cystic mass (M) into the bulbous penile urethra (u). (C) Transverse sonogram proximal to the area shown in B shows that the urethra (u)
adjacent to the entrance of the channel is dilated. The white arrows indicate the corpora cavernosa of the penis.
A 58-year-old man was transferred from a nursing facility because of fever and a supposed urinary tract infection that was unresponsive to parenteral antibiotics. He had undergone multiple
urinary catheterizations since becoming a quadriparetic after a motor vehicle accident several
years earlier. On admission of the patient to the
hospital, his scrotum was enlarged and erythematous and contained a firm, tender mass near the
base of the penis. A Foley urethral catheter was
inserted without difficulty and yielded cloudy
malodorous fluid. A urine culture revealed a
heavy growth of Escherichia coli. Sonography directed to the apparent scrotal mass showed a
round hypoechoic lesion near the upper pole of the
left testis (Figure 2A). On closer inspection, this
hypoechoic mass was seen to be the balloon tip of
the Foley catheter outside of the adjacent penile
urethra (Figure 2B). The catheter was then withdrawn and the patient sent to surgery. At surgery, a periurethral abscess near the penoscrotal
junction was evacuated, a perforation of the adjacent urethra was debrided, and a permanent suprapubic catheter was inserted.
Scrotal sonography is typically directed to lesions
in or near the testis or epididymis. However, primary extrascrotal lesions may also extend into,
and present within, the scrotum on clinical and
sonographic examinations.2 Among the more important of these extrascrotal lesions are bulbar
urethral abnormalities that complicate urinary
Debilitated or paralyzed male patients often
undergo long-term or intermittent transurethral
bladder catheterization to treat urinary inconti-
nence, to maintain adequate bladder function,
and to minimize residual urine volume.3,4 Unfortunately, the catheter tip may be misplaced into
the urethra or periurethral tissues.4 Moreover,
trauma or infection induced by the catheter may
disrupt the urethral wall and lead to urethral perforation, urethral stricture, urinary fistula/false
passage, periurethral abscess, urethral diverticulum, or scrotal gangrene.3–7 An imaging diagnosis
is important because the symptoms these complications produce (eg, pain, swelling, and fever)
may not be evident in a debilitated or paralyzed
patient with a concurrent renal infection or sacral
decubitus ulcer.13 Transabdominal, transperineal, or transrectal sonography and direct sonography of the penis have been used to diagnose
urethral diverticula,8,9 false passages,10 and misplaced Foley catheter tips.11–13 However, the lesions in our patients were diagnosed on sonographic examinations that were initially
requested for, and directed to, the scrotum. One
patient had a urethral diverticulum that, interestingly, eluded cystoscopic detection. The other
patient had a catheter misplaced through a ure-
FIGURE 2. Foley catheter tip misplaced through a urethral perforation. (A) Longitudinal sonogram near the base of the scrotum shows a hypoechoic
mass (M and black arrows) adjacent to the head of the left epididymis (E). The mass has an echogenic proximal wall and shows posterior acoustic
shadowing. (B) Oblique transverse sonogram near area shown in A reveals that the mass (M) is the balloon of a misplaced Foley urethral catheter.
The curved white arrow indicates the catheter tip.
VOL. 26, NO. 5, JUNE 1998
thral perforation. Both lesions extended inferiorly
and clinically simulated primary intrascrotal
Complications of urinary catheterization may
contribute significantly to patient morbidity.5 As
our cases demonstrate, these complications may
initially become evident on sonograms directed to
a presumed lesion of the testis, epididymis, or
spermatic cord. The differential diagnosis of an
apparent scrotal mass in a debilitated patient
with a urinary catheter must therefore include
not only epididymo-orchitis but also urethral perforation, abscess, diverticulum, or misplaced
catheter. The accurate diagnosis of these complications requires a careful sonographic examination beyond the area of presumed clinical interest.
In the appropriate clinical situation, any cystic
extratesticular mass should be evaluated for a
possible connection with the penile urethra.
1. Omo-Dare P: Posterior urethral diverticulum in
the male. Br J Urol 1968;40:445.
2. Garris EM, Jolles PR, Cole TJ: Large urethral diverticulum presenting as a scrotal tracer collection
on renal scintigraphy. Clin Nucl Med 1996;21:661.
3. Pate VA, Bunts RC: Urethral diverticula in paraplegics. J Urol 1951;65:108.
4. Cancio LC, Sabanegh ES Jr, Thompson IM: Managing the Foley catheter. Am Fam Physician 1993;
5. Jacobs SC, Kaufman JM: Complications of permanent bladder catheter drainage in spinal cord injury patients. J Urol 1978;119:740.
6. Karim MS: Fournier gangrene following urethral
necrosis by indwelling catheter. Urology 1984;23:
7. Conn IG, Lewi HJ: Fournier’s gangrene of the scrotum following traumatic urethral catheterisation.
J R Coll Surg Edinb 1987;32:182.
8. Kauzlaric D, Barmeir E, Peyer P, et al: Sonographic appearance of urethral diverticulum in the
male. J Ultrasound Med 1988;7:107.
9. Goyal M, Sharma R, Gupta DK, et al: Congenital
anterior urethral diverticulum: sonographic diagnosis. J Clin Ultrasound 1996;24:543.
10. Perkash I, Friedland GW: Ultrasonographic detection of false passages arising from the posterior
urethra in spinal cord injury patients. J Urol 1987;
11. Janus C: Sonographic appearance of the abnormally positioned Foley catheter. J Ultrasound Med
12. Fornage BD: Transrectal ultrasound diagnosis of a
misplaced Foley catheter. J Clin Ultrasound 1986;
13. Williams R, Thomas AM: The missing balloon sign.
Clin Radiol 1987;38:59.
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