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
In individuals with prior lower abdominal ...