Continuing Education Activity

Suprapubic catheterization refers to the placement of a drainage tube into the urinary bladder just above the pubic symphysis. This is typically performed for individuals who are unable to drain their bladder via the urethra. Suprapubic catheterization offers an alternative means to drain the urinary bladder when other methods are not clinically feasible, undesirable or impossible. This activity reviews the technique of suprapubic bladder catheterization, its indications, contraindications and role of the interprofessional team in the management of patients who are not able to void urine.

Objectives:

• Identify the anatomical structures involved in a suprapubic bladder catheterization.
• Describe the indications for suprapubic bladder catheterization.
• Review the contraindications to suprapubic bladder catheterization.
• Outline the importance of improving care coordination among the interprofessional team to enhance the delivery of care for patients needing suprapubic bladder catheterization.

Introduction

Suprapubic catheterization refers to the placement of a drainage tube into the urinary bladder just above the pubic symphysis. This is typically performed for individuals who are unable to drain their bladder via the urethra. Suprapubic catheterization offers an alternative means to drain the urinary bladder when other methods are not clinically feasible, undesirable or impossible. Suprapubic tubes are easier to change, can be of almost any size and are generally considered more comfortable for male patients with long term catheter requirements. Alternatives to suprapubic catheterization include urethral catheterization, intermittent catheterization, urinary diversion and percutaneous nephrostomy drainage. These specialized drainage catheters are typically placed either percutaneously or openly. Percutaneous access commonly employs visualization using cystoscopy.[1][2][3]

Anatomy and Physiology

The urinary bladder is a hollow organ made of muscle designed to store and evacuate urine from the human body.  A typical urinary bladder holds between 300 and 500 ml. The bladder is divided into the fundus, body, apex, and neck. The urinary bladder is located behind the pubic bone in the extraperitoneal space. The extraperitoneal space anterior to the bladder is referred to as the prevesical space or space of Retzius.  The space is named after Anders Retzius (1796-1860) the Swedish anatomist who first described this area.

The abdominal wall just above the pubis is comprised of the rectus muscle bellies lateral and the linea alba in the midline. Below the arcuate line, the aponeuroses of the external oblique, internal oblique and transversals muscles run anterior to the rectus muscle. It is through this area by which open access to the dome of the bladder is obtained. The dome or cephalad most portion of the bladder is covered with perineum. The urinary bladder is supported below by the pelvic diaphragm. Suprapubic drainage tubes commonly exit via a midline site, but off center (through the rectus) is also acceptable depending on the patient’s body habitus.

Indications

The most common indication for suprapubic tube placement is for urinary retention when urethral catheterization is not feasible. This can include severe BPH, false urethral passages, morbid obesity, urethral strictures, bladder neck contracture and genital malignancy. Urogenital trauma causing urethral disruption and severe damage are common indications. Suprapubic tube placement for the long-term diversion of urine in cases of neurogenic bladder is also sometimes indicated.[4][5]

Contraindications

Contraindications to suprapubic cystotomy are relatively few, and they depend on the approach being utilized. Percutaneous approaches are contraindicated in a non-distended bladder, and in the setting of bladder malignancy. The former places the patient at substantial risk of inadvertent bowel or vascular injury. Relative contraindications for suprapubic cystotomy include whether open or percutaneous include active skin infection, coagulopathy, osteomyelitis of the pubis, and orthopedic hardware of the pubic symphysis.

Equipment

Equipment utilized for the placement of a suprapubic catheter varies by technique. Typically, standard Foley catheters are used for drainage catheters. The open technique utilizes standard surgical instrumentation including a small self-retaining retractor such as a Weitlander retractor and dissolvable suture for closure of the cystotomy. Percutaneous (Seldinger) technique requires the use of a large-bore needle, a guide wire and peel away catheter insertion sheath. These are commercially available as an all-in-one kit. Percutaneous approaches are often performed under vision with a rigid or flexible cystoscope. Finally, a specialized retractor called a Lousley prostatic retractor can be used to assist in an open tube placement. Portable ultrasound devices are also helpful to confirm tube location. 

Personnel

Suprapubic catheterization is performed by a urologist, a surgeon who specializes in the genitourinary system. Other practitioners that may perform this procedure include general surgeons, gynecologists, urogynecologists, as well as emergency providers such as emergency room physicians and trauma surgeons.

Preparation

Suprapubic catheterization can be performed with local or general anesthetic depending on the situation. The lower abdomen is shaved and prepped with standard surgical prep. If the technique will involve entrance via the urethra, the genitals are prepped and draped accordingly. If rigid cystoscopy is required, the patient should be positioned in dorsal lithotomy. Flexible cystoscopy can easily be performed supine in most cases. The patient should always be placed in Trendelenburg position is help minimize the risk of bowel injury.  Having an abdominal ultrasound or CT scan is helpful, especially in patients with prior abdominal surgical procedures, to make certain there are no bowel loops between the distended bladder and the abdominal wall that could be inadvertently injured during suprapubic tube placement.

Technique or Treatment

Several techniques are well described for the placement of a suprapubic catheter. Two categories exist; these are open technique and percutaneous technique. Variations of each of these exist, and many are hybrid techniques.

Open cystotomy involves a small, typically transverse incision roughly 2 fingerbreadths above the pubic symphysis. The bladder ideally is filled prior, this aids in the identification of the bladder. The rectus fascia is opened allowing access into the preperitoneal space. The bladder is identified, and dissolvable stay stitches are placed on either side of the intended cystotomy. A small cystotomy is then made, and the drainage tube is placed. The tube is secured to the bladder with a dissolvable purse-string stitch. The facial layers and skin are then closed around the tube which is finally secured to the skin with a temporary stitch.

The Percutaneous Seldinger technique is also fairly common. Distention of the urinary bladder is imperative for this approach. This can be done physiologically (urinary retention) or with the aid of a cystoscope. Cystoscopic examination allows direct visualization of the puncture needle but is not required. In an area, roughly 2 fingerbreadths above the pubis, a large bore needle is inserted until urine returns. Sterile saline can be added to the bladder at this point if necessary. X-ray guidance is also optional as contrast can be added to better visualize the urinary bladder. A guide wire is then advanced through the needle into the urinary bladder. (Note: An 0.035" guidewire will comfortably fit in an 18 gauge or larger bore needle.) This tract is then dilated either mechanically with dilators or with balloon dilators to accommodate a pull away sheath. The suprapubic catheter is then passed into the bladder via the access sheath which is removed after the catheter balloon is inflated. The catheter is then secured. Cystoscopic confirmation of placement is recommended when feasible. 

The curved Lowsley prostatic retractor can be utilized for a modified open approach. This specialized instrument is passed per the urethra into the urinary bladder. Urethral access to the bladder is necessary for this technique to be used. Upward pressure is then applied bringing the curved instrument tip and bladder dome close to the abdominal wall. Except in very obese individuals, the tip of the Lowsley retractor is palpable through the skin of the lower abdomen. A suprapubic cut down is then performed exposing the retractor tip. The urinary catheter is then attached to the Lowsley prostatic retractor which is pulled back into the bladder taking the catheter tip with it. The balloon on the suprapubic tube is inflated and the catheter is released from the Lowsley by twisting open its jaws.  The jaws are then closed and the Lowsley is removed. Occasionally, the tip of the catheter will be in the bladder but the balloon will be inflated just outside. For this reason, a cystoscopy is recommended after placement to be absolutely certain of proper positioning.[6] 

Trocar kits are also available for direct puncture into the urinary bladder. These are used less frequently as they can have an increased risk of injury to adjacent organs. Several commercially available kits are available for the percutaneous technique which tends to be the most common approach.

Complications

Early complications of the operation include inadvertent bowel injury, bleeding, vascular injury, obstruction of the tube, and failure to enter the bladder during the initial procedure. Bowel injury can be limited with the use of preoperative imaging as well as intra-operative ultrasound. Other late complications include refractory hematuria, urosepsis, wound infection, bladder stones, tube calcification or malfunction, and loss of the cystotomy tract. In patients with a chronic obstruction such as BPH, decompression of the bladder can result in post-obstructive diuresis. This is defined as urine output greater than 200 mL per hour for 2 or more hours. This brisk diuresis is a physiologic response to the volume expansion that takes place when chronic obstruction is relieved.[7] Another late complication is chronic irritation of the bladder secondary to the tube. This is considered a risk factor for squamous cell carcinoma of the bladder. Finally, while not a surgical complication in the true sense of the term, body image alteration can later become a patient concern.[8][9]

Clinical Significance

Suprapubic catheters provide an alternate method to drain the urinary bladder. These are commonly utilized to manage bladder dysfunction and urinary retention not amenable to urethral catheterization. Like all urinary catheters, they have risks and benefits. Current literature is mixed concerning the risk of urinary tract infection. Some studies have suggested that limiting genital contact with the catheter may decrease symptomatic infection rates. However, other series have not supported this conclusion. Urethral catheters have obvious limitations on a patients sexual function, making suprapubic tubes potentially more appealing to those sexually active. Access for catheter exchange is a common consideration when choosing bladder drainage. Suprapubic tubes allow for more convenient tube exchanges based on their location. Furthermore, chronic urethral catheters carry the risk of urethral erosion over time, particularly in males. Urinary incontinence is often a consideration when considering bladder catheterization. It is important to note that urinary incontinence by the way to the urethra can occur despite suprapubic drainage. This is of particular concern when skin breakdown from bladder incontinence is present. Leakage around the suprapubic tube can also occur. This may indicate either tube blockage or bladder spasms.

Suprapubic catheters can be placed for certain surgical procedures. These can provide stable bladder drainage before and after complex urethral reconstructions. Additionally, they can be combined with a urethral catheter to provide a means for continuous irrigation. Irrigation inflow can be instilled through a suprapubic catheter and outflow by way of the urethral catheter, or vice versa. Usually, the larger diameter tube is used for outflow. In patients undergoing bladder, prostate or urethral surgery these tubes can be a valuable tool to maintain adequate urinary drainage.

Enhancing Healthcare Team Outcomes

An interprofessional approach to suprapubic catheters

Suprapubic catheterization is sometimes needed when drainage via the urethra is not possible. While the procedure is usually performed by a urologist, the nurse is usually in charge of monitoring the catheter and the urine output. Nurses need to know the potential complications of this procedure such as bowel injury and must regularly examine the abdomen. In addition, the patient needs to be monitored for signs and symptoms of a urinary tract infection. Patients who are confused may pull and try to remove their suprapubic or urethral catheters. Techniques and methods to secure catheters from such attempts are well described elsewhere.[10] Finally, a common problem with suprapubic catheterization is leakage at the skin site and hence the nurse should monitor this area for signs of incontinence. [11][12]