Chapter 6: Elimination
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Suprapubic catheterization
Evidence‐based approaches
Rationale
Suprapubic catheterization is the insertion of a catheter through the anterior abdominal wall into the dome of the bladder (Figure 6.13). The procedure is performed under general or local anaesthesia, using a percutaneous system (Robinson [213]). In 2009, a National Patient Safety Agency alert stated that the insertion of a suprapubic catheter should only be undertaken by experienced urology staff using ultrasound imaging, due to the risk of injury to the bowel (NPSA [179]).
Figure 6.13 Suprapubic catheter. Source: Reproduced with permission of Shutterstock.com.
Indications
Indications for the use of suprapubic catheters over indwelling catheters include the following:
- post‐operative drainage of urine after lower urinary tract or bowel surgery
- management of neuropathic bladders
- long‐term conditions, for example multiple sclerosis or spinal cord injuries
- people with long‐term catheters – to minimize the risk of urethral infections or urethral damage (NPSA [179]).
However, there are a number of risks and disadvantages associated with suprapubic catheterization (BAUS [14]):
- bowel perforation or haemorrhage at the time of insertion
- infection, swelling, encrustation or granulation at the insertion site
- pain, discomfort or irritation for some patients
- bladder stone formation and possible long‐term risk of squamous cell carcinoma
- urethral leakage and discharge from the insertion site is not uncommon.
Related theory
Evidence‐based research on the use of suprapubic catheters is limited (EAUN [71]). However, it is believed that there are advantages to their use when compared to urethral catheterization, such as greater patient comfort (especially for those who are chair bound) and greater ease of access to the entry site for cleaning and for catheter and drainage bag changing. The risk of patients developing infections from micro‐organisms commonly found in the bowel is reduced, as are the risks of urethral trauma, necrosis and catheter‐induced urethritis. Clamping the suprapubic catheter allows urethral voiding to occur, and the clamp can be released if voiding is incomplete. Patient satisfaction is increased as, for some, their level of independence is increased and sexual intercourse can occur with fewer impediments (EAUN [71]).
Post‐procedural considerations
Care of a suprapubic catheter is the same as that for a urethral catheter. Immediately following insertion of a suprapubic catheter, aseptic technique should be employed to clean the insertion site (Robinson [213]). Keyhole dressings around the insertion site may be required if secretions soil clothing, but they are not essential. Once the insertion site has healed (7–10 days), the site and catheter can be cleaned during bathing using soap, water and a clean cloth (Rigby [210]).
Changing a suprapubic catheter
Changes of a suprapubic catheter should be completed by staff who are appropriately trained and competent with regard to the technique and potential complications. It should be undertaken at the intervals recommended by the catheter manufacturer (EAUN [71]). The first change should take place no sooner than between 6–12 weeks.
The loss of the catheter tract can occur during a catheter change, usually as a result of the replacement catheter not being advanced into the bladder adequately so that the retaining balloon is inflated in the catheter tract, potentially causing trauma (RCN [208]). Partially filling the bladder with sterile saline or water before changing the catheter can be helpful in some cases (Sweeny [234]). Immediate access to a urology unit should be available in the event of a failed catheter change. It is advised that the first change takes place in a hospital for this reason; after this the tract should be well established. The second reason for the first change to take place in hospital is the very rare risk of a late presentation of bowel perforation at first catheter change.
Procedure guideline 6.6
