Catheterization of the Urinary Bladder and Suprapubic Cystostomy

Choosing a method for bladder emptying Urinary Catheter Policies for Short-Term Bladder Drainage in Adults

• Repeated catheterization is the preferred method Urinary Catheter Policies for Short-Term Bladder Drainage in Adults.
• 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 .
• If the urine is bloody a Ch 16 PVC catheter can be used Urinary Bladder Tamponade (Blood Clots in the Bladder).
• 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.

Catheterization Antiseptic Impregnated Urethral Catheters for Short-Term Use, Antibiotics for Short-Term Urethral Catheterization, Removal of Short-Term Indwelling Urethral Catheters

• Wash the urethral orifice with an antiseptic solution (e.g. 0.01% chlorhexidine).
• Inject 20 ml gel into the urethra of men (and somewhat less for women). Use preferably a gel containing a local anaesthetic.
• 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 try a Thieman catheter. 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.

Suprapubic cystostomy Urinary Catheter Policies after Urogenital Surgery

• Videos: Suprapubic cystostomy Suprapubic Cystostomy and Replacing a cystostomy catheter using a guide wire Replacing a Cystostomy Catheter Using a Guide Wire
• Inserting the catheter
  1. Check that the procedure is indicated.
  2. 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.
  3. Clean the skin with e.g. 0.01% chlorhexidine solution.
  4. Infiltrate 1% lidocaine in the skin fold just above the symphysis (approximately the width of two fingers) or just proximal to it with a long thin needle (e.g. a lumbar puncture needle). Aspiration of urine confirms the location of the bladder and its depth. Do not inject the aspirated urine into the tissues of the abdominal wall while drawing the needle back. It is important to inject the anaesthetic also to the bladder wall.
  5. Make a small skin incision with a lancet, insert the cystostomy needle perpendicular to the skin into the bladder, and insert the catheter.
  6. Withdraw the needle and ensure that the catheter is not withdrawn. Remove the needle.
  7. Fix the catheter either by inflating the balloon or by sutures.
  8. 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.
• The catheter is changed every 3 months. However, if the catheter does not become encrusted the frequency may also be every 4 months. If the balloon cannot be emptied when the catheter is to be changed it can be punctured under ultrasound guidance or through cystoscopy.

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 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 by water. Additional 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.

Long-term catheterization Types of Indwelling Urinary Catheters for Long-Term Bladder Drainage in Adults, Long-Term Bladder Management by Intermittent Catheterisation in Adults and Children

• A silicone catheter (size 12-14) is preferable. A PVC catheter (with a larger internal diameter) is most practical if the urine is bloody and flushing of the bladder 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 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]