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SUPRA-PUBIC CATHETERISATION APPLIED ANATOMY Bladder is a pelvic organ in the adult Extra-peritoneal When the bladder is full there is a “safe” window for supra-pubic catheter insertion tract will be completely extra-peritoneal bowel is displaced superiorly INDICATIONS Urinary retention with failed urethral catheterisation Suspected urethral injury Blood at the meatus pelvic fracture Necrotising fasciitis of perineum/ Fournier’s gangrene Diverts urine Temporary diversion of urine following urological surgery Selected neuropathic bladder patients Clean intermittent self-catheterisation not possible Epididymitis due to indwelling urethral catheter CONTRA-INDICATIONS Empty/small capacity bladder Previous lower abdominal surgery Bowel injury risk Macroscopic haematuria May have bladder tumour Tract seeding a concern Skin disease in supra-pubic area Gross obesity Trocar too short TECHNIQUE Counsel the patient about the indication Counsel the patient about the procedure Take a history ensure no history of bladder cancer or haematuria Ensure no bleeding diathesis Position the patient supine Sterile procedure REQUIREMENTS Supra-pubic set Trocar Skin blade Catheter Drainage bag Sterile pack Sterile drapes Gauze swabs Receptacle for cleaning solution Cleaning solution Syringe and saline to inflate bulb if bulb catheter 22 gauge (black) spinal needle and 5 ml syringe Nylon suture Needle holder if not in pack Local anaesthetic for infiltration (including syringe and needles to aspirate local and to inject the patient) TECHNIQUE Clean the skin in suprapubic area and drape sterile field Check if bladder percussable or palpable or do ultrasound-guided CANNOT INSERT A SUPRA-PUBIC CATHETER INTO AN EMPTY BLADDER Local infiltration midline supra-pubically To sheath level Use 22fr spinal needle and aspirate in the midline 1-2cm above symphysis Confirms full bladder Confirms position and depth of bladder Incise skin with blade TECHNIQUE Insert trocar/stylet Two areas of resistance Sheath Bladder wall Urine will drain once in bladder stop advancing trocar once urine drains Co-axial system remove stylet and advance catheter Peel away sheath system feed catheter through the lumen useful to feed the catheter into trocar half-way before inserting Push the catheter into the bladder but DO NOT PULL IT BACK trocar will cut it off Pull the trocar out and peel away once exits skin It may be necessary to pull some of the catheter out to get the trocar out if catheter was pushed in to the hub Inflate the bulb and /or suture the catheter to the skin COMPLICATIONS Bowel injury Migration Haematuria Rectal injury and Vascular injury Very rare Stay in the midline to avoid WATCH THE VIDEO https://www.youtube.com/watch?v=xa0CtwHToRk
