# Percutaneous Suprapubic Catheterisation

## Overview

This module describes the percutaneous method of suprapubic catheterisation.

## Indications

1. Urinary retention where urethral catheterisation is unsuccessful or contraindicated

2. Long-term relief of neurogenic bladder

## Contraindications

1. Overlying skin infection

2. Bladder undetectable by physical exam or ultrasound

3. Weigh up the risks and benefits in patients with osteomyelitis or orthopedic hardware in the pubis, patients with previous lower abdominal surgery, or patients with coagulopathy

## Patient information & consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“A suprapubic catheter is a tube placed through the skin of the lower tummy directly into the bladder, because your urine cannot drain out in the normal manner.”

### What can my patient expect?

“I will give you an injection to numb the skin. Then I will make a small cut to pass first a guiding tube and then a catheter into your bladder. The guiding tube is then removed and the catheter is fixed to the skin.”

### What is my patient’s role?

“Let me know if you have any allergies or a bleeding tendency, or use blood thinners. Fearing blood or needles is normal, but tell me if you have fainted from it. Keep as still as possible. If you feel strange sensations or severe pain, tell me immediately. Afterwards, don't fiddle with the stitches or catheter.”

## Preparation

Prepare a trolley with equipment. You will need an assistant to hold up your lignocaine and sterile water.

### Documentation

1. Patient notes

### Equipment

1. Alcohol-based hand rub

2. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

3. Sterile gloves

4. Suture pack

5. Sterile drapes
   Sterile drapes

   You may need to open a sterile dressing pack if your facility does not provide drapes.

6. Skin disinfectant
   Skin disinfectant

   Commonly used preparations include 0.5-2% chlorhexidine in 70% alcohol (Steriprep), or 10% povidone iodine. There is no consensus on the superiority of one agent above another. Caution: chlorhexidine solutions may be associated with burns and skin breakdown in infants < 2 months old.

7. Cotton balls

8. Sterile water (10 ml)

9. Lignocaine (usually 1-2% with adrenaline)

10. Alcohol swab

11. Two 10 ml syringes

12. Aspiration needle (ideally blunt fill) & small injection needle

13. No. 11 scalpel blade
    No. 11 scalpel blade

    This may be in your suprapubic catheter pack, so check before you open one.

14. 1-0 or 2-0 non-absorbable suture

15. Suprapubic catheter (14-16 Fr) with trocar and sheath

16. Urine drainage bag

17. Gauze pad and a transparent film dressing

## Site and Positioning

Be sure to first percuss and palpate the patient’s bladder to determine its position. Place the patient in

Trendelenburg

Trendelenburg

This assists with ensuring no bowel loops are in the suprapubic area.

position.

## Procedure

Follow medical asepsis with sterile gloves.

1. Perform hand hygiene.

2. Open a sterile pack to create a sterile field. Pour skin disinfectant into the well. Open the suture, 10 ml syringes and needles, catheter with trocar, sheath and blade, urine drainage bag and dressing onto the field.

3. Don sterile gloves.

4. Draw up

   5-10 ml
   5-10 ml

   The catheter packaging will usually indicate how many mls of water you need to fill the balloon on the appropriate port.

   sterile water in a syringe. Connect the catheter to the urine drainage bag.

5. Clean and drape the area from the pubis to the umbilicus.

6. Draw up up to 10 ml lignocaine and

   anaesthetise
   anaesthetise

   Start with a superficial area, then anaesthetise the deeper tissues.

   an area in the midline 2-3 cm above the pubis.

7. At the deepest point of injection, use the now empty syringe to

   aspirate urine
   aspirate urine

   Do not aspirate too much urine using the syringe as we want the bladder to remain filled for easy insertion and prevention of injury to bowel.

   to confirm the bladder’s position, and withdraw.

8. Using the scalpel, make a stab incision where you inserted the needle.

9. Insert a sheathed trocar through the stab incision, aiming for under the pubis, until there is loss of resistance, which usually does not require much force. Remove the trocar and observe urine drainage from the sheath.

10. Feed the catheter down the sheath as far as possible.

11. Inflate the catheter balloon with sterile water.

12. Retract the

    sheath
    sheath

    For a peel-off sheath, take care not to pierce or cut the catheter. For sheaths that must be pulled out, keep your one hand on the catheter where it enters into the abdomen to fix it while pulling the sheath upwards gently without pulling on the catheter. Always pull the sheath in line with the catheter so as not to pierce or cut it.

    from the abdomen and pull away the tear-down strip to remove it from the catheter.

13. Pull the catheter out until resistance is felt. Keep traction on the catheter for 5 minutes to tamponade bleeding.

14. Suture the catheter in place with the same technique used for an intercostal drain.

15. Dress the wound.

16. Dispose of medical waste safely.

17. Record the completion of the procedure in patient notes.

## Troubleshooting

I do not have a sheath and trocar or equipment for Seldinger technique.

Deepen the original incision and cut the rectus sheath. Use mosquito forceps to widen the opening. Mount the catheter tip under tension on a urethral dilator. Push the dilator and catheter through the bladder wall. Inflate the balloon, then withdraw the dilator.

I cannot palpate or percuss the bladder

Do not insert a suprapubic catheter if you are unable to detect the bladder. Patients with obstruction might have had overflow incontinence after a massive build up and the urine might have trickled out. Do not discharge the patient as it will obstruct again. Rather monitor the patient, allow them to drink fluids and re-examine in an hour or two.

My patient has an obstruction and is in pain, but I don’t have a suprapubic catheter.

Follow the steps for suprapubic bladder aspiration to provide the patient with relief until either a suprapubic catheter is obtained or the patient can be transferred to an appropriate facility. Always document the aspiration procedure in your referral letter.

My patient has a longstanding suprapubic catheter in situ, which has come out. Do I need to do the entire procedure from scratch?

Many of these patients will have a fibrosed tract in situ, which means that you should be able to pass a new suprapubic catheter through this tract. If you are unable to, the tract has probably closed and you will have to insert the suprapubic catheter from scratch. Be sure to allow the bladder to fill before doing this.

## Risks

1. Pain

2. Vascular injury & bleeding; haematuria

3. Local infection

4. Catheter leakage

5. Bowel injury
   Bowel injury

   This is one of the most feared complications. Reduce the risk by using ultrasound as well as physical examination to identify the bladder and exclude low-lying loops of bowel, using Trendelenburg position, and angling slightly caudally.

6. Postobstructive diuresis
   Postobstructive diuresis

   After relieving a significant bladder outlet obstruction, the polyuric response of the kidneys may rarely become life-threatening, leading to dehydration and electrolyte abnormalities.

7. Sharps injury to healthcare personnel

8. Vasovagal response (fainting)

## References

1. Ross A, Naidoo C. How To Insert a Urinary Catheter. In: Mash B, Blitz-Lindeque J, eds. South African Family Practice Manual. 2nd ed. Pretoria: Van Schaik Publishers; 2010: 117-119.

2. Corder CJ, LaGrange CA. Suprapubic Bladder Catheterization. [Updated 2020 Nov 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482179/

3. Siriwardana HD. Modified simple percutaneous suprapubic cystostomy. Ceylon Medical Journal. 2009;53(4):138–139. DOI: http://doi.org/10.4038/cmj.v53i4.285

4. Goyal NK, Goel A, Sankhwar SN. Safe percutaneous suprapubic catheterisation. Ann R Coll Surg Engl. 2012;94(8):597-600. doi:10.1308/003588412X13373405385412