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Clinical Procedures > Genitourinary Procedures
Suprapubic Aspiration
Article Last Updated: Nov 5, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 13  
Author: Adam J Rosh, MD, MS, Assistant Professor, Department of Emergency Medicine, Wayne State University/Detroit Receiving Hospital
Adam J Rosh is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Editors: Andrew K Chang, MD, Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine; Luis M Lovato, MD, Associate Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center; 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; 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:
suprapubic aspiration, urinary tract infection, pediatric fever workup, urine culture, urethral trauma, spinal cord injury, urinary retention, bladder catheterization, urethral catheterization in men, urethral catheterization in women, urine aspiration, suprapubic catheterization, ED urine collection, urine analysis, urine collection, bedside ultrasonography, cystostomy, indwelling catheter, Foley catheter, suprapubic catheter
Suprapubic aspiration and catheterization is a procedure to obtain uncontaminated bladder urine. It is easy to perform in the emergency department and is associated with minimal complications. Huze and Beeson first published this practice in 1956 as an alternative to more traditional methods of obtaining urine for analysis and culture.1 Their findings suggested that suprapubic catheterization and aspiration was superior to clean-catch or transurethral (via catheterization) collection of bladder urine for bacteriologic study. The sensitivity of the aspirated urine for bacteriuria on urinalysis approaches 100% and is rarely associated with contamination.2
- Empty or unidentifiable bladder (eg, child’s last urination within 1 hr, nonpalpable bladder in adults)
- Known bladder tumor
- Lower abdominal wounds or scarring
- Overlying cellulitis
- Local anesthesia, in the form of a skin wheal, is placed using lidocaine at the insertion site to reduce discomfort.
- The insertion site can be identified beforehand with bedside ultrasonography, if available (see Technique for more details).
- For more information, see Local Anesthetics Agents, Infiltrative Administration.
- Sterile gloves
- Sterile drapes
- Povidone-iodine (Betadine) skin preparation with sterile gauze
- Local anesthetic (1% or 2% lidocaine) with syringe and needle
- Sterile syringe, 10 or 20 mL
- Needle, 22 gauge (ga), 1.5 in, for pediatric patients
- Spinal needle, 20 ga, for adult patients
- Foley catheter tray (catheter size must be at least 1F smaller than the introducer sheath size)
- Cystostomy kit with peel-away introducer sheath (eg, Cook cystostomy kit)
- Sterile urine specimen container
- Sterile dressing
- The patient should be supine, with the abdomen and pubic areas exposed.
- Parents of small children may help hold and calm the child. Otherwise, at least one assistant is needed to immobilize the pediatric patient in a frog-legged position.3
- Localization of the bladder is critical for the procedure. Bedside ultrasonography is remarkably helpful, especially in patients who are obese or contracted. Ultrasonography should be used, if available, even if the bladder is readily palpable.4
- If ultrasonography is unavailable and the bladder is not palpable, the authors advise delaying the procedure.
- If the bladder is distended, it appears on ultrasound as an anechoic (black) squarelike structure just below the abdominal musculature. General landmarks for this site include the midline lower abdomen, which is located approximately 2 cm above the symphysis pubis.5
- Sterilize the area with povidone-iodine (Betadine).
- Palpate the symphysis pubis and inject local anesthetic 2 cm above the superior edge of the symphysis or at the sonogram-determined insertion site.
Palpate the symphysis pubis. - Place a small skin wheal of lidocaine at the planned insertion site.
- For aspiration, select a 22-ga needle of appropriate length (eg, shorter for children, longer for adults) and attach it to a 10- or 20-mL syringe.
- Insert the needle while aspirating until urine appears within the syringe. The insertion approach is slightly different in children and adults.3
- Pediatric: Insert the needle slightly cephalad, 10-20° off perpendicular, and advance. In a young child, the bladder is still an abdominal organ.
- Adult: Insert the needle slightly caudad, 10-20° off perpendicular. In an adult, the bladder is a pelvic organ.
- If the procedure is performed using ultrasonographic guidance, the bladder appears to tent as the needle pierces its anterior wall.4 (Of note, the ultrasound transducer should be placed in a sterile glove that contains ultrasound gel to maintain a sterile field during the procedure.)
Insert the needle while aspirating.
Urine appears within the syringe. - If the insertion is unsuccessful, do not withdraw the needle fully. Instead, pull back until the needle tip rests in the subcutaneous tissue and then redirect 10° in either direction. Do not attempt more than 3 times.5
- Once urine is obtained, remove the needle and apply gentle pressure at the insertion site with sterile gauze. Place a sterile dressing at the site of insertion.
- Place the urine specimen in a sterile container approved for urinalysis and culture.
- If a suprapubic catheter is to be left in place, follow the initial steps above, but use a cystostomy kit.6
- Once placement is confirmed (urine aspirated), remove the syringe and insert the guidewire from the cystostomy tray through the needle.
- Remove the needle and use a scalpel to make a small incision at the insertion site, adjacent to the guidewire.
- Thread the peel-away sheath introducer over the guidewire into the bladder and remove the wire.
- Insert the Foley catheter through the peel-away sheath introducer. Deploy the Foley catheter balloon with 10 mL of 0.9% saline.
- Remove the peel-away sheath introducer from the Foley catheter and pull back on the catheter until resistance is met. Secure the catheter tubing to the abdominal wall with sterile dressing.
- The Foley catheter should be attached to a urine meter drainage bag.4
- The needle insertion site is approximately 2 cm above the symphysis pubis.
- From the true vertical, the needle should be angled 10º cephalad in children and 10º caudad in adults.
- If available, use bedside ultrasonography to visualize the bladder and observe the needle puncture the bladder wall.
- Use a cystostomy kit with a peel-away introducer sheath for suprapubic catheterization.
- The Foley catheter must be at least 1F smaller than the peel-away introducer sheath.
Complications are rare and include the following:
- Peritoneal perforation with or without bowel perforation;7 unlikely to cause significant ramifications unless a catheter is placed
- Infection (eg, intra-abdominal, bladder, skin, soft tissues); more likely to occur with indwelling catheter than with simple suprapubic aspiration3
- Hematuria (usually transient and microscopic, gross hematuria is uncommon)
- Inability to aspirate urine
eMedicine from WebMD: Urinary Tract Infection, Males
eMedicine from WebMD: Urinary Tract Infection, Female
- Beeson PB, Guze LB. Observations on the reliability and safety of bladder catheterization for bacteriologic study of the urine. N Engl J Med. Sep 6 1956;255(10):474-5. [Medline].
- Hardy JD, Furnell PM, Brumfitt W. Comparison of sterile bag, clean catch and suprapubic aspiration in the diagnosis of urinary infection in early childhood. Br J Urol. Aug 1976;48(4):279-83. [Medline].
- Gochman RF, Karasic RB, Heller MB. Use of portable ultrasound to assist urine collection by suprapubic aspiration. Ann Emerg Med. Jun 1991;20(6):631-5. [Medline].
- Noller KL, Pratt JH, Symmonds RE. Bowel perforation with suprapubic cystostomy Report of two cases. Obstet Gynecol. Jul 1976;48(1 Suppl):67S-69S. [Medline].
- O'Brien WM. Percutaneous placement of a suprapubic tube with peel away sheath introducer. J Urol. May 1991;145(5):1015-6. [Medline].
- Promes SB. Miscellaneous Applications. In: Simon BC, Snoey ER. Ultrasound in Emergency and Ambulatory Medicine. St. Louis, MO: Mosby, Inc; 1997:256-261.
- Schneider RE. Urologic Procedures. In: Robert JR, Hedges JR. Clinical Procedures in Emergency Medicine. 6(3). 4th ed. Philadelphia, PA: W.B. Saunders Co; 2004:1098-1100.
- Stine RJ, Avila JA, Lemons MF, et al. Diagnostic and therapeutic urologic procedures. Emerg Med Clin North Am. Aug 1988;6(3):547-78. [Medline].
- Vilke GM. Bladder Aspiration. Rosen P. Atlas of Emergency Procedures. St. Louis, MO: Mosby, Inc; 2001:130-131.
Suprapubic Aspiration excerpt Article Last Updated: Nov 5, 2008
Topic originally published: Jan 5, 2006
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