Overview of Suprapubic Bladder Catheterization
Suprapubic catheterization is a method used to drain urine from the bladder. This involves inserting a tube into the bladder through a small hole in the abdomen, just above the pubic bone. This method is usually adopted for individuals who are unable to pass urine normally through the urethra, which is the tube that carries urine out of the body from the bladder.
Suprapubic catheterization serves as an alternative way to drain urine when other options are not suitable, desirable, or possible for clinical reasons. Some reasons for using this method might be that the suprapubic tubes are easier to replace, come in different sizes, and are generally more comfortable, especially for males who need to use a catheter for a long time.
There are other ways to drain urine from the bladder. These include urethral catheterization (a tube through the urethra), intermittent catheterization (using a catheter at certain times), urinary diversion (rerouting the pathway of urine), and percutaneous nephrostomy drainage (inserting a tube directly into the kidney).
The specialized tube for suprapubic catheterization can be inserted in two ways: percutaneously (through the skin) or openly (through a surgical cut). A cystoscopy, which uses a special telescope-like instrument, is commonly used to help with percutaneous insertion.
Anatomy and Physiology of Suprapubic Bladder Catheterization
The urinary bladder is a bag-like muscle in your body where urine is stored before it leaves your body. The typical bladder can hold between 300 and 500 ml of urine. It’s divided into four parts: the bottom (fundus), the main part (body), the top (apex), and the connecting passage (neck).
The bladder is located behind the pubic bone in a space outside the lining of the abdominal cavity, known as the extraperitoneal space. There’s a space in front of the bladder called the prevesical space or the space of Retzius, named after the Swedish anatomist Anders Retzius who first detailed it.
The wall of the abdomen just above the pubic bone is made up of muscles called the rectus muscle on the sides and a strip in the center called the linea alba. Below a boundary called the arcuate line, there are layers of muscles—external oblique, internal oblique, and transversal muscles—that protect the rectus muscle. This area gives access to the dome of the bladder, which is the top part that mostly gets covered by another area called the perineum.
The bottom of the urinary bladder is supported by a group of muscles in the pelvic area called the pelvic diaphragm. If a tube is needed to drain urine from the bladder (known as a suprapubic drainage tube), it typically exits through a site in the midline of the bladder, but it can also be placed through the rectus muscle, depending on the individual’s body shape and size.
Why do People Need Suprapubic Bladder Catheterization
A suprapubic tube is a type of catheter that’s inserted directly into the bladder through the lower abdomen to drain urine. This procedure is commonly done when a regular catheter, which is passed through your urethra, doesn’t work or is not possible. This could happen for a few reasons, such as:
- Severe benign prostatic hyperplasia, which is an enlarged prostate that blocks urine flow.
- False urethral passages, which are additional, abnormal passages that can make it hard to insert a catheter.
- Morbid obesity, which can make it difficult to find and access the urethra for catheterization.
- Urethral strictures, when the urethra narrows and makes it difficult for urine to pass.
- Bladder neck contracture, when the muscle where the bladder connects to the urethra becomes too tight and blocks urinary flow.
- Lastly, cancers of the genital area could block the usual urinary pathway or make a regular catheter insertion too risky.
Suprapubic tubes may also be placed if you’ve had a severe injury that affects your urinary tract, or if you have a condition called a neurogenic bladder, which means the nerves that control your bladder aren’t working correctly. Sometimes, in such cases, a suprapubic tube may be needed for long-term urine drainage.
When a Person Should Avoid Suprapubic Bladder Catheterization
There are certain situations where a surgeon will advise against suprapubic cystotomy, a procedure to create a direct way to release urine from the bladder, depending on the method used. Usually, these are few.
For instance, if a surgeon intends to approach the bladder directly through the skin (a percutaneous approach), they would avoid carrying out this procedure for two main reasons:
1. The bladder is not filled (nondistended). If this is the case, there is a big risk of accidentally causing injury to the bowels or blood vessels.
2. The patient has a form of bladder cancer (bladder malignancy). This is to prevent any unnecessary complications.
Additionally, there are certain conditions that make the procedure more risky, regardless of the approach (open or percutaneous). These are:
1. Active skin infection – this increases the chances of the wound getting infected.
2. A problem with clotting (coagulopathy) – this can put the patient at risk of uncontrolled bleeding during the surgery.
3. A bone infection in the pubic area (pubis osteomyelitis) – this can complicate the procedure.
4. Having joint replacement hardware in the pubic area (pubic symphysis) – as the cystotomy may interfere with the hardware.
Equipment used for Suprapubic Bladder Catheterization
The tools a doctor uses to place a suprapubic catheter, which is a tube that allows urine to leave your body, can vary depending on the method they’re using. Often, they use a standard Foley catheter as the drainage tube.
For an open procedure, which is a traditional surgery, they typically use basic surgical tools. These might include a small self-holding tool called a Weitlander retractor that keeps the wound open, and a special type of thread called a dissolvable suture to close up the hole in the bladder, known as a cystostomy.
There’s another method called the Percutaneous (or Seldinger) technique. This strategy needs a large needle, a guide wire to help position the catheter, and a sheath for the catheter to glide into the body. All these items are usually sold together in a kit. The doctor often uses a rigid or flexible cystoscope, which is a thin tube with a camera, to ensure everything is going smoothly under the skin.
Sometimes, a specialized tool called a Lousley prostatic retractor can aid in the placement of the tube during an open procedure. Plus, portable ultrasound devices can also be quite handy to make sure the tube is in the right place.
Who is needed to perform Suprapubic Bladder Catheterization?
A urologist is a kind of doctor who is an expert in the male and female urinary-tract systems and the male reproductive organs. This doctor is trained to perform a procedure called suprapubic catheterization, which is a way to drain urine from the bladder. However, it’s not only urologists who can do this. Other types of doctors like general surgeons (who operate on all parts of the body), gynecologists (who focus on women’s health), urogynecologists (who concentrate on urinary problems in women), and emergency room physicians (who handle sudden and serious health problems) along with trauma surgeons (who specialize in treating injuries), can do this procedure as well.
Preparing for Suprapubic Bladder Catheterization
Suprapubic catheterization, a procedure where a tube is inserted into the bladder to help with urination, can be done under local or general anesthesia depending on the patient’s situation. First, the lower abdomen area is shaved and cleaned with a standard surgical solution to prevent any infections. If the procedure involves accessing the bladder through the urethra, the genital area is also prepared and covered. If a rigid cystoscopy (a bladder examination using a stiff tube-like instrument) is required, the patient will be positioned on their back with legs raised and spread apart.
In some cases, a more flexible cystoscopy can be done while the patient is lying flat on their back. However, during this procedure patients are generally put in a position known as Trendelenburg, where the body is tilted with the feet higher than the head. This position helps reduce the chance of accidentally injuring the bowel.
Before this procedure, patients might undergo ultrasound or CT scans. These tests, especially for people who’ve had abdominal surgery before, help the doctors ensure there are no loops of bowel between the bladder and the abdominal wall which could be mistakenly harmed during the catheter placement. In essence, these scans help doctors be certain about where to insert the tube, which is especially helpful in this process.
How is Suprapubic Bladder Catheterization performed
There are several known methods for putting in a suprapubic catheter, which is a tube that drains urine from the bladder through a hole in your belly. We can group these methods into two main categories: open technique and percutaneous technique. Some methods are a blend of both.
The open technique involves a small cut, about the width of two fingers, above your pubic bone. Your bladder is filled up beforehand so the surgeon can locate it more easily. Once they’ve found the bladder, the surgeon stitches up either side of it with a thread that dissolves over time. They make a little opening in the bladder, insert the drain tube, and secure it in place with another dissolvable stitch. Finally, they stitch up the layers of tissue and skin around the tube and attach it to the skin with a temporary stitch.
Another common method is called the Percutaneous Seldinger technique. In this procedure, the bladder needs to be filled up, either naturally (because you can’t pee), or with a special tool called a cystoscope. The surgeon uses a large needle to pierce your bladder, which they can do under the guidance of an X-ray or by checking to see when urine comes out. Once the bladder is punctured, they can add a contrast dye to make it show up better on the X-ray. They then insert a guide wire into the bladder through the needle, and open up the path with dilators to fit the catheter and a cover sheath. After inflating a small balloon at the end of the catheter, they remove the sheath and secure the catheter in place. It’s recommended to check the placement of the catheter using a cystoscope when possible.
Sometimes a curved instrument called the Lowsley prostatic retractor is used for a modified open method. The surgeon inserts this from the urethra up into the bladder and applies upward pressure to push the bladder close to the belly. The tip of the retractor can usually be felt on the lower belly, and a cut is made there to expose it. The urine catheter is attached to the retractor and pulled into the bladder with the tip. A balloon at the end of the catheter is inflated, and the catheter is disconnected from the Lowsley by twisting and opening the tool, then closing it to remove it. Sometimes the balloon ends up just outside the bladder, so a follow-up cystoscope check is recommended to make sure the catheter is in the right place.
Trocar kits are also available for direct puncture into the bladder. However, they are used less frequently because they can increase the risk of injury to organs near the bladder. There are many kits available for the percutaneous technique, which is the most common approach.
Possible Complications of Suprapubic Bladder Catheterization
After an operation, some people might experience early issues like accidental damage to the bowel, bleeding, harm to blood vessels, blockage of the tube, and failure to reach the bladder. To limit possible harm to the bowel, doctors use imaging techniques before the operation, as well as an ultrasound during the operation.
Late complications could include unmoving blood in the urine, a severe infection in the urine, infection in the surgical wound, bladder stones, tube problems, and loss of the cystotomy tract. The cystotomy tract is a small passageway made during the surgery. If patients have a long-term blockage, such as benign prostatic hyperplasia (which is a non-cancerous enlargement of the prostate), relieving of the bladder can result in a lot of urine being produced quickly, known as ‘post-obstructive diuresis’. This is normal and is the body’s reaction to the sudden relief of a long-term blockage.
Further down the line, other complications could be ongoing irritation of the bladder because of the tube. It’s worth knowing that this might increase the risk for a particular type of bladder cancer. And lastly, although not a complication of the surgery itself, some people might feel concerned about changes to their body’s appearance after the operation.
What Else Should I Know About Suprapubic Bladder Catheterization?
Suprapubic catheters are a type of tube inserted into the bladder through a small incision in your lower stomach to help drain urine. They are often used when people are unable to urinate on their own and when inserting a catheter through the urethra (the tube that carries urine out of the body) isn’t suitable.
Like any medical device, suprapubic catheters have pros and cons. For instance, there’s a debate about whether these catheters reduce the risk of urinary tract infections. Some research suggests there might be fewer infections because the catheter doesn’t touch the genital area; however, other research disagrees.
One key advantage of suprapubic catheters is that they don’t interfere with sexual activity like catheters inserted through the urethra do. Also because of their location, these catheters are generally easier to replace. However, they can sometimes cause urine leakage, which can be problematic, especially if the skin around the catheter becomes irritated. In some cases, urine leak could also indicate a blockage in the catheter or bladder spasms.
Suprapubic catheters can be very helpful during some surgeries, especially those involving the bladder, prostate, or urethra. They can help ensure a stable flow of urine before and after the operation and can be combined with a urethral catheter for continuous irrigation — this can help cleanse the area by flushing fluids in through one catheter and out through the other. This arrangement can be particularly useful in operations involving the urinary tract, contributing to a smoother recovery.
