After having suprapubic catheterization for around four to eight weeks, the bladder requires training to work as before. “Suprapubic catheterization is an increasingly common procedure undertaken by Urologists. Indications include recurrent problems passing urethral catheters, urethral trauma, long term incontinence management and suitability for patients. The procedure retains a high level of satisfaction among its recipients, but is not without complications.”1
A suprapubic urinary catheter is used for draining urine when the urethra or the bladder have been damaged or are convalescent. The catheter goes through a surgical incision above the pubic bone (hence the term supra which means above and pubic in reference to the pubic bone).
“Suprapubic catheter insertion is widely used to manage acute or chronic urinary retention and neurological diseases (e.g., multiple sclerosis and spinal cord injury) […] The procedure may also be performed during investigative or surgical procedures or for postoperative bladder drainage, including cystoscopy, ultrasound-assisted positioning, and auxiliary transurethral catheterization.”2
Suprapubic Catheter Benefits
After surgery, prolonged use of a suprapubic catheter can deter bladder functions from returning to normal. ‘Bladder training’ helps patients resume their bladder’s natural work. Some of its benefits are:
- “Less urethral trauma,
- More positive body image, able to use more discreet and purpose-made urine drainage bags,
- Greater comfort, especially for wheelchair-bound patients,
- Able to access entry site easily for cleansing,
- Greater freedom of expression of sexuality,
- Easier trial without catheter (TWOC) as a catheter valve can be used, enabling the patient to void urethrally.”3
The benefits of suprapubic catheterization are commonly greater than the disadvantages. “Frequent postoperative complications of suprapubic catheter insertion include hematuria, urinary tract infections, and catheter obstruction”4
Reasons for a Suprapubic Catheter
- “Urinary retention
- Inability to pass a urethral catheter due to an obstruction
- Trauma to the pelvis or urinary tract
- The patient’s inability to tolerate a urethral catheter
- Following pelvic or urinary tract surgery
- To minimize the risk of urethral trauma
- A need for long term catheterization.”5
Training the bladder
Training the bladder requires preventing the catheter from continuously draining by clamping it during the day. To do this, adjust the ‘lock’ to the ‘closed’ position.
- Leave it closed for about 2-3 hours. During that time, some urine will accumulate in the bladder. Attempt to empty the bladder naturally (without unclamping the catheter) into a measuring container and write down the amount of urine drained.
- After passing urine naturally, release the ‘lock’ by turning it to the ‘on’ position. Drain residual urine from the bladder, gauge it and record it.
- Clamp the catheter again and redo this process every 2-3 hours throughout the day. Once less urine residue flows through the catheter, it means bladder training is progressing. Increasing amounts of urine passed naturally will also indicate improvement.
- Allow the catheter to drain freely at night attaching a urine drain bag. Uncap the drain bag, connect it to the catheter and set the catheter lock to the ‘on’ position. Bladder training resumes as soon as you wake up in the morning.
- The last part of home bladder training is clamping the catheter overnight. If urine residue measures less than 100ml in the morning, call your doctor for scheduled catheter removal (usually within 24 hours except for weekend). If the amount of urine collected reaches about 100 ml during a 24-hour period, also schedule a catheter removal appointment. Meanwhile, clamp the catheter. If you feel excessive bladder pressure, unclamp the catheter and restart bladder training. Keep your doctor informed about this.
- Continue emptying your bladder every 2-3 hours until the removal of the catheter. Adhere to prescribed antibiotics or other medications as instructed. Keep a daily report with your bladder training results.
Bladder Emptying Hygiene
- “Empty the drainage bag when it is full or at least every 8 hours
- Wash your hands with soap and water. If you are emptying another person’s collection bag, you may wish to wear disposable gloves.
- Remove the drain spout from its sleeve at the bottom of the collection bag. Open the valve on the spout.
- Let the urine flow out of the bag and into the toilet or a container. Do not let the tubing or drain spout touch anything.
- After you empty the bag, wipe off any liquid on the end of the drain spout. Close the valve and put the drain spout back into its sleeve at the bottom of the collection bag.
- Wash your hands again with soap and water.”6
Considerations when wearing a suprapubic catheter
- Shower only with protective dressings on.
- Do not direct water to the catheter insertion site.
- Avoid using a bathtub with the catheter on.
- “Personal hygiene is very important to prevent infection
- Wash around your catheter (twice a day) and the surrounding area using plain soap and water and remove any crusting
- Pat dry. Do not use scented soap or talcum powder
- Change clothing and washcloths every day
- Gently roll the catheter between your thumb and forefinger once a day (preferably after a shower)
- Move the catheter in a cross (+) shape to allow the stoma to form
- Keep the catheter taped to your abdomen to prevent pulling
- All disposable drainage bags (including leg and overnight bags) must be disposed of into the garbage after 10 days of use
- A drainage bottle can be used for 6 months and the tubing changed every 3 months. To be changed earlier if in poor condition (ie. cloudy tubing)
- Always keep the bag below the bladder level to ensure good drainage and avoid kinking of the catheter tubing.”7
Potential Complications of Suprapubic Catheter Use
Suprapubic catheterization is a relatively safe procedure, especially if you have good hygiene practices, though it also depends on the approach. “Contraindications to suprapubic cystostomy are relatively few, and they depend on the approach being utilized. Percutaneous approaches are contraindicated in a non-distended bladder, and in the setting of bladder malignancy. The former places the patient at substantial risk of inadvertent bowel or vascular injury. Relative contraindications for suprapubic cystostomy include whether open or percutaneous include active skin infection, coagulopathy, osteomyelitis of the pubis, and orthopedic hardware of the pubic symphysis.”8
“Insertion of a suprapubic catheter is usually done using a trocar system. This may be done using cystoscopy or ultrasound guidance. Intraoperative complications of suprapubic catheter insertion areis higher in patients with a neuropathic bladder than those with insertion for bladder outlet obstruction (BOO). This may be because the bladder is harder to fill in the neuropathic group. There is a small risk of small bowel injury due to adhesions or failure of the filled bladder to adequately push away small bowel loops. Bowel injuries occurred in 2.4% of patients. Mortality rate has been reported in a study of 232 patients at 1.8%. These are often frail elderly patients that are having the catheter inserted usually under general anesthetic or local anesthetic and sedation, so the risks need to be considered compared with continuing with urethral drainage.”9
Instances when you should contact your health professional
“Call your doctor now or seek immediate medical care if:
- Your catheter becomes blocked and urine does not collect in the drainage bag.
- Your catheter leaks.
- You have blood or pus in your urine.
- You have pain in your back just below your rib cage. This is called flank pain.
- You have a fever, chills, or body aches.
- You have groin or belly pain.
- Your urine is cloudy or smells bad.
- You have pain, increasing redness, or bleeding around the catheter.
- You have swelling around the catheter or in your belly.”10
- Body temperature is101ºF or higher (could be a sign of infection).
- Redness and swelling around the catheter insertion point.
- If the catheter falls out.
- If the dressings come off.
Constantly observe hygiene before and after touching your suprapubic catheter. Wash your hands with soap and water for at least 15 seconds. Alternatively, if no visible dirt is on your hands, alcohol hand sanitizer may suffice.
“Generally changing a SPC (suprapubic catheter) is easier and less uncomfortable for the patient. However, if the catheter inadvertently falls out, it may not be possible to reinsert the catheter down the same tract especially if some time has elapsed before this is performed. The patient may then have to undergo a further suprapubic catheter insertion under anesthetic.”11 Avoid this situation listening and following the doctor’s indications, and carefully treating the catheterization area.
“SPC (suprapubic catheter) is a common procedure performed worldwide for bladder drainage when urethral access is not possible or advisable. It is an effective and even superior alternative to a chronic indwelling urethral catheter as it is easier to take care of and protects the urethra. Literature from different countries supports the role of SPC for continued bladder drainage.”12 However, patients require time to feel the urge to urinate after removing the catheter, so the bladder may not empty completely at first. Training it to return to normal functioning is an important step during the recovery process. Patients should also check the amount of urine expelled through the urethra to verify if the bladder is working properly.
(1, 4) Suprapubic catheterization complicated by an iatrogenic enterocutaneous fistula: a case report. Barai, K., & Islam, S. Cases Journal. 2009. https://casesjournal.biomedcentral.com/articles/10.1186/1757-1626-2-9311
(3, 5) Urinary Catheter Care Guidelines. Houghton, M. NHS Southern Health. 2017. http://www.southernhealth.nhs.uk/_resources/assets/inline/full/0/70589.pdf
(2) Development and evaluation of a training model for paracentetic suprapubic cystostomy and catheterization. Gao, W., Ou, T., Jia, J., Fan, J., Xu, J., Cui, X., He, X., & Li, X. Clinics Journal. 2019. https://www.clinicsjournal.com/article/development-and-evaluation-of-a-training-model-for-paracentetic-suprapubic-cystostomy-and-catheterization/
(6, 10) Suprapubic Catheter Care. HealthWise. Michigan Medicine: University of Michigan. 2018. https://www.uofmhealth.org/health-library/abo8459
(7) Caring for and Changing your Supra-Pubic Catheter (SPC). Queensland Health. Fact Sheet. 2017. https://www.health.qld.gov.au/__data/assets/pdf_file/0024/422619/spc-care.pdf
(8) Suprapubic Bladder Catheterization. Corder, C., & LaGrange, C. StatPearls. 2018. https://www.ncbi.nlm.nih.gov/books/NBK482179/
(9, 10) Update on voiding dysfunction managed with suprapubic catheterization. English, S. Translational Andrology and Urology. 2017. http://tau.amegroups.com/article/view/14779/15701
(11, 12) Safe percutaneous suprapubic catheterization. Goyal, N., Goel, A., & Sankhwar, S. The annals of The Royal College of Surgeons of England. 2012. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3954289/