Chapter 123

Complaints involving the lower genitourinary system are among the most common urologic problems encountered by the Emergency Physician. The collection and evaluation of urine plays a critical role in the process of diagnosis and treatment. Volitional voiding and transurethral urinary catheterization are the preferred methods of bladder drainage and can be accomplished in most instances. There are situations when the transurethral route is contraindicated or technically not possible and alternate avenues must be explored. A percutaneous approach to urinary bladder drainage and decompression becomes the solution, offering both therapeutic and diagnostic results.1–6 Suprapubic bladder catheterization has been used for decades as an effective means of accessing the bladder.

Suprapubic bladder catheterization, or percutaneous cystostomy, has become the treatment of choice for the patient with acute urinary retention regardless of the cause. It is commonly performed in the trauma patient with a known or suspected urethral injury. The catheters are well tolerated, easy to care for, and can easily be replaced and/or removed. The placement of a suprapubic catheter into the bladder is fast and may be performed under local anesthesia. It is a relatively safe procedure but does have potential complications that are significant.

Residing in the retropubic space approximately 5 cm above the superior margin of the symphysis pubis, the adult urinary bladder has both retroperitoneal and intraperitoneal attachments. A working knowledge of this anatomy makes percutaneous bladder manipulation both safe and possible. The rectum lies just inferior and posterior to the urinary bladder and this relationship must be kept in mind when attempting percutaneous access. The bladder dome has peritoneal attachments and access in this area carries a risk of bowel injury and intraperitoneal bladder perforation.

Multiple vascular structures, including the common iliac and hypogastric vessels, reside in the bony pelvis alongside the bladder. These structures are lateral to the bladder and eccentric percutaneous access may result in troublesome hemorrhage.

Suprapubic bladder catheterization is indicated in cases when the transurethral route of bladder drainage or decompression is technically not possible or contraindicated. This includes patients with iatrogenic urethral injuries, obstructing urethral lesions, bladder neck lesions, enlarged prostates (benign hypertrophy or cancer), urethral strictures, urethral scarring, an obstructing phimosis, a urethral foreign body, and a suspected or known traumatic urethral or prostatic disruption. Continuous bladder irrigation can be accomplished via a combined suprapubic and transurethral route.

The single most important aspect of suprapubic bladder manipulation is the presence of a palpable and distended urinary bladder and under no circumstances should “blind” percutaneous access be attempted. The bladder must be distended to push the bowel away from the anterosuperior surface of the bladder.

Patients with a coagulopathy are at an increased risk for troublesome hemorrhage from any percutaneous procedure, including suprapubic bladder access. Any coagulopathy, bleeding diathesis, platelet dysfunction, and/or thrombocytopenia should be corrected prior to performing this procedure.

In individuals with prior lower abdominal ...

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