The purpose of this guideline is to provide guidance about suprapubic catheterisation at Great Ormond Street Hospital (GOSH).
Suprapubic catheterisation is a procedure that drains the bladder by passing a catheter to the bladder through the abdominal (Shah and Shah 1998). The procedure is carried out using an aseptic technique and in children and young people is usually performed under a general anaesthetic. In life threatening situations or acute retention of urine, a suprapubic catheter may however, be inserted under local anaesthetic.
The suprapubic catheter 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 used 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 11)
- 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 38)
- provide long-term urinary drainage
- perform radiological and urodynamic investigations (Pratt et al 2007)
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).
Suprapubic catheters 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) 2014).
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
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 (Rationales 1 and 2). The strapping and retention suture should be checked for security whenever the catheter bag is being emptied (Rationale 2).
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 14). 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 15).
The following equipment should be gathered:
- non-sterile latex free gloves and plastic apron (Rationale 18)
- dressing pack
- additional lint free sterile gauze (Rationale 19)
- sachet sterile 0.9% sodium chloride (Rationale 20)
- adhesive remover
- hypoallergenic, latex free adhesive strapping (Rationale 21)
To clean a bleeding or infected suprapubic entry site:
- Explain the procedure to child and family and ensure privacy (Rationale 22).
- Place a sachet of 0.9% sodium chloride in a bowl of warm water (Rationale 23).
- Put on plastic apron.
- Perform hand wash and dry hands thoroughly (Rationale 18).
- Remove strapping and dressing as appropriate, using adhesive remover (Rationale 24).
- Perform hand wash and dry hands thoroughly (Rationale 18).
- 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 25).
- 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 26).
- Re-secure the catheter to the child’s abdomen (Rationale 2).
- Dispose of equipment in an appropriate waste bag in line with Hospital Waste Management Policy (Rationale 27).
- Remove gloves and apron (dispose of in an appropriate waste bag in line with Hospital Waste Management Policy) and perform a hand wash and dry hands thoroughly.
- Record procedure in child’s health care records (Rationale 28).
The child will require analgesia prior to the catheter being removed (Rationale 29). This must be prescribed and administered according to the Trust’s Medicine Administration 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 30).
To remove a suprapubic catheter the following equipment should be gathered (Rationale 33):
- 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 34).
- Thirty minutes prior to procedure administer analgesia as prescribed (Rationale 29).
- Put the catheter on free drainage if clamped to empty the bladder (Rationale 35).
- Put on an apron (Rationale 31).
- Perform a hand wash, dry hands thoroughly and put on gloves.
- If present cut the retaining suture (Rationale 36).
- 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 37).
- Withdraw the documented volume of sterile water (this should be written in the patient notes on insertion of catheter) (Rationale 38).
- The child’s doctor must be contacted if the sterile water cannot be withdrawn (Rationale 41).
- Hold the catheter at entry site.
- Encourage the child to take deep breaths (Rationales 40 and 41).
- 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 42).
- Following removal, apply pressure using sterile gauze to the entry site for one minute to promote closure of the bladder and abdominal wall (Rationale 43).
- Leave gauze in situ and apply strapping to secure (Rationale 44).
- If site is bleeding/leaking urine, inform the child’s doctor (Rationale 47).
- Dispose of urine and equipment according to the Trust’s waste management policy (Rationale 20).
- 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 45).
- The time limit for the child to have micturated for the first time should be determined with the child’s doctor (Rationale 46).
- The child and family must be reminded that pain may be experienced as the bladder fills up and during the first micturition (Rationale 12).
- The child’s first micturition must be documented on the fluid balance chart and in the child’s health care record (Rationale 11).
- The child’s doctor must be informed if the child:
The dressing should be removed after 24 hours (Rationale 51). Once the site is healed a dressing will no longer be required.
The appropriate children’s community nursing team must be informed on admission to allow them time to prepare for discharge and again prior to the child’s discharge (Rationale 52). The child’s parents should be advised to contact the ward if, once discharged, they have concerns about the wound site.
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 (Parry et al 2013).
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 and Douglas 2004).
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 ensure appropriate management.
Rationale 15: To enable identification of micro-organisms (Higgins 2000).
Rationale 16: Routine cleansing may cause a urinary tract infection due to manipulation of the tube and introduction of skin commensals to the tract.
Rationale 17: To minimise the risk of introducing further infection.
Rationale 18: To minimise the risk of cross-infection (Sanders 2001; NICE 2014).
Rationale 19: 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 20: There is no advantage in using antiseptic preparations for cleansing (Sanders 2001).
Rationale 21: To replace the strapping if necessary.
Rationale 22: To promote co-operation and involvement and reduce anxiety.
Rationale 23: Warm solution causes less discomfort.
Rationale 24: To gain access to entry site.
Rationale 25: To prevent trauma to the entry site.
Rationale 26: A dry environment is less conducive to the growth of micro-organisms.
Rationale 27: To prevent cross infection and adhere to the Trust’s waste management policy.
Rationale 28: To provide an accurate record and enhance communication.
Rationale 29: To relieve any discomfort the child may experience.
Rationale 30: The action of the drug reduces bladder tone, which could delay micturition following catheter removal (BMA and Royal Pharmaceutical Society of Great Britain 2014).
Rationale 31: To minimise the risk of introducing infection (Pratt et al 2007; Sanders 2001).
Rationale 32: To minimise associated risks (Sanders 2001).
Rationale 33: To enable the procedure to be performed safely and efficiently.
Rationale 34: To promote co-operation and involvement.
Rationale 35: To reduce the risk of urine leakage.
Rationale 36: To reduce trauma.
Rationale 37: To enable the balloon of the catheter to be deflated.
Rationale 38: Occasionally the one-way valve fails to release the sterile water.
Rationale 39: To enable catheter to be gently pulled.
Rationale 40: To relax abdominal wall.
Rationale 41: If catheter gets caught it can cause bladder spasms.
Rationale 42: The internal suture may still be intact or it may be caught in oedematous tissue.
Rationale 43: To reduce the risk of leakage of urine and bleeding.
Rationale 44: The entry site may not have sealed following the application of initial pressure.
Rationale 45: To ensure the child is not retaining urine.
Rationale 46: If the child has had bladder surgery there is a risk of urine leakage due to excess pressure.
Rationale 47: The bladder or urethra may be oedematous causing pain or obstruction.
Rationale 48: Increased bladder pressure may cause a leak.
Rationale 49: The entry site must be observed for haemorrhage and urine leakage.
Rationale 50: If either occurs, pressure must be applied and the child’s doctor informed.
Rationale 51: To promote healing.
Rationale 52: To provide support in the community.
British Medical Association and the Royal Pharmaceutical Society of Great Britain (2014) British National Formulary for Children 2014-2015. London, British Medical Association and the Royal Pharmaceutical Society of Great Britain.
Fillingham S, Douglas J (2004) Urological Nursing (3rd Ed). London, Bailliere Tindall.
Higgins C (2013) Understanding Laboratory Investigations: A text for healthcare professionals 3rd ed. Oxford, Blackwell Science.
National Institute for Health and Care Excellence (2014) Standard principles of prevention and control of healthcare-associated infections in primary and community care. Manchester, NICE.
Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SR, McDougall C, Wilcox M (2007) Epic2: National evidence-based guidelines for preventing healthcare associated infections in NHS hospitals in England. Journal of Hospital Infection 65(1): 1-64.
Sanders C (2001) Suprapubic catheterisation: Risk management. Paediatric Nursing 13(10): 14-18.
Shah N, Shah J (1998) Percutaneous suprapubic catheterisation. Urology News 2 (5): 11-12.
Parry MF, Grant B, Sestovic M (2013) Successful reduction in catheter-associated urinary tract infections: Focus on nurse-directed catheter removal. American Journal of Infection Control 41: 1178-1181.
Woodward A (1997) Complications of allergies to latex urinary catheters. British Journal of Nursing 6(14): 786-790.