How should a suprapubic catheter (cystostomy) be removed and the tract closed in an adult, particularly if there is recent infection or the catheter has been in place for more than two weeks?

Suprapubic Catheter (Cystostomy) Removal and Tract Closure

For suprapubic catheters in place less than 2 weeks, simply remove the catheter after deflating the balloon and allow the tract to close spontaneously; for catheters in place longer than 2 weeks, remove the catheter and expect the tract to close within 24-48 hours, but if closure fails or if recent infection is present, consider formal surgical closure with layered suturing of the bladder and abdominal wall. 1, 2

Removal Technique for Established Tracts (>2 Weeks)

Standard Removal Process

• Deflate the balloon completely using a syringe to aspirate all fluid from the balloon port 3
• Gently withdraw the catheter in a steady, continuous motion 3
• If resistance is encountered, the catheter balloon may have developed a "cuffing" effect, particularly with 100% silicone catheters—do not force removal, as this can cause bladder or tract trauma 3
• For stuck catheters, re-inflate the balloon with 2-3 mL of sterile water, wait 30 seconds, then deflate again to release the cuff before attempting removal 3

Immediate Post-Removal Management

• Apply sterile gauze dressing to the suprapubic site after catheter removal 1
• Monitor for spontaneous tract closure within 24-48 hours in most patients with mature tracts 1, 2
• Ensure the patient can void spontaneously or arrange alternative bladder drainage (intermittent catheterization or temporary urethral catheter if no contraindications exist) 1, 4

Management Based on Duration of Catheterization

Short-Term Catheters (<2 Weeks)

• Spontaneous closure is expected within hours to 1-2 days 1
• No surgical intervention is typically required for tract closure 1
• Monitor for urinary leakage through the tract site 1

Long-Term Catheters (>2 Weeks)

• The tract becomes epithelialized and may not close spontaneously 1, 2
• Most tracts will still close within 24-48 hours after catheter removal even when mature 1, 2
• If the tract fails to close after 48-72 hours, formal surgical closure is indicated 1

Special Consideration: Recent Infection

Pre-Removal Assessment

• Obtain urine culture 24-48 hours before planned removal if the catheter has been in place for extended periods and infection is suspected 5
• Treat active symptomatic urinary tract infection (fever ≥38°C, suprapubic pain, systemic signs) with culture-directed antibiotics before elective removal 2, 4
• Do not treat asymptomatic bacteriuria prior to catheter removal, as this is universal in long-term catheterization and treatment does not prevent subsequent infection 2, 4

Antimicrobial Prophylaxis at Removal

• Antimicrobial therapy at catheter removal may be therapeutic rather than prophylactic since colonization has likely occurred with prolonged catheterization 5
• One option is to administer culture-directed therapy based on pre-removal urine culture 5
• The alternative is to administer empirical antimicrobial treatment at the time of removal 5
• Duration of therapeutic treatment depends on host factors, duration of catheterization, and potential morbidity of infection—typically 24 hours to 7 days 5
• Prophylaxis should not extend beyond 24 hours in the absence of preexisting bacterial colonization or infection 5

Surgical Tract Closure Technique

Indications for Formal Closure

• Persistent urinary leakage through the suprapubic site beyond 48-72 hours 1
• Large-bore or long-standing tracts (>30 French or >6 months duration) that fail conservative management 1
• Patient preference for immediate definitive closure 1

Closure Procedure

• Excise the epithelialized tract down to the bladder wall 1
• Close the bladder defect in two layers using absorbable suture (e.g., 2-0 or 3-0 polyglycolic acid) 1
• Close the rectus fascia with interrupted or running absorbable suture 1
• Close skin and subcutaneous tissue in standard fashion 1
• Place urethral or new suprapubic catheter for 7-10 days to allow bladder healing 1

Common Pitfalls and How to Avoid Them

Forcing Catheter Removal

• Never force a stuck catheter, as this can cause bladder rupture or significant tract trauma 3
• Use the re-inflation technique described above or consider cystoscopy-guided removal if standard measures fail 3

Treating Asymptomatic Bacteriuria

• Do not obtain urine cultures or treat bacteriuria in asymptomatic patients with chronic suprapubic catheters, as this increases antimicrobial resistance without clinical benefit 2, 4
• Only treat when systemic signs of infection are present (fever, rigors, hypotension, altered mental status, or new suprapubic/flank pain) 2, 4

Inadequate Bladder Drainage After Removal

• Verify the patient can void spontaneously before removing the catheter, or arrange alternative drainage 1, 4
• If urinary retention develops after removal and the tract has closed, insert a temporary urethral catheter (if no contraindications such as urethral trauma, stricture, or acute prostatitis exist) while awaiting urology consultation 1

Prolonged Antimicrobial Use

• Avoid extending prophylactic antibiotics beyond 24 hours after catheter removal in the absence of documented infection 5
• Prolonged antimicrobial use selects for resistant organisms and increases risk of Clostridioides difficile infection 2, 4

Post-Removal Monitoring

• Inspect the suprapubic site daily for signs of persistent leakage, erythema, or purulent drainage 5, 1
• Monitor voiding function to ensure adequate bladder emptying 1, 4
• Watch for signs of urinary tract infection (fever, dysuria, suprapubic pain) in the first week after removal 2, 4
• If the tract fails to close by 72 hours or if significant leakage persists, refer for surgical closure 1