Suprapubic urinary catheter

The purpose of this guideline is to provide guidance about suprapubic catheterisation at Great Ormond Street Hospital (GOSH). 

It is usually sutured at skin level and is secured to the abdomen using a hypoallergenic latex free dressing, eg Mefix™ (Rationales 1 and 2). A dressing is only required if there is bleeding or urine leakage. 

Note: While this guideline refers to the ‘child’ throughout, all activities are applicable to young people.

The commonest types of suprapubic catheters at GOSH are Foley™ and Cystofix™. It is recommended that the smallest size catheter should be used that will effectively empty the bladder (Rationale 3). The surgeon will decide the size and design of the catheter at the time of insertion, taking into consideration the intended use of the catheter.

A suprapubic catheter may be used to:

• accurately manage fluid balance, eg following major surgery or acute illness (Rationale 4) 
• promote wound healing, eg following bladder neck surgery (Rationale 5) 
• minimise pressure and thus prevent urine leakage following bladder surgery, eg re-implantation of ureters (Rationale 6) 
• provide long-term urinary drainage 
• perform radiological and urodynamic investigations (Pratt 2001) 

Suprapubic catheterisation must only be performed when absolutely necessary and be for the minimum possible time, usually three to 28 days. However, long-term use is suitable for some children (Rationale 7).

They must always be managed using a non-touch technique (Sanders 2001). It is recommended that all catheters and securing devices are latex free (Rationale 8). The child may experience discomfort from the catheter, even if it is the correct size and correctly positioned.

Analgesia should be given as prescribed. The child may experience bladder spasms (burning and cramping pain in the lower abdomen) (Rationale 9). Anti-spasmodic medication, eg Oxybutynin™, may be given as prescribed considering the child’s age and underlying condition (British Medical Association (BMA) 2003).

Inform child and family

The surgical team will inform the child and family of the following (Rationale 10):

• that a catheter is necessary 
• the reason for the catheterisation 
• what it entails 
• the likely duration of the procedure 
• the anticipated duration of being catheterised

This discussion must be recorded in the child’s health care record (Rationale 11). If appropriate a play specialist should help to prepare the child (Rationale 12).

Written information is available from the urology ward for all children going home with a suprapubic catheter in situ (Rationale 13).

Download our information sheet on looking after your child's suprapubic catheter.

Catheter care: entry site

The catheter must be secured to the child’s abdomen using hypoallergenic, latex free adhesive strapping at all times (Rationale 14). The strapping and retention suture should be checked for security whenever the catheter bag is being emptied (Rationale 15).

Usual hygiene appropriate for the age of the child should be maintained whilst the catheter is in situ, eg nappy care. Bathing may be performed in shallow water, taking care not to soak the entry site. 

The suprapubic entry site should be observed for signs of trauma and infection. The child’s doctor should be informed of any bleeding, discharge or inflammation (Rationale 16). If present, record these observations in the child’s health care records (Rationale 11). If an infection is suspected a swab should be taken for microbiological examination (Rationale 17).

Entry site cleansing should only be performed if there is bleeding or discharge (Rationale 18). The entry site must be cleaned using a non-touch technique (Rationale 19).

The following equipment should be gathered:

• non-sterile latex free gloves and plastic apron (Rationale 20) 
• dressing pack 
• additional lint free sterile gauze (Rationale 21) 
• sachet sterile 0.9% sodium chloride (Rationale 22) 
• adhesive remover 
• hypoallergenic, latex free adhesive strapping (Rationale 23) 

To clean a bleeding or infected suprapubic entry site:

• Explain the procedure to child and family and ensure privacy (Rationale 24). 
• Place a sachet of 0.9% sodium chloride in a bowl of warm water (Rationale 25). 
• Put on plastic apron. 
• Perform a hygienic hand wash and dry hands thoroughly (Rationale 20). 
• Remove strapping and dressing as appropriate, using adhesive remover (Rationale 26). 
• Perform a hygienic hand wash and dry hands thoroughly (Rationale 27). 
• Open the dressing pack and prepare the sterile field adding extra gauze. 
• Dry the sachet of 0.9% sodium chloride and add to the sterile field. 
• Apply alcohol-based gel to hands and put on gloves. 
• With non-dominant hand hold catheter using sterile gauze (Rationale 28). 
• Using gauze soaked in 0.9% sodium chloride wipe around the entry site once. 
• A new piece of gauze must be used each time until the entry site is clean. 
• Dry around the entry site using new piece of gauze (Rationale 29). 
• Re-secure the catheter to the child’s abdomen (Rationale 2). 
• Dispose of equipment in a yellow waste bag (Rationale 30). 
• Remove gloves and apron (dispose of in orange waste bag) and perform a hygienic hand wash and dry hands thoroughly. 
• Record procedure in child’s health care records (Rationale 31). 

Catheter removal

The child will require analgesia prior to the catheter being removed (Rationale 32). This must be prescribed and administered according to the Trust’s Drug Policy. If the child has been prescribed an antispasmodic, the drug should be stopped eight hours prior to the planned removal of the catheter (Rationale 33).

Universal precautions and a non-touch technique must be used (Rationale 34). The catheter must only be removed by or under the supervision of a competent nurse or doctor (Rationale 35).

To remove a suprapubic catheter the following equipment should be gathered (Rationale 36):

• non-sterile latex free gloves 
• plastic apron 
• sterile gauze 
• stitch cutter as required 
• hypoallergenic strapping
• adhesive remover 
• appropriate sized syringe, to remove water from balloon, if it is a Foley catheter

To remove the catheter: 

• Explain the procedure to the child and family and ensure privacy (Rationale 37). 
• Thirty minutes prior to procedure administer analgesia as prescribed (Rationale 32). 
• Put the catheter on free drainage if clamped to empty the bladder (Rationale 38).
• Put on an apron (Rationale 34). 
• Perform a hygienic hand wash, dry hands thoroughly and put on gloves. 
• If present cut the retaining suture (Rationale 39).
• Using adhesive remover, remove the adhesive strapping from the child’s abdomen, whilst supporting the weight of the catheter. 

To remove a Foley catheter:

• Insert a syringe into its one-way valve (Rationale 40). 
• Withdraw the documented volume of sterile water (Rationale 41). 
• The child’s doctor must be contacted if the sterile water cannot be withdrawn (Rationale 42). 
• Hold the catheter at entry site. 
• Encourage the child to take deep breaths (Rationales 43 and 44). 
• Gently pull on the catheter in one steady motion, whilst the child exhales, until the catheter is completely removed. 
• Contact the child’s doctor if the catheter cannot be removed (Rationale 45).  
• Following removal, apply pressure using sterile gauze to the entry site for one minute to promote closure of the bladder and abdominal wall (Rationale 46).
• Leave gauze in situ and apply strapping to secure (Rationale 46). 
• If site is bleeding/leaking urine, inform the child’s doctor (Rationale 47). 
• Dispose of urine and equipment according to the Trust’s waste policy (Rationale 27). 
• Perform a hygienic hand wash and dry hands thoroughly. 
• Record the volume of urine in the drainage bag on the child’s fluid balance chart (Rationale 11). 
• Record procedure in the child’s health care records (Rationale 11). 
• Following removal of the catheter, ensure the child is able to pass urine per urethra, unless another bladder catheter is in situ (Rationale 48). 
• The time limit for the child to have micturated for the first time should be determined with the child’s doctor (Rationale 49). 
• The child and family must be reminded that pain may be experienced as the bladder fills up and during the first micturition (Rationale 11). 
• The child’s first micturition must be documented on the fluid balance chart and in the child’s health care record. 
• The child’s doctor must be informed if the child:
  • is unable to pass urine (Rationale 50) 
  • has dysuria (Rationale 51) 
  • if the entry site leaks on their first micturition 

The entry site must be observed for haemorrhage and urine leakage (Rationale 52). If either occurs, pressure must be applied and the child’s doctor informed (Rationale 53).

The dressing should be removed after 24 hours (Rationale 54). Once the site is healed a dressing will no longer be required.

The appropriate children’s community nursing team must be informed prior to the child’s discharge (Rationale 55). The child’s parents should be advised to contact the ward if, once discharged, they have concerns about the wound site.

Rationale

Rationale 1: To prevent trauma to the entry site.
Rationale 2: To prevent accidental removal.
Rationale 3: Smaller gauge catheters minimise trauma and mucosal irritation, which can predispose a child to catheter-associated infection (Sanders 2001).
Rationale 4: They are easier to change and clean.
Rationale 5: They are less likely to block than a urethral catheter.
Rationale 6: They can be clamped to assess the child's ability to void per urethra.
Rationale 7: Duration of catheterisation is strongly associated with risk of infection, ie the longer the catheter is in place, the higher the incidence of urinary tract infection (Stamm 1998).
Rationale 8: The use of latex catheters and securing devices is a risk factor in acquiring latex allergy (Woodward 1997).
Rationale 9: The tip of the catheter is normally in the trigone of the bladder, which can cause bladder spasm (Fillingham 2000).
Rationale 10: To provide information enabling informed consent to be obtained.
Rationale 11: To provide an accurate record.
Rationale 12: To assist in the psychological preparation of the child.
Rationale 13: To reinforce verbal explanations.
Rationale 14: To prevent trauma to the entry site and accidental removal.
Rationale 15: To maintain the security of catheter.
Rationale 16: To ensure appropriate management.
Rationale 17: To enable identification of micro-organisms (Higgins 2000).
Rationale 18: Routine cleansing may cause a urinary tract infection due to manipulation of the tube and introduction of skin commensals to the tract.
Rationale 19: To minimise the risk of introducing further infection.
Rationale 20: To minimise the risk of cross-infection (Sanders 2001; NICE 2003).
Rationale 21: Cotton wool should not be used as it can deposit fibres around the entry site which can increase irritation and the risk of infection.
Rationale 22: There is no advantage in using antiseptic preparations for cleansing (Sanders 2001).
Rationale 23: To replace the strapping if necessary.
Rationale 24: To promote co-operation and involvement and reduce anxiety.
Rationale 25: Warm solution causes less discomfort.
Rationale 26: To gain access to entry site.
Rationale 27: To minimise the risk of infection.
Rationale 28: To prevent trauma to the entry site.
Rationale 29: A dry environment is less conducive to the growth of micro-organisms.
Rationale 30: To prevent cross infection and adhere to the Trust’s waste policy (Clark 2002).
Rationale 31: To provide an accurate record and enhance communication.
Rationale 32: To relieve any discomfort the child may experience.
Rationale 33: The action of the drug reduces bladder tone, which could delay micturition following catheter removal (BMA and Royal Pharmaceutical Society of Great Britain 2003).
Rationale 34: To minimise the risk of introducing infection (Pratt 2001; Sanders 2001).
Rationale 35: To minimise associated risks (Sanders 2001).
Rationale 36: To enable the procedure to be performed safely and efficiently.
Rationale 37: To promote co-operation and involvement.
Rationale 38: To reduce the risk of urine leakage.
Rationale 39: To reduce trauma.
Rationale 40: To enable the balloon of the catheter to be deflated.
Rationale 41: Occasionally the one-way valve fails to release the sterile water.
Rationale 42: To enable catheter to be gently pulled.
Rationale 43: To relax abdominal wall.
Rationale 44: If catheter gets caught it can cause bladder spasms.
Rationale 45: The internal suture may still be intact or it may be caught in oedematous tissue.
Rationale 46: To prevent leakage of urine and bleeding.
Rationale 47: The entry site may not have sealed following the application of initial pressure.
Rationale 48: To ensure the child is not retaining urine.
Rationale 49: If the child has had bladder surgery there is a risk of urine leakage due to excess pressure.
Rationale 50: The bladder or urethra may be oedematous causing pain or obstruction.
Rationale 51: Increased bladder pressure may cause a leak.
Rationale 52: The entry site must be observed for haemorrhage and urine leakage.
Rationale 53: If either occurs, pressure must be applied and the child’s doctor informed.
Rationale 54: To promote healing.
Rationale 55: To provide support in the community.

References

Reference 1:
British Medical Association and the Royal Pharmaceutical Society of Great Britain (2011) British National Formulary for Children 2011-2012. London, British Medical Association and the Royal Pharmaceutical Society of Great Britain. 

Reference 2:
Pentayya D, Cornish A (2012) Waste Management Policy London, Great Ormond Street Hospital. 

Reference 3:
Fillingham S, Douglas J (1997) Urological Nursing. London, Bailliere Tindall. 

Reference 4:
Higgins C (2000) Understanding Laboratory Investigations: A text for nurses and healthcare professionals. Oxford, Blackwell Sciences. 

Reference 5:
National Institute of Clinical Excellence (2003) Clinical Guideline 2 Infection Control: Prevention of healthcare-associated infection in primary and community care; (No 1) Standard Principles. London, NICE. 

Reference 6:
Pratt RJ, Pellowe C, Loveday HP, Robinson N, Smith GW and the epic guideline development team (2001) Guidelines for preventing infections associated with the insertion and maintenance of short-term indwelling urethral catheters in acute care. J Hosp Infect 47 Suppl: S39-46.

Reference 7:
Sanders C (2001) Suprapubic catheterisation: Risk management. Paediatric Nursing 13(10): 14-18.

Reference 8:
Shah N, Shah J (1998) Percutaneous suprapubic catheterisation. Urology News 2 (5): 11-12.

Reference 9:
Stamm WE (1998) Urinary Tract Infections In: Bennet JV and Barcham PS (Editors) Hospital Infection (4th Ed). Philadelphia, Lippincott-Raven. 

Reference 10:
Woodward A (1997) Complications of allergies to latex urinary catheters. British Journal of Nursing 6(14): 786-790.

Document control information

Lead author(s) 
Liane Pilgrim, Senior Nurse, Nephro-urology

Additional authors
Fiona Bell, Lecturer Practitioner, Nephro-urology

Document owner
Karen Ryan, Clinical Nurse Specialist, Urology

Approved by
Clinical Practice Committee

First introduced: 21 July 2004
Date approved: 5 January 2012
Review schedule: Two years
Next review: 5 January 2014
Document version: 2.0
Replaces version: 1.0