Suprapubic Catheterization 

• 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:

• Urethral injuries
• Urethral obstruction
• Bladder neck masses
• Benign prosthetic hypertrophy (BPH)
• Prostate cancer

• Suprapubic catheterization is absolutely contraindicated in the absence of an easily palpable or ultrasonographically localized distended urinary bladder.
• Suprapubic catheterization is relatively contraindicated in the following situations:

  • Coagulopathy (until the abnormality is corrected)
  • Prior lower 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 without proper anesthesia.
• All patients should receive parenteral analgesia with or without sedation.

  • The authors recommend using procedural sedation and analgesia in all patients who are uncooperative or agitated to ensure patient and practitioner safety during this invasive procedure. For more information, see Procedural Sedation.
  • Local anesthetic use is described in the Technique section. For more information, see Local Anesthetic Agents, Infiltrative Administration.

• 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
• Assembled equipment shown in image below 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.
• 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 (see image below). 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 (see image below). 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 (see image below). 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 (see images below). 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 (see image below). 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 (see images below). 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 practitioner’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 (see image below). Suprapubic tube insertion.
• While securing the unit with the nondominant hand, unscrew the obturator from the catheter (see image below). Unlocking the needle obturator from the catheter.
• Advance the catheter approximately 5 additional centimeters over the obturator and then completely withdraw the obturator needle (see image below). Advancing the catheter over the needle.
• Connect the extension tubing to the catheter and connect the tubing to a urinometer or a leg bag (see images below). Connection of the extension tubing. Connection to a urinometer.
• Gently withdraw the catheter to lodge the wings against the bladder wall (see image below). 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 (see image below). Application of a drain dressing.
• Tape the catheter to the skin (leaving a mesentery between the skin and catheter) or stitch the catheter to the skin (see image below). Taping the catheter to the skin.
• 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.
• Do not change a newly inserted catheter for 4 weeks; this allows the catheter tract to become established.^[2] Subsequently inserted tubes should be changed at least once a month to decrease infections.
• The video below demonstrates the entire suprapubic catheterization procedure.

  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.
• When changing a suprapubic catheter, speed is very important. The new catheter should be inserted within 5-10 minutes of removal of the old catheter. Never remove a suprapubic catheter unless it is going to be changed immediately.^[2]
• Blind insertion should not be undertaken in patients with no history of lower abdominal surgery but in whom the distended (>300 mL) bladder cannot be palpated because of obesity. In such circumstances, ultrasonography may be used to identify the distended bladder, or cystoscopy may be used to ensure that an aspirating needle on the planned catheter track is entering the bladder at an appropriate point on the anterior bladder wall.^[3]

• Gross hematuria is typically a transient condition that is common after the placement of a suprapubic tube.
• 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 for intravenous fluid administration and monitoring or correction of electrolytes.
• The insertion 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.