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Clinical Procedures > Genitourinary Procedures
Suprapubic Catheterization
Article Last Updated: Jun 26, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 12  
Author: Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Editors: Luis M Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
cystostomy, suprapubic catheterization, suprapubic tube, urinary retention, percutaneous, catheter over the needle obturator, urethral injury, urethral obstruction, SPT, catheter obstruction, gross hematuria, postobstruction diuresis, insertion site complications, bowel perforation, intra-abdominal visceral injuries, suprapubic catheter
- When placement of a urethral catheter is contraindicated or unsuccessful, percutaneous suprapubic urinary bladder catheterization is a commonly performed procedure to relieve urinary retention.1
- This topic describes the Catheter over needle technique. The Seldinger technique is described in the Clinical Procedures topic Suprapubic Aspiration.
Suprapubic catheterization is indicated (when transurethral catheterization is contraindicated or technically not possible) to relieve urinary retention due to the following conditions:
- Suprapubic catheterization is absolutely contraindicated in the absence of an easily palpable or ultrasonographically localized distended urinary bladder.
- Suprapubic cathterization is relatively contraindicated in the following situations:
- Coagulopathy (until the abnormality is corrected)
- Prior abdominal or pelvic surgery (potential bowel adherence to the bladder or anterior abdominal wall; may recommend that a urologist perform an open cystostomy)
- Pelvic cancer with or without pelvic radiation (increased risk of adhesions)
- Suprapubic catheterization is a painful procedure.
- All patients should receive parenteral analgesia with or without sedation.
- Sterile gloves
- Antiseptic solution
- Gauze squares, 4 X 4
- Sterile drapes
- Anesthetic solution without epinephrine
- Syringe, 10 mL
- Needles, 18 and 25 gauge
- Scalpel blade, No. 11
- Syringe, 60 mL
- Percutaneous suprapubic catheter set (Pediatric: 8F, 10F; Adult: 12F, 14F, 16F)
- Needle obturator
- Malecot catheter
- Connecting tube
- One-way stopcock
- Sterile urinometer or urine leg bag
- Drain sponges
- Skin tape or nylon suture (3-0) with a needle driver
Equipment.
- Place the patient supine on a gurney with his or her legs spread apart.
- Obtain informed consent from the patient or guardian.
- Provide adequate parenteral analgesia with or without sedation.
- Clean the lower abdominal wall with a towel.
- Shave the suprapubic area if the patient is hirsute.
- Palpate the distended bladder and mark the insertion site at the midline and 2 fingers (4-5 cm) above the pubic symphysis.
- The authors recommend the routine use of ultrasonography to verify the bladder location and to ensure that no loops of bowel are present between the abdominal wall and the bladder.
Ultrasound image of distended urinary bladder. - Apply an antiseptic solution from the pubis to the umbilicus.
- Repeat the application of the antiseptic solution 2 more times and allow the area to dry.
Skin preparation. - Apply sterile drapes and verify the insertion site by palpating the anatomic landmark.
- Fill the 10-mL syringe with a local anesthetic agent and use the 25-gauge needle to raise a skin wheal at the insertion site.
Local anesthesia - skin wheal. - Advance the needle through the skin, subcutaneous tissue, rectus sheath, and retropubic space, while alternating injection and aspiration, until urine enters the syringe. Note the direction and depth required to enter the bladder.
Local anesthesia - deep infiltration.
Local anesthesia - urine return into syringe. - Using the No. 11 blade, make a 4-mm stab incision at the insertion site with the blade facing inferiorly.
Skin incision. - Insert the needle obturator into the Malecot catheter and lock it into the port by twisting it so that the needle tip projects 2.5 mm from the distal end of the catheter.
- Connect the 60-mL syringe to the port of the needle obturator.
Suprapubic catheter tip.
Suprapubic catheter over the needle obturator. - Place the tip of the catheter–obturator unit into the skin incision and direct it caudally and at a 20- to 30-degree angle from true vertical toward the patient’s legs.
- The physician’s nondominant hand should be placed on the lower abdominal wall, and the unit should be stabilized between the thumb and index fingers.
- The dominant hand should be used to advance the unit, while aspirating, until urine enters the syringe.
- Once urine enters the syringe, advance the unit 3-4 additional centimeters into the bladder.
Suprapubic tube insertion.
- While securing the unit with the nondominant hand, unscrew the obturator from the catheter.
Unlocking the needle obturator from the catheter. - Advance the catheter approximately 5 additional centimeters over the obturator and then completely withdraw the obturator needle.
Advancing the catheter over the needle. - Connect the extension tubing to the catheter and connect the tubing to a urinometer or a leg bag.
Connection of the extension tubing.
Connection to a urinometer. - Gently withdraw the catheter to lodge the wings against the bladder wall.
Repositioning of the suprapubic tube. - Undrape the patient and apply skin preparatory solution (eg, benzoin) to the skin.
- Apply drain dressings around the catheter at the insertion site.
- Tape the catheter to the skin (leaving a mesentery between the skin and catheter) or stitch the catheter to the skin.
Taping the catheter to the skin.
Application of a drain dressing. - All patients who undergo suprapubic tube placement should be referred to a urologist for correction of the underlying disease as well as routine cystostomy tube care.
- Suprapubic tubes should not be left in place for more than 4 weeks.
Video of entire suprapubic catheterization procedure.
- The absence of an easily palpable or ultrasonographically localized distended urinary bladder is an absolute contraindication to suprapubic catheterization.
- An ultrasonographic examination to localize the bladder is recommended.
- Gross hematuria is typically a transient condition is common after the placement of a suprapubic tube. (Click here to complete a Medscape CME activity on persistent hematuria.)
- Postobstruction diuresis is possible, and all patients should be observed in the emergency department for 2-3 hours. If this complication occurs, patients should be admitted to the hospital.
- The site should be inspected and cleaned with soap and water to prevent cellulitis and abscess formation.
- Simple irrigation with normal saline should resolve most catheter obstructions. If displacement or malposition is a concern, cystography should be performed.
- Bowel perforation and intra-abdominal visceral injuries are possible. Every effort should be made to ensure the bladder position with palpation and ultrasonography to prevent or minimize the chance of these complications.
| Media file 11:
Unlocking the needle obturator from the catheter. |
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| Media file 18:
Video of entire suprapubic catheterization procedure. |
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Media type: Video
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- O'Brien WM. Percutaneous placement of a suprapubic tube with peel away sheath introducer. J Urol. May 1991;145(5):1015-6. [Medline].
- Karram M, Partoll L, Miklos J, Goldwasser S. Suprapubic bladder drainage after extraperitoneal cystotomy. Obstet Gynecol. Aug 2000;96(2):234-6. [Medline].
- Papanicolaou N, Pfister RC, Nocks BN. Percutaneous, large-bore, suprapubic cystostomy: technique and results. AJR Am J Roentgenol. Feb 1989;152(2):303-6. [Medline].
- Parry NG, Rozycki GS, Feliciano DV, Tremblay LN, Cava RA, Voeltz Z, et al. Traumatic rupture of the urinary bladder: is the suprapubic tube necessary?. J Trauma. Mar 2003;54(3):431-6. [Medline].
- Stokes S, Wu D. Suprapubic bladder catheterization. In: Reichman E, Simon R, eds. Emergency Medicine Procedures. New York: McGraw-Hill; 2004:1134-41.
Suprapubic Catheterization excerpt Article Last Updated: Jun 26, 2008
Topic originally published: Jun 26, 2008
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