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INTRODUCTION

Complaints involving the lower genitourinary system are among the most common urologic problems encountered by Emergency Physicians. The collection and evaluation of urine play a critical role in the process of diagnosis and treatment. Volitional voiding and transurethral urinary catheterization (Chapter 173) 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 methods must be explored. A percutaneous approach to urinary bladder drainage and decompression becomes the solution, offering both therapeutic and diagnostic results.1-11 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 patients 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.

ANATOMY AND PATHOPHYSIOLOGY

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. 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 (i.e., off the midline) percutaneous access may result in iatrogenic injury and hemorrhage.

INDICATIONS

Suprapubic bladder catheterization is indicated in cases when the transurethral route of bladder drainage or decompression is technically not possible or contraindicated.9,12,13 This includes patients with bladder neck injuries and lesions, enlarged prostates (e.g., benign hypertrophy or cancer), iatrogenic urethral injuries, intractable urinary incontinence, obstructing urethral lesions, neurologic disease, an obstructing phimosis, palliative care, post-operation, suspected or known traumatic urethral or prostatic disruption, a urethral foreign body, urethral scarring, and/or urethral strictures. Continuous bladder irrigation can be accomplished via a combined suprapubic and transurethral route. Long-term bladder drainage is the final indication for a suprapubic bladder catheterization.14

CONTRAINDICATIONS

Suprapubic catheterization is absolutely contraindicated in the absence of an easily palpable and distended or ultrasonographically localized and distended urinary bladder.9 Under no circumstances should “blind” percutaneous access be attempted. The bladder must be distended to push the bowel ...

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