If this is not feasible (the patient has an obstruction, urinary output/hour must be monitored, catheterization cannot be performed at home in long-term care, or the patient has considerable retention > 1 000 ml) suprapubic cystostomy is preferred. It is also well suitable for long-term catheterization.
Suprapubic cystostomy is particularly useful for checking that urine production starts to function. It is also easier for the patient than repeated catheterization.
If the need for catheterization is temporary, the capacity of the bladder is small, or there are operative scars in the lower abdomen (risk of bowel perforation at insertion in cystostomy) a thin silicone or PVC catheter should be used.
If ultrasonography is available immediately before percutaneous cystostomy, the absence of bowel between the bladder and the abdominal wall can be confirmed relatively reliably.
A permanent indwelling catheter should not be inserted without a medical cause in an incontinent patient in long-term care.
Long-term catheterization is always associated with bacterial colonization. Therefore, only symptomatic infections should be treated. Infection of a suprapubic cystostomy catheter can be delayed by taking care of its base.
Catheters
The number of the catheter gives its circumference in millimetres. The diameter of the catheter is roughly the circumference divided by 3.
Silicone and PVC are the most suitable materials for long-term catheterization as they cause the least tissue irritation.
Wash the urethral orifice (normal saline solution suffices).
Inject 20 ml gel into the urethra of men (and somewhat less for women). Use preferably a gel containing a local anaesthetic. In men, the gel should also reach the posterior urethra (area of the prostate).
Both gel injection and insertion of the catheter should be performed gently and slowly.
In men the penis should be straightened to an angle of 90 degrees to the body in order to facilitate catheter insertion.
Fill the balloon only after making sure that both the tip of the catheter and the balloon are in the bladder: the urine flows freely, or if the bladder is empty, saline solution injected into the catheter flows in easily.
If the catheter cannot be inserted with gentle handling, a Thieman catheter may be tried. Do not attempt repeatedly but perform a cystostomy. If the patient has an enlarged prostate, changing to a bigger catheter is often helpful. If the patient has had transurethral prostatic resection, simultaneous transrectal lifting of the prostate makes it easier for the catether to find its way to the bladder.
The catheter should be changed every 3 months. However, provided that the catheter does not become encrusted, the frequency may also be every 4 months. It is important to rotate the catheter regularly to prevent formation of adhesions. If the balloon cannot be emptied when the catheter is to be changed it can be punctured under ultrasound guidance or through cystoscopy.
Insertion of a cystostomy catheter
Inserting the catheter
Check that the procedure is indicated.
The bladder should be filled with over 300 ml of urine (urinary retention or a minimum of 4 hours since last voiding). If ultrasonography is easily available, determining the location and volume of the bladder before the procedure is always recommended Determining the Volume of Residual Urine by Ultrasonography. Use ultrasonography also to ensure that there is no bowel between the bladder and abdominal wall, if the patient has a surgery scar on the lower abdomen.
Clean the skin of lower abdomen with e.g. 0.01% chlorhexidine solution.
Infiltrate the puncture route with 1% lidocaine in the skin fold area just above the symphysis (approximately the width of two fingers from symphysis) or just proximal to it with a sufficiently long thin needle (e.g. a lumbar puncture needle). Confirm the location of the bladder and its depth by aspiration of urine. Do not inject the aspirated urine into the tissues of the abdominal wall while drawing the needle back. It is important to anaesthetize also the bladder wall.
Make a small skin incision with a lancet for the cystostomy needle, insert the cystostomy needle perpendicular to the skin into the bladder, and insert the catheter through the needle.
Withdraw the needle and ensure that the catheter is not withdrawn. Remove the needle.
Fix the catheter either by filling the balloon or by placing a suture on the abdominal skin.
The patient can try to void with the catheter in place (after it has been closed). If voiding is repeatedly successful and the residual volume is less than 200 ml, a catheter inserted because of urinary retention can be removed.
Changing the catheter (without a guide wire)
Check that the catheter has been closed for a few hours before the procedure (so that there is urine in the bladder) and that a new catheter of the same size is available for the change.
After cleaning the base of the cystostomy catheter, apply half of the anaesthetic gel to the base of the catheter and move it a couple of centimeters up and down while rotating it. Apply the remaining anaesthetic gel to the tip of the new catheter.
Assistant should empty the catheter balloon completely.
Remove the old catheter by pulling with a steady force and then insert the new catheter immediately, approximately to the same depth.
Fill the balloon (10 ml glycerol/hypertonic sodium chloride fluid; no other fluids are allowed!). While filling the balloon, if the patient reports pain or resistance is felt, the catheter is either in too deep or too superficial position: change the catheter's position and try again.
After changing the catherer, check that urine starts to enter the catheter (you can gently press the lower abdomen to empty the bladder) and that the cathere remains in place (pull the catheter until the balloon stops the movement).
Practical challenges in treatment involving a cystostomy catheter
No urine enters the catheter after the procedure.
The bladder was probably empty during the procedure (the valve/spigot had not been closed, or the patient's hydration status is poor).
Irrigate with 50-100 ml normal saline.
If the liquid coming out of the catheter is slightly yellow, the catheter is in the correct position and no further actions are needed.
If the colour of the normal saline does not change, ask the patient to drink and monitor diuresis.
If no urine comes into the catheter within 2 hours, it is likely that the catheter is in a wrong position and the patient should be referred as an emergency case to a hospital for assessment.
Blood or blood clots enter the catheter after the procedure.
The mucosa of the bladder or the stoma channel has been injured and bleeds.
If the patient clearly has pain, refer immediately as an emergency case to a hospital for an assessment.
If there is only a scant amount of blood, i.e. the urine looks like mildly red (lingonberry) juice, the situation can be monitored for a day, even for several days, provided that the amount of blood reduces during follow-up.
If there are blood clots in the catheter, irrigations should be performed to ensure unobstructed passage for the urine.
Catheter bypassing (leakage)
A minor occasional bypassing is common.
If there is more substantial leakage, check that urine drains without problems (no blood clots or precipitates causing obstruction, the spigot/valve is not closed for too long; change over to a urinary bag, as necessary).
Consider changing the size of catheter if no other cause presents for the problem.
Catheter spontaneously falls out between changes
Try inserting a new catheter.
Insertion of a new catheter is usually possible within a few hours, since opening of the stoma is still open.
If more than 6 hours have passed since the catheter fell out, it is better to immediately refer the patient for an assessment to a hospital where a completely new cystostomy can be performed, as necessary.
If the catheter has fallen out without pulling/plucking it, the balloon may have deflated due to wrong fluid (isotonic normal saline) or ruptured due to sharp urinary calculi.
If you suspect that the balloon has ruptured, refer the patient to an urologist for a cystoscopy assessment (whereby the bladder can be cleaned from urinary stone materials).
Repeated catheterization
The most physiological means of emptying the bladder.
Teach the patient in the hospital (and provide written instructions).
Catheterization should be repeated frequently enough so that the bladder is not filled above 500 ml.
If the patient is totally unable to void spontaneously, the recommended minimum frequency is 4 times a day. If the treated residual is large, fewer catheterizations may suffice.
The best catheter type is one that has been covered with a hydrophilic lubricant and that can be moistened and lubricated before the procedure by normal saline solution or water. Lubrication with gel is thus not needed.
In self-catheterization it is sufficient for the patient to wash hands well before the procedure. In hospital aseptic techniques should be used.
Antimicrobial medication is not recommended. Only symptomatic infections are treated. Routine urine specimens are not collected as most patients undergoing repeated catheterization have bacteriuria that has no clinical significance.
A silicone catheter (size 12-14) is preferable. A PVC catheter (with a larger internal diameter) is practical especially if the urine is bloody and irrigation is necessary.
In long-term catheterization the balloon should be filled with 5% saline or glycerol solution.
The catheter must not be pulled downwards by gravity (risk for iatrogenic hypospadias) and the bag should always be positioned below the urinary bladder (use a thigh bag).
Prophylactic antibiotics are not indicated for a patient with an indwelling catheter Urinary Catheter Policies for Long-Term Bladder Drainage. Symptomatic UTIs should be treated. Before starting medication take a sample by puncturing the catheter aseptically.
References
Lamont T, Harrison S, Panesar S, Surkitt-Parr M. Safer insertion of suprapubic catheters: summary of a safety report from the National Patient Safety Agency. BMJ 2011 Feb 24;342():d924. [PubMed]
Ellahi A, Stewart F, Kidd EA et al. Strategies for the removal of short-term indwelling urethral catheters in adults. Cochrane Database Syst Rev 2021;(6):CD004011. [PubMed]
Prieto JA, Murphy CL, Stewart F et al. Intermittent catheter techniques, strategies and designs for managing long-term bladder conditions. Cochrane Database Syst Rev 2021;(10):CD006008. [PubMed]