Chapter 144. Suprapubic Bladder Catheterization (Percutaneous Cystostomy)

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.1–9 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 (e.g., 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.

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 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 catheterization. Any coagulopathy, bleeding diathesis, platelet dysfunction, and/or thrombocytopenia should be corrected prior to performing this procedure.

In individuals with prior lower abdominal surgery or traumatic injury, the peritoneal cavity has been violated and the bowel may be displaced more caudal and to the level of the urinary bladder. The bowel may be adhesed to the anterior abdominal wall. This heightens the risk of inadvertent entry into the peritoneal cavity and injury to the bowel.

Relative contraindications to percutaneous bladder catheterization include patients who have a history of pelvic cancer or pelvic radiation therapy, ascites, urinary tract infections, or who are uncooperative. A history of pelvic cancer or irradiation will increase the risk of anatomical distortion, adhesions, and scarring. Attempts at suprapubic cystostomy increase the risk of peritoneal and/or bowel perforation. The return of ascitic fluid may lead the physician to a false sense of security when the catheter is actually intraperitoneal. Urine leakage in patients with a urinary tract infection may result in bacteremia, peritonitis, and/or sepsis. In these circumstances, consult a Urologist for an open suprapubic cystostomy or Interventional Radiology for a percutaneous cystostomy using fluoroscopic or ultrasonic guidance. An uncooperative patient will require parenteral sedation or procedural sedation prior to performing this procedure.

Any physical alteration, spinal deformities, extremity contractures, truncal obesity, or other conditions that would preclude patients from lying supine and inhibiting bladder palpation are also contraindications to performing a percutaneous cystostomy.

• Povidone iodine or chlorhexidine solution
• Sterile gloves
• Percutaneous cystostomy catheter kit
• Foley catheter, 14 to 16 French
• 60 mL catheter-tipped syringe
• 10 mL syringes
• 24 to 25 gauge spinal needle, 3 inches long
• #11 Surgical scalpel blade on a handle
• 3-0 nylon suture
• Needle driver
• Local anesthetic solution, with or without epinephrine
• 4 × 4 gauze squares
• 25 gauge needle, 1 inch long
• 18 gauge needle
• Urine meter or urine leg bag
• Sterile towels
• Sterile drapes
• Tincture of benzoin
• 2 inch tape
• Ultrasound machine (recommended)

The percutaneous cystostomy catheter kit is commercially available and prepackaged by several manufacturers. One type contains a cystostomy tube, an obturator, and connector tubing (Figures 144-1, 144-2, & 144-4). Another type uses a Seldinger-type kit with a peel-away sheath (Figure 144-3).

A commonly used suprapubic catheter kit is the Rutner Percutaneous Suprapubic Balloon Catheter Set (Cook Urological Inc., Spencer, IN). It consists of a 10 French catheter that is 22 cm long, a needle obturator, a connecting tube, and a 3 mL syringe (Figures 144-1 & 144-2A). The proximal end of the catheter has two ports (Figures 144-1 & 144-2B). One port is for the insertion of the obturator through the catheter. The obturator screws and locks into this port. The other port is an inflation port for the cuff of the catheter. A 3 to 5 mL syringe attaches to this port. The obturator is a hollow tube that tapers to a sharp point distally. When properly inserted and locked into the port, the obturator will project 2.5 mm from the distal end of the catheter (Figures 144-1C & 144-2C). The cuff is donut-shaped and centered 1 cm from the tip of the catheter (Figure 144-2D). The connector tube has a stopcock at its distal end that attaches to the catheter (Figure 144-2E). The proximal end of the connector tube has a flared flange to attach to a urine drainage system.

As with all procedures, the risks and benefits of suprapubic bladder catheterization should be discussed with the patient and/or their representative. Obtain an informed consent and place it in the medical record.

Place the patient supine. Clean any dirt and debris from the abdominal wall. Shave the lower abdomen if the patient is hirsute. Identify the bladder by palpation, percussion, and/or ultrasonography. Apply povidone iodine or chlorhexidine solution to the lower abdomen, from the umbilicus to the pubis, and allow it to dry. Consider the administration of parenteral analgesics, sedatives, or procedural sedation as this is a painful procedure.

Anesthetize the abdominal wall. Fill a 10 mL syringe with local anesthetic solution. Apply a 24 to 25 gauge spinal needle onto the syringe. Identify the insertion site in the midline and 4 to 5 cm above the pubic symphysis. The use of ultrasound to verify the bladder location and to ensure that no loops of bowel are present between the abdominal wall and bladder is recommended.9 Make a skin wheal with the local anesthetic solution at the insertion site. Insert the spinal needle at a 20° to 30° angle from true vertical and aimed caudally (Figure 144-3A). Advance the needle through the subcutaneous tissue, rectus sheath, and retropubic space while simultaneously aspirating and injecting 5 to 10 mL of local anesthetic solution. A loss of resistance will be felt as the spinal needle traverses the rectus sheath and enters the retropubic space. Continue to aspirate while advancing the spinal needle until the bladder is entered and urine fills the syringe. The bladder appears to tent as the needle pierces its anterior wall when ultrasonographic guidance is used.8 Note the needle direction and depth of insertion required to enter the bladder.

Seldinger Technique with a Peel-Away Sheath

This method is similar to that of placing a central venous catheter. The needle is used to locate the bladder. Place the needle on a 10 mL syringe. Insert the needle through the skin wheal of local anesthetic solution located in the midline and 4 to 5 cm above the pubic symphysis. Direct the needle caudally and at a 20° to 30° angle from the true vertical (Figure 144-3A). It is important to ensure that the needle enters, and is advanced, in the midline. This area is avascular. If the needle is paramedian, it may traverse the rectus muscles and inferior epigastric vessels resulting in significant hemorrhage. Advance the needle caudally while applying negative pressure with the syringe. Stop advancing the needle when urine is aspirated into the syringe. Advance the needle an additional 2 to 3 cm into the bladder from the point at which urine is initially aspirated into the syringe. The aspiration of urine will confirm the proper position of the needle within the bladder.

Firmly hold the needle against the abdominal wall. Carefully remove the syringe from the needle. Do not allow the needle to move as it may shear the bladder wall. Advance the guidewire through the needle and into the bladder (Figure 144-3B). Withdraw the needle over the guidewire while leaving the guidewire in place. Make a superficial stab incision with the #11 scalpel blade adjacent to the guidewire. This will facilitate passage of the dilator and sheath. Insert the dilator through the peel-away sheath. Advance the dilator and peel-away sheath as a unit over the guidewire and into the bladder (Figure 144-3C). Remove the guidewire and dilator as a unit (Figure 144-3D), leaving only the peel-away sheath (Figure 144-3E).

Insert a Foley catheter through the peel-away sheath and completely into the bladder (Figure 144-3F). The Foley catheter should be two sizes (2 French) smaller than the size of the peel-away sheath. Urine should spontaneously flow from the Foley catheter. If not, insert a 60 mL catheter-tipped syringe into the Foley catheter and aspirate (Figure 144-3G). The flow of urine will confirm that the catheter is properly positioned within the bladder. Inflate the cuff of the Foley catheter. Attach a urine collection system to the proximal end of the Foley catheter (Figure 144-3H).

Remove the peel-away sheath. Grasp the free ends or arms of the peel-away sheath. Pull the free ends upward and opposite each other (Figure 144-3H). The peel-away sheath will split in half as it is withdrawn over the Foley catheter and out of the abdominal wall. Gently withdraw the Foley catheter to lodge the cuff against the bladder wall (Figure 144-3I).

Obturator Technique

Prepare the equipment. Insert the obturator through the catheter and lock it in position. Inflate the cuff with sterile saline and check its integrity. Deflate the cuff. Inflate and deflate the cuff two more times to soften the cuff. The spinal needle was previously used to infiltrate local anesthetic solution and locate the urinary bladder. This maneuver allows the operator to determine both the depth and angle needed for bladder entry.

Make a 3 to 4 mm stab incision in the midline and 4 to 5 cm above the pubic symphysis through the skin wheal of local anesthetic solution with a #11 scalpel blade. Place the tip of the obturator-catheter unit in the skin incision. It is important to ensure that the unit enters, and is advanced, in the midline. This area is avascular. If the unit is paramedian, it may traverse the rectus muscles and inferior epigastric vessels resulting in significant hemorrhage. Direct the unit caudally and at a 20° to 30° angle from true vertical (Figure 144-4A). Place the nondominant hand on the lower abdominal wall. Grasp the tip of the obturator-catheter unit with the thumb and index finger of the dominant hand. The hand and fingers will stabilize the unit and control the depth of insertion.

Advance the obturator-catheter unit with the dominant hand. Resistance may be felt as the trocar traverses the linea alba. Apply firm pressure to the unit to advance through the linea alba. Do not plunge as the unit is advanced. Continue to advance the unit through the retropubic space until resistance is felt. The tip of the trocar is now against the anterior bladder wall. Advance the unit with a short and rapid stabbing motion to enter the bladder (Figure 144-4A). Urine should spontaneously flow from the proximal end of the obturator. If not, attach a syringe to the obturator and aspirate. The flow of urine will confirm that the tip of the obturator-catheter unit is properly positioned within the bladder. Advance the unit an additional 2 to 3 cm into the bladder to ensure the cuff is completely within the bladder.

Inflate the cuff of the catheter (Figure 144-4B). Unscrew the obturator from the catheter. Securely hold the catheter, with the nondominant hand, as it exits the abdominal wall. Remove the obturator from the catheter (Figure 144-4C). Attach the stopcock at the distal end of the connector tube to the catheter (Figure 144-4D). Gently withdraw the catheter to lodge the cuff against the bladder wall. Attach a urine collection system to the proximal end of the connector tube.

Ultrasound (US) can ensure there is sufficient urine to aspirate and locate a bladder that is located off midline or deep in the pelvis.10 It is especially helpful in infants and toddlers, who have small bladders. There are no contraindications to using ultrasound other than those for the procedure itself. For adults, a general-purpose curvilinear abdominal or phased-array probe provides the best combination of penetration and field of view into the abdomen. A linear probe can be used for children. Either a static or dynamic (real-time) technique can be used. The static technique is preferred as it is the easier technique to learn and master. The dynamic technique will increase the success rate for small bladders with minimal urine.

Image the bladder to ensure there is sufficient urine to aspirate. Place the US probe transversely and just superior to the pubic symphysis. If the bladder is not immediately visible, slowly fan the probe cephalad and caudal until it appears. If the bladder is not visible, repeat the scan just off the midline. The bladder will appear anechoic (Figure 144-5). Moderate to large bladders are amenable to the static US technique. Bladders smaller than 2 cm in anteroposterior or transverse diameter have lower success rates for aspiration and the dynamic US technique may be necessary to obtain urine.

Static US Technique

Identify the bladder using US and center the image on the US machine screen. Angle the US probe so that the largest dimensions of the bladder appear on the screen. Note the angle of the US probe as this will correspond to the angle of entry for the needle. Make sure that the bladder is centered on the screen. Move the probe off midline, if necessary, to minimize lateral angulation. This will prevent the need to angle the needle laterally to reach the bladder. Note the depth on the screen from the skin to the bladder in order to gauge the necessary needle length. Mark the entry point on the skin where the middle of the probe meets the skin. Prep the skin and proceed with procedure as described previously for either the Seldinger or obturator technique.

Dynamic US Technique

Prepare the skin, apply sterile single-use US gel to the patient's skin, and apply a sterile US probe cover. Stand to the side of the patient so that your dominant hand is cephalad (Figure 144-6). Position the US monitor on the opposite side of the patient so that it is easy to see (Figure 144-6). A longitudinal US probe orientation is preferred for the dynamic approach since it allows visualization of the entire needle as it courses toward the bladder. In infants and toddlers, there may not be enough space to place the US probe longitudinally and a transverse probe orientation may be necessary. In either case, place the US probe marker to your left. This will ensure that the left–right orientation on the US screen matches the real-world orientation.

Place the longitudinally oriented US probe in the suprapubic area and move it from side to side to locate the largest bladder dimension. Place the procedure needle on a 10 mL syringe. Position the procedure needle on the cephalad side of the US probe and angle it caudally (Figure 144-7). Insert and slowly advance the needle. Look for the needle on the US screen as it is inserted and advanced. If the needle is a narrow gauge and the US probe is low frequency, the needle will not necessarily be visible in the tissue. Rather, look for movements in the tissue as the needle is advanced (Figure 144-8). Adjust the needle and the US probe side to side as needed to keep the needle in the same plane as the US beam. Aspirate as the needle is advanced. When the needle appears to enter the bladder, aspiration should result in urine return. Remove the US probe once urine is aspirated. The remainder of the procedure for the Seldinger technique can proceed as previously described. The US procedure is the same if using the obturator technique; just substitute the catheter-obturator unit for the needle described above.

For the transverse orientation, position the US probe so that the image of the bladder is centered on the screen. Position the procedure needle attached to a syringe just superior to the center of the US probe (Figure 144-9). Slowly advance the needle toward the bladder. Angle the needle slightly more caudal than the US probe since the entry point of the needle is superior to the US probe. The needle will be seen on screen in cross section and will appear as an echogenic point with a ring-down artifact or bright shadow (Figure 144-10). As the needle is advanced toward the bladder, the US probe may need to be fanned slightly cephalad or caudal to keep the needle tip in view. Aspirate as the needle is advanced. When the needle appears to enter the bladder, aspiration should result in urine return. Remove the US probe once urine is aspirated. The remainder of the procedure for the Seldinger technique can proceed as previously described. The US procedure is the same if using the obturator technique; just substitute the catheter-obturator unit for the needle described above.

The return of urine confirms the correct placement of the catheter into the bladder. If the catheter ceases to work after initially functioning properly, inspect it for kinks. Flush the catheter with sterile saline to remove any potential clots. A catheter that flushes easily but cannot be subsequently aspirated suggests that the tip has been withdrawn into the perivesical space of the pelvic cavity or that the catheter is kinked. The catheter is kinked if saline cannot be flushed through or aspirated. The catheter is properly positioned within the bladder if saline flushes and aspirates without difficulty. Consider the use of ultrasound to confirm catheter placement and presence of urine within the bladder.

Secure the catheter to the abdominal wall (Figure 144-11). Place 4 × 4 gauze squares over the pubic symphysis to bolster the catheter as it exits the abdominal wall. Apply tincture of benzoin to the abdominal wall and allow it to dry. Tape over the catheter and gauze. The ends of the tape should be applied to the dried benzoin solution. Prophylactic antibiotics are not required unless a urinary tract infection is present.

Examine the puncture site twice a day for any signs of infection. Routine wound care should be performed at the puncture site. If removed within 7 days, the bladder wall and abdominal wall will heal without complications. A transurethral catheter should be inserted to ensure urine egress through the urethra and not the bladder wall while the suprapubic catheter tract heals. After 10 to 14 days, the tract of the catheter is epithelialized and mature. The catheter may be exchanged through the mature tract if necessary. Suprapubic tubes should not be left in place for more than 4 weeks.9

Bowel perforation, intraabdominal visceral injury, uncontrolled hemorrhage, vascular injury, peritonitis, catheter misplacement, and catheter migration are the major complications of suprapubic cystostomy catheter placement.1–11 Perforation of the bowel can be prevented by ensuring that the bladder is distended by palpation, percussion, or ultrasonography. Intraperitoneal perforation is more common in patients with ascites, a distended abdomen, or prior abdominal surgery. Gross hematuria is common and transient. Through-and-through perforation of the bladder can injure the rectum, vagina, and/or uterus. Other minor complications are associated with length of indwelling catheter time and include infections (e.g., cellulitis and abscesses), occasional bleeding, and stone formation.

When catheter placement is in doubt or when a previously draining tube no longer continues to drain, simple flushing and irrigation will usually suffice. Bedside ultrasound is a quick means to confirm catheter placement. However, if concern persists, a gravity cystogram under fluoroscopy is diagnostic. In the unfortunate situation when bowel contents or continuous blood is aspirated or flows from the catheter, the appropriate surgical consultations should be obtained.

In those clinical situations when transurethral bladder decompression is no longer an option, percutaneous access is the preferred alternative. Years of experience have demonstrated suprapubic bladder catheterization to be an effective and relatively safe method of accessing the bladder. A prior understanding of the associated anatomy is paramount to avoid of adverse results.