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Clinical Procedures > Genitourinary Procedures
Suprapubic Aspiration
Article Last Updated: Feb 10, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 14  
Author: David R Roth, MD, Staff Physician, Jacobi/Montefiore Emergency Medicine Residency Program, Bronx, NY
David R Roth is a member of the following medical societies: American College of Emergency Physicians and Emergency Medicine Residents Association
Coauthor(s):
Hong Keun Choi, MD, MPH, Assistant Professor, Associate Residency Site Director, Montefiore Medical Center
Editors: Andrew K Chang, MD, Department of Emergency Medicine, Albert Einstein College of Medicine, Assistant Professor, Montefiore Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, Pharmacy Editor, University of Nebraska Medical Center College of Pharmacy, eMedicine.com, Inc; 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; Gil Z Shlamovitz, MD, Emergency Medicine Center, UCLA Medical Center, David Geffen School of Medicine, Los Angeles, CA; 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:
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, suprapubic aspiration, ED urine collection, urine analysis, urine collection, bedside ultrasonography, cystostomy, indwelling catheter, Foley catheter, suprapubic catheter
Suprapubic aspiration and catheterization is an easily performed emergency department procedure that is associated with minimal complications. Huze and Beeson1 first published this practice in 1956 as an alternative to more traditional methods of obtaining urine for analysis and culture. Their findings suggested that suprapubic catheterization and aspiration was superior to clean-catch or transurethral (via catheterization) collection of bladder urine for bacteriologic study. Since then, the indications for suprapubic catheterization and aspiration have expanded to acute and chronic conditions.
- Urinary retention (eg, prostate hypertrophy or cancer, gynecologic malignancy, spinal cord injury)
- Urinalysis or urine culture in neonates or children younger than 2 years
- Phimosis
- Chronic infection of the urethra or periurethral glands
- Urethral stricture
- Urethral trauma
- Empty or undefinable bladder (eg, child’s last urination within 1 hr, nonpalpable bladder in adults)
- Known bladder tumor
- Lower abdominal wounds or scarring
Local anesthesia, in the form of a skin wheal, is placed using lidocaine at the insertion site. 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 (2% lidocaine) with syringe and needle
- Sterile syringe, 10 or 20 mL
- Needle, 22 gauge (1.5 in) for pediatric patients
- Spinal needle, 20 gauge for adult patients
- Foley catheter tray (catheter size must be at least 1 F 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.2
- Localization of the bladder is the most important part of this procedure. Bedside ultrasonography is immensely helpful, especially in patients who are obese or contracted. Ultrasonography should be used, if available, even if the bladder is readily palpable.3 If ultrasonography is unavailable and the bladder is not palpable, the authors advise delaying the procedure. If the bladder is distended, it appears as an anechoic square-like 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.4 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. This procedure requires only a small skin wheal.
Palpate the symphysis pubis.
- For aspiration, select a 22 gauge 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.
Insert the needle while aspirating.
Urine appears within the syringe.
The bladder appears to tent as the needle pierces its anterior wall.3 This tenting is visible on bedside sonogram. If ultrasonography is used, place the transducer in a sterile glove that contains sonographic lubricant. The insertion approach is slightly different in children and adults.2
- 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 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.4
- Once urine has been 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 urine analysis and culture.
- If a suprapubic catheter is to be left in place, follow steps 1-5 above, but use a cystostomy kit.5
- Once placement is confirmed (urine aspirated), remove the syringe and insert the guidewire from the cystostomy tray through the needle. Next, 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% NaCl (normal 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.3
- The needle insertion site is approximately 2 cm above the symphysis pubis.
- If available, use bedside ultrasonography to visualize bladder puncture.
- Use a cystostomy kit with a peel-away introducer sheath for suprapubic catheterization.
- The Foley catheter must be at least 1 F smaller than the peel-away introducer sheath.
Complications are rare and include the following:
- Peritoneal perforation with or without bowel perforation;6 unlikely to cause significant ramifications unless a catheter is placed
- Infection (eg, intra-abdominal, bladder, skin and soft tissues); more likely with indwelling catheter than with simple suprapubic aspiration2
- Hematuria (usually transient and microscopic)
- Inability to aspirate urine
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- 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].
- 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. 3rd. Philadelphia, PA: W.B. Saunders Co.; 1998:971-976.
- Stine RJ, Avila JA, Lemons MF, Sickorez GJ. Diagnostic and therapeutic urologic procedures. Emerg Med Clin North Am. Aug 1988;6(3):547-78. [Medline].
- Vilke GM. Bladder Aspiration. In: Rosen P. Atlas of Emergency Procedures. St. Louis, MO: Mosby, Inc.; 2001:130-131.
Suprapubic Aspiration excerpt Article Last Updated: Feb 10, 2006
Topic originally published: Jan 5, 2006
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