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Keywords: Bladder// Suprapubic/Urology Nursing Practice Review ●This article has been double-blind peer reviewed Continence Suprapubic can improve some patients’ quality of life but health professionals must also understand the associated risks and limitations The risks and benefits of suprapubic catheters

In this article... 5 key Indications for indwelling suprapubic catheterisation points Health Situations when suprapubic catheters should not be used 1professionals How to manage a patient with a suprapubic catheter must understand indications for suprapubic Author Ann Yates is director of continence should be reviewed regularly (Loveday et catheterisation services, Cardiff and Vale University Health al, 2014; Royal College of Nursing, 2012), Alternatives Board, Cardiff. Insertion of an indwelling catheter is 2should be Abstract Yates A (2016) The risks and indicated in any of the following clinical considered before benefits of suprapubic catheters. Nursing circumstances: a suprapubic Times; 112: 6/7, 19-22 . » Acute ; catheter is used Suprapubic catheterisation can improve » Chronic urinary retention – only if Suprapubic some patients’ quality of life but the symptomatic and/or with renal 3catheter insertion procedure, as well as changing compromise; insertion is and managing the catheter, carry risks of » Monitoring renal function during associated with and other negative patient critical illness; risks as well as outcomes. This article highlights the » During and after surgery for a variety of advantages advantages and disadvantages, indications reasons, such as radical prostatectomy; Only and contraindications, and the potential » Bypassing an obstruction such as an 4appropriately benefits, so health professionals can enlarged , urethral strictures or trained staff should Female understand the relevant issues and assess urethral damage; change a Retention balloon and inform patients accordingly. » Facilitating continence and suprapubic maintaining skin integrity (when all catheter

ndwelling suprapubic catheters are conservative treatment methods have BladderStaff must be hollow, flexible tubes inserted into the failed) (RCN, 2012). 5aware of the bladder through a small cut in the However, when identifying whether a complicationsCatheter Iabdomen (Fig 1). They are used to drain patient is suitable for a suprapubic cath- associated with from the bladder and, in the eter, certain indicators also apply, which suprapubic management of bladder dysfunction, are are listed in Box 1. catheters often considered an alternative to a ure- Suprapubic catheters are not suitable Pubic bone thral catheter. Insertion of indwelling suprapubic catheter is becoming an increasingly common urological proce- FIG 1. male suprapubic catheter dure, but is not without risks (Harrison et Female Male al, 2011). Health professionals need to be Retention balloon Retention balloon aware of the: » Indications and contraindications for suprapubic catheters; Bladder Bladder » Advantages and limitations; » Insertion techniques; Catheter Catheter » Subsequent catheter changes, management and complications.

Indications and contraindications Pubic bone The decision to catheterise a patient should be taken after careful assessment Pubic bone by a competent health professional, and Lamb Peter

Male www.nursingtimes.net / Vol 112 No 6/7 / Nursing Times 10.02.16 19 Retention balloon

Bladder

Catheter

Pubic bone Copyright EMAP Publishing 2015 This article is not for distribution

Nursing Practice Review

Box 1. Indications for suprapubic catheter Box 3. Limitations of insertion suprapubic catheters In addition to the indications for urethral term urethral catheterisation, such as ● Haemorrahage, including haematuria catheterisation, the following apply for urethral trauma and intra-abdominal bleeding suprapubic catheter insertion: ● When long-term catheterisation is ● Infection, including UTI and infection ● Acute and chronic urine retention that used to manage incontinence of the track site cannot be adequately drained with a ● Complex urethral, abdominal surgery ● Pain and possible injury to abdominal urethral catheter or where urethral or gynaecological surgery organs (Harrison et al, 2011) catheterisation is contraindicated ● Faecally incontinent patients who are ● Insertion is an invasive procedure that ● Preferred by patient due to needs for constantly soiling urethral catheters or carries with it the risk of bleeding and comfort and access to catheter care, experience moisture lesions visceral injury such as wheelchair user ● Sexually active patients ● The patient may still leak urine via ● Acute prostatitis ● Neuropathic disorders causing the ● Obstruction, stricture, abnormal frequent catheter expulsion ● Specialised training is required to urethral anatomy ● Restricted hip mobility, spasticity teach health professionals and carers ● Traumatic injury to lower urinary tract Source: Adapted from European Association of how to change a suprapubic catheter or pelvic trauma Urology Nurses (2012), Royal College of Nursing ● Patients with artificial heart valves ● To minimise complications of long- (2012); Rew and Smith (2011) may require therapy before initial insertion or routine catheter changes, although this will depend on FIG 2. A suprapubic Box 2. local healthcare management policy catheter insertion kit Contraindications ● Patients on anticoagulant therapy for suprapubic will require coagulation levels to be catheters checked before a suprapubic catheter is inserted Absolute contraindications Source: European Association of Urology Nurses ● Non-palpable bladder (2012) ● Unable to visualise a distended bladder by ultrasound Relative contraindications » The procedure is less intimate than ● Coagulopathy (until the abnormality insertion via the urethra. is corrected) Suprapubic catheterisation has also ● Known or suspected carcinoma of the been highlighted as contributory to for everyone and there are a number of bladder – absolutely contraindicated in patients’ improved recovery times, com- contraindications. These are highlighted the absence of an easily palpable or pared with urethral catheterisation (Nwa- in Box 2. localised distended on diaro et al, 2007; Wyndaele et al, 1985). ultrasound Advantages of suprapubic ● Localised distended urinary bladder Risks and limitations catheters ● Previous lower abdominal surgery Although suprapubic catheters have many There is little evidence-based research on ● Ascites advantages, there are also several risks and the use of suprapubic catheters but, ● Prosthetic devices in lower abdomen limitations. These are outlined in Box 3. according to the RCN (2012) and the such as a hernia mesh One risk of suprapubic catheterisation European Association of Urology Nurses Source: European Association of Urology Nurses is of bowel perforation. Sheriff et al (1998), (2012), there may be several advantages to (2012), Harrison et al (2011) reviewed 185 cases and identified a 2.7% their use compared with urethral incidence, with one fatal outcome, but the catheterisation: National Patient Safety Agency (2010) » There is no risk of urethral trauma, catheter is removed (trial without placed the figure at 0.15% (NPSA, 2010). necrosis or catheter-induced catheter, or TWOC); and urethral strictures; » Micturition is still possible if the Insertion techniques » Greater comfort, particularly for urethra is not surgically closed or The initial insertion of a suprapubic cath- patients who are chair bound as the obstructed; eter should be undertaken by a clinician catheter is not positioned between their » Evidence of greater satisfaction and with the appropriate skills (Harrison et al, legs and there is less risk of sitting on it; quality of life when compared with 2011). It can be done under a local or gen- » Reduced risk of catheter contamination urethral catheterisation (Reitz et al, eral anaesthetic and different insertion with micro-organisms that are 2006). kits are available for different clinical pres- commonly found in the bowel; Other benefits have also been identified entations. The procedure is usually carried » Easier access to the entry site for by Dingwall (2008), including: out in theatres but some specialist clini- cleansing and catheter change; » Decrease in rates cians can insert the initial catheter in » Makes it easier to engage in sexual through reduced contact with genitalia home or community settings. Fig 2 shows intercourse than a urethral catheter; before the catheter is introduced into an insertion kit for a suprapubic catheter. » Can be blocked off and the ability to the bladder; Suprapubic catheters can be divided void via the urethra assessed before the » Reduced pain on catheter insertion; into different types:

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» Foley balloon catheter (the most FIG 3. Belly bag Complications commonly used); drainage bag Although suprapubic catheters have many » Catheter without a balloon, which advantages, they are still associated requires a suture to secure; with complications. Addison and Mould » Foley balloon with open end. (2000) identified that suprapubic catheter- The patient should have a palpable isation can have a negative impact on bladder that is filled to at least 300ml or patients’ body image and self-esteem. In full (Shah and Shah, 1998). Ultrasonog- addition, some patients experience phys- raphy may be used to assist insertion. The ical complications such as swelling, infec- catheter’s Charriere size is usually larger tion, cellulitis or overgranulation of the than that used for a urethral insertion and cystostomy site. often starts at 14Ch or 16Ch. A standard length catheter is normally used as it has to Overgranulation pass through the width of the abdominal Management The catheter insertion cystostomy site wall (Rew and Smith, 2011), but the shorter The management of suprapubic catheters is highly vascularised but lacks a protec- female length can be selected, provided is covered by the same national guidance as tive epithelial layer and, therefore, remains the patient’s mobility, weight and selected management of urethral catheters moist and unable to withstand trauma, drainage system are taken into account. (Loveday et al, 2014; RCN, 2012). Local especially from rubbing (McGrath, 2011). For example, a female length may not be policies should also be followed. National Evidence suggests that overgranulation is suitable for a wheelchair user as it may guidance states that the catheter should be precipitated by an inflammatory response restrict drainage. Catheter length may also connected to a sterile closed urinary (McGrath, 2011) and different catheter be influenced by whether the patient drainage system – this connection should materials may affect this process. Hanlon selects a short or long tube drainage bag. not be broken unless clinically indicated or and Heximer (1994) reported a higher inci- Patient assessment is important in making for changing urinary drainage bags when dence of overgranulation associated with these decisions. clinically indicated and in line with latex catheters compared with silicon. A sterile dressing is normally applied the manufacturer’s recommendations Changing the position of the catheter following insertion, which can be removed (Loveday et al, 2014). against the abdomen and alternating the on healing within 7-10 days (RCN, 2012). Health professionals must: leg to which the drainage bag is attached The intervention should be documented » Decontaminate hands and put on a new may reduce the pressure on the site according to local policy. pair of clean, non-sterile gloves before (Getliffe and Dolman, 2007). manipulating the catheter; Catheter changes » Decontaminate hands immediately Encrustation The catheter should remain in situ for at after removing the gloves; Problems with urethral catheter encrusta- least four weeks before the first change so » Take urine samples aseptically via the tion and subsequent blocking may be the cystostomy tract can become estab- sampling port if required; improved by a suprapubic catheter. lished (RCN 2012; Robinson, 2008; Getliffe » Not allow the urinary drainage bag to Encrustation is mainly caused by a Pro- and Dolman, 2007). Subsequent catheter become more than three-quarters full; teus mirabilis infection, which causes changes should be undertaken on an indi- » Empty the drainage bag into a separate, crystalline biofilms to form on the catheter vidual basis when clinically indicated, clean container for each patient, surface (Stickler and Feneley, 2010). local policies dictate, or according to cath- avoiding contact between the urine This, in turn, causes blockage. Suprapubic eter material in line with the manufactur- drainage tap and the container; catheters are associated with a reduced er’s licence, up to a maximum of 12 weeks. » Position the drainage bag below the risk of infection as compared with urethral Patients may experience trauma on level of the bladder – this could be a leg catheters (Niel-Weise and van de Broek, removal of the catheter due to cuffing of bag or belly bag (Fig 3) or could be a 2005) which in turn reduces the opportu- the balloon on deflation (RCN, 2012) catheter valve; nity for encrustation of the catheter Insertion is an aseptic technique that » Support the drainage bag on the leg to occur. should adhere to national and local guide- using appropriate straps or on a stand lines. For indwelling catheters, this should that prevents contact with the floor Bladder spasm include observing: (Loveday et al, 2014). Bladder spasms identified by bypassing » The lie of the existing catheter; National guidance recommends that or pain should be treated the same way as » Angle of insertion; routine daily personal hygiene is all that is for urethral catheters by the use of » How much of the catheter length is required for cleansing the entry site and anti-muscarinic therapy if indicated and visible outside the body. there is no indication to add antiseptic or appropriate. On insertion of the new catheter, antimicrobial solutions into urinary advance into the tract 3cm deeper than the drainage bags (Loveday et al, 2014). Bypassing removed catheter but no more – the tip can Bladder irrigation, instillation or wash- Many patients in the community who have irritate the bladder wall and the catheter outs are not recommended to prevent problematic urethral catheters that bypass may pass into the urethra (EAUN, 2012). catheter-associated infection. It is also rec- urine are referred for a suprapubic cath- The catheter should be attached to the ommended that health professionals be eter to resolve these issues. However, preferred drainage bag or device and trained and updated in the appropriate patients with a suprapubic catheter may secured with the correct supporting and use, selection, insertion, maintenance and still experience leakage from the urethra if fixation devices. The procedure should be removal of urinary catheters including urethral closing pressure is inadequate or documented according to local policy. those that are suprapubic. absent (Addison and Mould, 2000).

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Bladder stones References spinal injured patients. Nigerian Journal of The formation of bladder stones is more Addison R, Mould C (2000) Risk assessment in Medicine; 16: 4, 318-321. Niël-Weise BS, van de Broek PJ (2005) common in patients with a suprapubic suprapubic catheterisation. Nursing Standard; 14: 36, 43-46. Urinary catheter policies for short-term bladder catheter than those catheterised via other Dingwall L (2008) Promoting social continence drainage in adults. routes (Shah and Shah, 1998). using incontinence management products. Cochrane Database of Systematic Reviews; 3: British Journal of Nursing; 17: S4, S12-S19. CD004203. Reitz A et al (2006) Neurogenic bladder Bladder European Association of Urology Nurses (2012) Catheterisation – Indwelling Catheters in Adults: dysfunction in patients with neoplastic spinal cord Some evidence suggests patients with a Urethral and Suprapubic. compression: adaptation of the bladder suprapubic catheter have increased risk of Bit.ly/EAUNCatheter management strategy to the underlying disease. Neurorehabilitation; 21: 1, 65-69. and regular cystoscopy is Getliffe K, Dolman M (2007) Promoting Continence: A Clinical and Research Resource. Rew M, Smith R (2011) Reducing infection through recommended (Shah and Shah, 1998), London: Bailliere Tindall. the use of suprapubic catheters. especially if repeated blockages of the Hanlon M, Heximer B (1994) Excess granulation British Journal of Neuroscience Nursing; catheter occurs (Lekka and Lee, 2006). tissue around a gastrostomy tube exit site with 7: 5, S13-S16. peritubular skin irritation. Journal of Wound, Robinson J (2008) Insertion, care and Ostomy and Continence Nursing; 21: 2, 76-77. management of suprapubic catheters. Nursing Urinary tract infection Harrison SCW et al (2011) British Association of Standard; 23: 8, 9-56. Urinary tract are a common Urological Surgeons’ suprapubic catheter practice Royal College of Nursing (2012) Catheter Care: RCN Guidance for Nurses. complication associated with catheterisa- guidelines. International Journal of Urological Nursing; 5: 3, 146-149. Bit.ly/RCNCathCare2012 tion but incidence in patients with Lekka E, Lee LK (2006) Successful treatment with Shah N, Shah J (1998) Percutaneous suprapubic suprapubic catheters is less than that for intradetrusor botulinum-A toxin for urethral urinary catheterisation. Urology News; 2: 5, 11-14. Sheriff MK et al (1998) Long-term suprapubic those with urethral catheters. This could leakage (catheter bypassing) in patients with end-staged multiple sclerosis and indwelling catheterisation: clinical outcome and satisfaction be because the suprapubic catheter inser- suprapubic catheters. European Urology; 50: 4, survey. Spinal Cord; 36: 3, 171-176. tion site, unlike the urethra, is not in close 806-810. Stickler DJ, Feneley RC (2010) The encrustation Loveday HP et al (2014) epic3: national evidence- and blockage of long-term indwelling bladder proximity to the rectum where cross-con- catheters: a way forward in prevention and control. tamination from the bowels can occur. based guidelines for preventing healthcare- associated infections in NHS hospitals in England. Spinal Cord; 48: 11, 784-790. Journal of Hospital Infection; 8651: S1-S70. Wyndaele JJ et al (1985) Evaluation of different Conclusion McGrath A (2011) Overcoming the challenge of methods of bladder drainage used in the early care of spinal cord injury patients. Paraplegia; There is evidence that suprapubic cathe- overgranulation. Wounds UK; 7: 1, 42-49. National Patient Safety Agency (2010) Minimising 23: 1, 18-26. terisation improves quality of life for many Risks of Suprapubic Catheter Insertion (Adults people. It is becoming an alternative Only). Rapid Response Report NPSA/2009/ For more on this topic go online... option for those who require an indwelling RRR005. Managing indwelling urinary catheter, and health professionals must Bit.ly/NPSASuprapubicCath Nwadiaro HC et al (2007) Comparative analysis of catheters in adults ensure they understand the positive and urethral catheterization versus suprapubic bit.ly/NT CatheterManag negative elements associated with it. NT cystostomy in management of neurogenic bladder

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