Suprapubic Catheterization Technique
Suprapubic catheterization should be performed using ultrasound guidance whenever possible to minimize the risk of bowel perforation and vascular injury, with the procedure involving percutaneous insertion of a catheter through the lower abdominal wall into the bladder under local anesthesia. 1, 2
Pre-Procedure Requirements
Patient Selection and Contraindications
- Avoid the procedure in patients with: 3, 2
- Previous lower abdominal surgery (risk of bowel adhesions)
- Inadequately distended bladder
- Acute pelvic trauma
- Suspected bladder cancer (relative contraindication)
Bladder Preparation
- Ensure adequate bladder distension (typically >300-400 mL) to displace bowel loops away from the puncture site 3, 2
- Confirm bladder fullness by clinical palpation and percussion, though ultrasound verification is superior 3, 2
Step-by-Step Procedure
Equipment Setup
- Use either a reusable stainless steel trocar system or disposable commercial kits 3
- Have a Foley catheter (typically 14-16 Fr) ready for insertion 3
- Ultrasound machine should be available to guide needle placement 1, 2
Technique
Position and prepare: Place patient supine, identify insertion site 2-3 cm above pubic symphysis in midline 3, 4
Ultrasound guidance: Use real-time ultrasound to visualize the bladder, confirm adequate filling, and identify any bowel loops in the trajectory path 1, 2
Local anesthesia: Infiltrate skin and deeper tissues down to bladder wall with local anesthetic 3
Skin incision: Make a small (5-10 mm) vertical incision through skin only 3
Trocar insertion: Advance the trocar through the abdominal wall at a slightly caudal angle (aiming toward the pelvis) with controlled pressure until bladder entry is confirmed by urine return 3, 4
Catheter placement: Remove the obturator while an assistant immediately inserts the Foley catheter through the trocar sheath 3
Balloon inflation: Rapidly inflate the balloon with appropriate volume (typically 10 mL) once catheter is fully inserted 3
Secure catheter: Apply gentle traction for approximately 5 minutes to ensure balloon is seated against bladder wall and achieve hemostasis 3
Critical Safety Measures
Ultrasound Use is Essential
- The British Association of Urological Surgeons strongly recommends ultrasound guidance whenever possible to reduce bowel injury risk, which occurs in up to 2.4% of blind insertions with a mortality rate of 1.8% 2
- Real-time visualization during needle puncture significantly reduces complications 1, 2
Common Pitfalls to Avoid
- Never attempt insertion with an inadequately filled bladder - this is the primary cause of bowel perforation 3, 2
- Avoid excessive force during trocar advancement - controlled, steady pressure is safer 3
- Do not delay balloon inflation after catheter insertion, as this can lead to catheter malposition 3
- Ensure the catheter is fully advanced before inflating the balloon to prevent urethral or bladder neck injury 3
Post-Procedure Management
Immediate Care
- Confirm adequate urine drainage and secure catheter to abdominal wall 5, 3
- Monitor for complications including hematuria (usually self-limiting), bleeding, or signs of bowel injury 1, 3
- The procedure typically takes less than 5 minutes when performed by experienced operators 3
Expected Outcomes
- Minimal hematuria is common and typically resolves within 24-48 hours 3
- Patients should be educated about catheter care, including maintaining closed drainage system 6, 5
When to Choose Suprapubic Over Urethral Catheterization
Suprapubic catheterization is preferred for long-term bladder drainage as it demonstrates significantly lower rates of catheter-associated bacteriuria (relative risk 2.60 for urethral vs. suprapubic), reduced urethral complications, less patient discomfort (relative risk 2.98 for discomfort with urethral vs. suprapubic), and allows attempts at normal voiding without recatheterization 1