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Home , Cystoscopy, Suprapubic cystostomy

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Ins and Outs of Suprapubic – A Clinician’s Experience

Susan Bullman

Initial Insertion of Suprapubic In today’s evolving health care field, outpatient procedures are Catheters becoming more commonplace. Many patients with suprapubic Initial suprapubic catheters are now being seen in outpatient or home care settings. placement can occur by two dif- Addressing the educational needs of patients, family members, and ferent methods. In the author’s nursing staff is now more important than ever for successful patient institution, the urologist uses suprapubic catheter management. A basic understanding of how either a Stamey catheter under these catheters are initially placed is essential for proper care and local anesthesia or a Lowsley™ avoidance of possible complications. This review of initial placement tractor under moderate sedation of suprapubic catheters and post-insertion care is based on one clin- or anesthesia. Table 1 provides a ician’s experience and practice at a local hospital in Pennsylvania. definition of terms. In the state of Pennsylvania, physician’s assis- © 2011 Society of Urologic Nurses and Associates tants (PAs) and nurse practition- ers (NPS) do not perform initial Urologic Nursing, pp. 259-264. placement of suprapubic cathet - ers unless they have a supervi- Key Words: Suprapubic catheters, patient education, Stamey catheter, sion agreement and have had Lowsley™ tractor. additional credentialing. is the usual Objectives presenting patient symptom. Causes of urinary retention can 1. List the causes of urinary retention. include paraplegia, quadriplegia, 2. Explain the Stamey catheter procedure. multiple sclerosis, and urethral 3. Discuss the Lowsley™ tractor procedure. or perineal trauma. If initial 4. Discuss the process for changing a suprapubic catheter. attempts at placing a catheter via the have been unsuccess- ful, the urologist would then be consulted. After completing an considered if the patient’s blad- tion) would decrease the possibil- examination, the urologist may der was distended. The bladder ity of perforation into the bowel. choose to proceed with suprapu- must be distended for the proce- The Stamey catheter has a metal bic catheter placement. dure to be performed safely. To obturator that allows a guide wire understand this concept, it may to pass through the catheter and Stamey Procedure be helpful to imagine trying to assists with placement. A Stamey catheter would be insert a needle into a deflated bal- This procedure is generally loon as opposed to an over-inflat- performed under a local anesthet- ed balloon. This (bladder disten- ic and is considered clean tech- Susan Bullman, BSN, RN, CURN, is a Urology Procedure Unit Charge Nurse, St. Vincent Health Center, Erie, PA. Urologic Nursing Editorial Board Statements of Disclosure In accordance with ANCC-COA governing rules Urologic Nursing Editorial Board state- Note: Objectives and CNE Evaluation Form ments of disclosure are published with each CNE offering. The statements of disclosure for appear on page 264. this offering are published below. Susanne A. Quallich, ANP-BC, NP-C, CUNP, disclosed that she is on the Consultants’ Statement of Disclosure: The author Bureau for Coloplast. reported no actual or potential conflict of interest in relation to this continuing nursing All other Urologic Nursing Editorial Board members reported no actual or potential con- education activity. flict of interest in relation to this continuing nursing education article.

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Table 1. Figure 1. Definition of Terms Suprapubic Catheter with Pigtail End Anesthesia – Drug induced state of unconsciousness. Clean Technique – Practice that reduces the number of infectious agents (Northern Territory Government: Department of Health and Families, 2010). Local Anesthesia – Technique used to induce the absence of sensation in any part of the body. Lowsley™ Tractor – Metal surgical instrument designed to facilitate suprapubic catheter placement. Meatotomy – An incision into the meatus to enlarge it. Moderate Sedation – A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Obturator – Metal piece that occludes the needle, which introduces a Source: Reprinted with permission . from Cook Medical. Prevesicle Space (or Space of Retizus) – Space between pubic symphysis and that is the retropubic space in front of the bladder. Sound – Curved metal instrument used to dilate the urethra. Figure 2. Rutner Suprapubic Balloon Stamey Catheter – Style of suprapubic catheter used for initial placement. Catheter Sterile Technique – Aims to eliminate micro-organisms from areas and objects such as surgical incisions or wounds (Northern Territory Government: Department of Health and Families, 2010). Suprapubic Catheter – Also known as a suprapubic cystostomy; created connection between urinary bladder and the skin used to drain from the body. Urethral Dilation – Procedure performed by the urologist that opens a urethra. nique at our facility (Northern for urinalysis and culture at this Territory Government: De part - time if ordered by the physician. ment of Health and Families, The obturator is then removed 2010). The patient is placed in a and the catheter secured as rec- supine position, and the abdo - ommended by the manufacturer. men/suprapubic area is prepped The suprapubic catheter may with povidone iodine (Beta- have a balloon or pigtail that ® Source: Reprinted with permission dine ) scrub and solution. If holds it in the bladder depending from Cook Medical. there is an iodine allergy, an on the manufacturer (see Figures alternate prep such as 4% chlor- 1 and 2). The urologist may also hexidine gluconate (Hibiclens®) place a suture to help reinforce is used. The patient is then the security of the catheter. The bag is also offered. This allows draped with sterile linen if area around the catheter is for uninterrupted patient sleep at requested by the urologist. cleaned and dressed with a 4x4 night without getting up to The urologist dons sterile and taped in an occlusive fash- empty a smaller bag. gloves and palpates the suprapu- ion. An additional piece of tape bic area feeling for a distended can also be placed on the catheter Lowsley™ Insertion bladder. Once the bladder is outside of the dressing, attaching The second method involves located, a is used to the abdomen or thigh for extra insertion of the suprapubic cathe- per physician preference. The security. A urinary drainage bag, ter under anesthesia or moderate urologist uses the Stamey to push either a leg bag or night bag, is sedation, which also uses clean through the skin, pre-vesicle then applied. If a leg bag is technique. This method is used space, and into the bladder. A applied, a larger volume night in non-emergent cases in which urine specimen may be obtained

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Figure 3. Complicated Suprapubic Catheter Lowsley™ Tractor Insertion At times, additional help may be needed in placing these catheters. If the patient is unable to be catheterized, a urethral dila- tion or a meatotomy may be required. It is not uncommon to additionally use fluoroscopy (X- ray) or ultrasound when placing suprapubic catheters. If it is a particularly difficult case, a cys- togram may be performed to ver- Source: Image Courtesy of Gyrus ACMI Inc. ify placement. Patients requiring additional diagnostic and or pro- cedural interventions may be admitted overnight to the hospi- Figure 4. tal for observation. Lowsley™ Tractor Grasping Catheter Potential complications re lat- ed to insertion of suprapubic cath - eters include hemorrhage, perfo- ration into the bowel, catheter with poor or no urine drainage, and (Ramakrishnan & Mold, 2005). Astute nursing assessment of these complications is particularly important after ini- tial insertion.

Changing a Suprapubic Catheter Formation of a well-estab- lished tract for the suprapubic Source: Image Courtesy of Gyrus ACMI Inc. catheter takes approximately six weeks to six months to develop. Until then, the suprapubic catheter change is performed by the patient is not in acute reten- the patient’s abdominal wall. A the urologist. Once the tract is tion. The patient’s abdomen is scalpel or cautery pencil is used established and optimal catheter prepped and draped in the same to cut through the abdomen to size has been achieved, a trained manner as discussed with the the Lowsley™ tractor, which will nurse can perform this proce- Stamey method. The perineal then come up through the pre- dure. Patients usually tolerate area is prepped with chlorhexi- vesicle space and out of the going up one catheter size (for dine gluconate and water on a 4x4. abdomen. The tractor is then example, from 16 Fr to 18 Fr) This method of insertion requires opened up to grasp the catheter without difficulty. The physician the use of a Lowsley™ tractor for that will be used for placement generally increases the size of the placement (see Figure 3). (see Figure 4). Once the catheter catheter at each visit until a size The Lowsley™ tractor is a is firmly grasped, it is brought is reached that allows for optimal metal instrument resembling a back through the pre-vesicle drainage. It is not unusual to see sound or curved dilator. The space into the bladder and out some in the urinary drain- instrument goes through the ure- the urethra. A cystoscope is used age bag after a catheter is chang - thra and into the bladder. The to follow the catheter back into ed to a larger size. Patients are tractor is used to “tent up” the the bladder. The catheter should encouraged to increase their bladder. This is a process that be plugged to allow the bladder fluid intake. Minimal bleeding at pushes the tractor up against the to fill. Once placement is veri- the site may also be noted. bladder wall into the pre-vesicle fied, the catheter balloon is then However, the bleeding should space. The tractor can usually be inflated. Dressings and drainage not last for more than a day at felt through the abdominal wall bag are applied as with the either the stoma site or in the depending on the thickness of Stamey method. urine. Figure 5 outlines the sup-

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Figure 5. also important to discuss. Gen - Supplies Needed and Steps for Changing a Suprapubic Catheter erally, soap and water to clean the stoma area is sufficient. Supplies Needed Petroleum-based ointments should • 10 cc syringe to deflate the balloon on the existing catheter. not be used because they could • Under pad to protect patient from getting soiled. harm the catheter (if it is latex- • New suprapubic catheter. based) and could also lead to • Filled 10 cc syringe to inflate new balloon. infection. The patient is encouraged to • Urinary drainage bag. drink adequate fluids to keep the • Graduate container. urine clear and free-flowing. • Gloves – Sterile in appropriate size. Suprapubic catheters chronical- • Culturette. ly leave some residual urine in • 4x4s with gluconate and warm water. the bladder, which can lead to • Water-soluble lubrication. stone formation. Therefore, the • Dressing. importance of drinking fluids • Tape. should be stressed. Some patients may note that their Steps for Changing a Suprapubic Catheter urine looks cloudy or sometimes • Place the patient in a supine position. “milky.” This can be sediment • Place underpad under the suprapubic catheter to protect the patient from from stone formation caused by becoming soiled. infection (Basler, Catrill, Lucas, • Remove the old dressing. & Ghobriel, 2009). The nurse • Assess the insertion site for redness and drainage. If there is should notify the urologist if this or drainage, a culture may be obtained. is a new finding. The urologist • Prep with 4x4s with chlorhexidine gluconate and warm water. will need to assess the situation. Reviewing the patient’s history • Lubricate the new catheter. and noting whether this is a • Deflate the balloon of the old catheter to remove. chronic problem or an acute • Grasp the old catheter at the skin level and remove at a steady rate. issue will help direct further • Measure the new catheter to the old catheter and insert to the same level. investigation. The urologist may (This is particularly important in males to avoid placing the catheter in the advise gentle irrigation of the urethra where the balloon may get inflated, causing pain and trauma.) bladder as a first step. This can • Insert the new catheter. When removing or inserting the catheter, there may be done with either sterile water be some slight resistance. This resistance is similar to catheterizing a male or normal saline solution (per patient as the catheter passes through the prostatic urethra. physician preference) and a bulb • Inflate balloon. or Toomey syringe. Proper in- • Apply drainage bag. struction by the nurse with suc- • Clean patient and apply dressing. cessful return demonstration by the patient or family is required if this procedure is to be contin- ued at home. If a is suspected, the pa - tient may be placed on an antibi- plies necessary and the steps of Care of Suprapubic Catheters/ otic. medication changing a suprapubic catheter. Patient Family Teaching can be prescribed if bladder If the patient has cloudy spasms become problematic It is vital for the patient and/ urine, the urologist may want the (Ramakrishnan & Mold, 2005). A catheter irrigated to ensure the or family to be taught how to care may be performed to flow of urine is optimal. Cath et ers for the suprapubic catheter prior examine the bladder more fully are routinely changed per physi- to discharge, either as an inpa- if further investigation is war- cian choice. In the author’s facili- tient or outpatient. Teaching ranted. ty, this is anywhere from three to aspects would include dressing In the event the suprapubic six weeks. If the patient experi- changes, stoma site care (includ- catheter becomes dislodged, it is ences catheter-related problems ing signs and symptoms of infec- important for the patient to have (such as not draining adequately tion), fluid intake, monitoring of the catheter reinserted as soon as or stone material forming on the urine output for volume, and possible. This may involve call- tube), then a more frequent signs of a bladder infection. ing the urologist’s office or com- change is preferable. Frequency of catheter change is ing to the emergency room unless

262 UROLOGIC NURSING / September-October 2011 / Volume 31 Number 5 SERIES the patient/caregiver has been patients have different ways of ting. Requests for educational in- properly instructed on how to applying their dressings and sta- services regarding suprapubic reinsert the suprapubic catheter. bilizing their catheters. To foster a catheter care and management The site of insertion can close sense of control, it is important to have increased as well. Edu- fairly quickly, so prompt atten- allow these differences as long as cating ourselves, our patients, tion is needed. Anecdotally, this it does not compromise the and their families is vital for suc- clinician has observed a signifi- integrity of the catheter system. cessful outpatient patient supra- cant decrease in the stoma open- Generally, after a few visits, pubic catheter management and ing size in as little as eight hours. patients are not as angry because prevention of complications. If the site has begun to close, and they feel they have regained some References the catheter cannot be safely control and are more comfortable Basler, J., Cantrill, C.H., Lucas, J.J., & reinserted, then the urologist is with their altered body image. Ghobriel, A. (2009). Bladder stones. notified. A stoma site dilation Re trieved from http://e medicine. may be indicated. Flouroscopy medscape. com/ article/ 44 06 57- Conclusion and a cystogram may also need to overview# show all Northern Territory Government: Depart - be performed. As health care delivery con- ment of Health and Families. (2010). It is important for the nurse to tinues to change, nurses need to Aseptic technique. Re triev ed from assess the psychosocial needs of prepare for the possible increase http:// remote health atlas. nt.gov. au/ patients requiring suprapubic in numbers of outpatients requir- aseptic_ technique.pdf Ramakrishnan, K., & Mold, J.W. (2005). catheter insertion. Anger issues ing suprapubic catheters, which Urinary catheters: A review. The due to the loss of control and can impact their practice set- Internet Journal of Family Practice, decreased self-esteem related to tings. In the author’s facility, 3, 2. changes in body image or diagno- there has been a rise in the num- sis may need further exploration. ber of patients who have supra- In the author’s practice, many pubic catheters in the home set-

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