Meleney's gangrene triggered by suprapubic catheter dislodgment and urine extravasation: A case report and review of management strategies.

Abstract

Background: Necrotizing soft tissue infection represents a spectrum of bacterial infections that result in rapidly progressive, life-threatening tissue necrosis. Early diagnosis remains a challenge due to the rarity of the condition and variable presentation. Herein, we present a case of Meleney's gangrene managed at a tertiary healthcare facility in Nigeria.

Case presentation: The patient presented to the emergency department with a 13-hour history of inability to pass urine associated with pain. Physical examination revealed a tender urinary bladder consistent with a diagnosis of acute urinary retention. Following multiple failed attempts at urethral catheterisation, an ultrasound-guided percutaneous suprapubic cystostomy (SPC) was performed. Four days after being discharged home, he came back with a complaint of a dislodged suprapubic tube and leakage of urine through the SPC stoma. Physical examination revealed mild peristomal skin discolouration and tenderness. He underwent an open suprapubic cystostomy. However, the skin discoloration progressed to Meleney's gangrene. Surgical debridement was performed, and broad-spectrum antibiotic therapy was initiated. The wound was later skin grafted after satisfactory wound care. However, most of the graft was lost, and the patient had successful secondary wound healing.

Discussion: We strongly believe that the dislodgement of the suprapubic tube and subsequent extravasation of urine into the tissue planes and the retropubic space were the likely precipitating events in our patient, especially given that the urine was infected. Chemicals in urine, such as urea and ammonia, can irritate tissue, leading to chemical cellulitis and inflammation. Additionally, the extravasated urine creates an ideal environment for microbial proliferation. Consequently, the combined chemical and bacterial assault potentiates the local inflammatory response, allowing infection to spread quickly along fascial planes. Successful treatment relies on surgical debridement, broad-spectrum antibiotic therapy, wound management, and supportive care.

Conclusion: This case report underscores the importance of proper suprapubic catheter placement to avoid dislodgement and urinary leak into subcutaneous tissue planes, which can trigger Meleney's gangrene. It provides a clear lesson that any suprapubic tube dislodgement must be regarded as high risk, warranting vigilant monitoring for signs of deep soft tissue infection.