Suprapubic Catheter

Indications

Urethral Trauma
Complete Urethral obstruction (refractory to Urinary Catheter placement)

Contraindications

Coagulopathy
No urine in Bladder
Infection overlying skin or abdominal wall region of Suprapubic Catheter placement
Altered anatomy or anticipated significant adhesions (e.g. pelvic cancer, radiation, suprapubic mesh)

Preparation

Suprapubic Catheter Kit
1. Kits vary but include a trochar and catheter with needle (some kits include a seldinger guidewire)
2. In an emergency, if Suprapubic Catheter kit is unavailable, central venous catheter may be used instead
Ultrasound preparation
1. Use Curvilinear transducer (2-5 MHz)
2. Survey the Bladder with transducer in short axis (transverse)
  1. Bladder must contain urine for safe procedure
  2. Identify overlying loops of bowel or other interfering anatomical structures
3. Apply a sterile cover to Ultrasound probe
4. Use sterile Surgilube packets (or similar sterile lubricant) for Ultrasound gel within probe cover
Patient
1. Position supine

Technique

Prepare the Suprapubic Catheter
1. With the plastic guard on the catheter to maintain its shape
2. Insert the trochar within the catheter so the sharp tip protrudes from the end
3. Remove the plastic outer guard
Identify the insertion site
1. Find a midline point three finger breadths (2 inches) above the Symphysis Pubis
Prepare the insertion site
1. Prepare the suprapubic skin repeatedly with Chlorhexidine or Betadine (allowed to dry)
2. Drape the area
3. Inject up to 10 ml Lidocaine 1% with Epinephrine at the insertion site
  1. Raise a skin wheel
  2. Inject along the anticipated tract
4. Make a 4 mm horizontal incision at the insertion site
Position the Ultrasound transducer
1. Short axis (transverse)
2. Superior to the catheter insertion site
Insert the catheter
1. Attach a 20 to 60 ml syringe to a Suprapubic Catheter, needle and obturator unit
  1. Catheter should be locked into the obturator unit until Bladder entered
2. Direct the catheter caudal (inferiorly towards the Bladder neck) at a 60 degree angle
3. Observe the catheter tip on Ultrasound enter the Bladder dome (approximately 2 inches below the skin level)
  1. Aspirate while inserting the needle, until after urine is aspirated
  2. Unlock the catheter from the needle obturator
  3. Continue to insert the catheter an additional 2 inches (5 cm)
  4. Remove the trochar
4. Confirm placement
  1. Inject saline and observe on Ultrasound the jets and bubbles inside the Bladder
  2. Aspirate urine
5. Inflate the catheter balloon (if present)
  1. Withdraw the catheter until it stops against inside wall of Bladder
6. Secure Suprapubic Catheter to skin with tape
7. Connect urine bag to the catheter via extension tubing
Catheter replacement
1. Tract will mature over 4-6 weeks
  1. Once tract matures, catheter may be removed and new catheter inserted without difficulty
2. Prior to tract maturation, catheter replacement can be difficult
  1. Risk of urine leakage out of Bladder into Abdomen
  2. Consider seldinger technique (place guide via old catheter, withdraw, and place new catheter over guide)

Efficacy

Suprapubic Catheters carry lower risk of Urinary Tract Infections than uretheral catheters
Suprapubic Catheters avoid Urethral Trauma and secondary Urethral Strictures that may occur with Urethral catheters

Complications

Bleeding from Bladder or skin
Bowel perforation
Bladder perforation
Pelvic organ injury (vagina, Uterus)
Secondary infection

Resources

Medscape EMedicine Suprapubic Catheterization
1. http://emedicine.medscape.com/article/145909-overview#showall

References

James and Palleschi in Pfenninger (1994) Procedures for Primary Care Physicians, p. 500-7
Islam (2017) Crit Dec Emerg Med 31(11): 12-3