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In today’s evolving health care field, outpatient procedures arebecoming more commonplace. Many patients with suprapubiccatheters are now being seen in outpatient or home care settings.Addressing the educational needs of patients, family members, andnursing staff is now more important than ever for successful patientsuprapubic catheter management. A basic understanding of howthese catheters are initially placed is essential for proper care andavoidance of possible complications. This review of initial placementof suprapubic catheters and post-insertion care is based on one clin-ician’s experience and practice at a local hospital in Pennsylvania.

© 2011 Society of Urologic Nurses and AssociatesUrologic Nursing, pp. 259-264.

Ins and Outs of SuprapubicCatheters – A Clinician’s ExperienceSusan Bullman

Initial Insertion of SuprapubicCatheters

Initial suprapubic catheterplacement can occur by two dif-ferent methods. In the author’sinstitution, the urologist useseither a Stamey catheter underlocal anesthesia or a Lowsley™

tractor under moderate sedationor anesthesia. Table 1 provides adefinition of terms. In the state ofPennsylvania, physician’s assis-tants (PAs) and nurse practition-ers (NPS) do not perform initialplacement of suprapubic cath et -ers unless they have a supervi-sion agreement and have hadadditional credentialing.

Urinary retention is the usualpresenting patient symptom.Causes of urinary retention caninclude paraplegia, quadriplegia,multiple sclerosis, and urethralor perineal trauma. If initialattempts at placing a catheter viathe urethra have been unsuccess-ful, the urologist would then beconsulted. After completing anexamination, the urologist maychoose to proceed with suprapu-bic catheter placement.

Stamey ProcedureA Stamey catheter would be

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Objectives

1. List the causes of urinary retention.2. Explain the Stamey catheter procedure.3. Discuss the Lowsley™ tractor procedure.4. Discuss the process for changing a suprapubic catheter.

Susan Bullman, BSN, RN, CURN, is aUrology Procedure Unit Charge Nurse, St.Vincent Health Center, Erie, PA.

Note: Objectives and CNE Evaluation Formappear on page 264.

Statement of Disclosure: The authorreported no actual or potential conflict ofinterest in relation to this continuing nursingeducation activity.

Key Words: Suprapubic catheters, patient education, Stamey catheter,Lowsley™ tractor.

Urologic Nursing Editorial Board Statements of Disclosure

In accordance with ANCC-COA governing rules Urologic Nursing Editorial Board state-ments of disclosure are published with each CNE offering. The statements of disclosure forthis offering are published below.

Susanne A. Quallich, ANP-BC, NP-C, CUNP, disclosed that she is on the Consultants’Bureau for Coloplast.

All other Urologic Nursing Editorial Board members reported no actual or potential con-flict of interest in relation to this continuing nursing education article.

considered if the patient’s blad-der was distended. The bladdermust be distended for the proce-dure to be performed safely. Tounderstand this concept, it maybe helpful to imagine trying toinsert a needle into a deflated bal-loon as opposed to an over-inflat-ed balloon. This (bladder disten-

tion) would decrease the possibil-ity of perforation into the bowel.The Stamey catheter has a metalobturator that allows a guide wireto pass through the catheter andassists with placement.

This procedure is generallyperformed under a local anesthet-ic and is considered clean tech-

260 UROLOGIC NURSING / September-October 2011 / Volume 31 Number 5

nique at our facility (North ernTerritory Government: De part -ment of Health and Families,2010). The patient is placed in asupine position, and the abdo -men/ suprapubic area is preppedwith povidone iodine (Beta -dine®) scrub and solution. Ifthere is an iodine allergy, analternate prep such as 4% chlor -hexidine gluconate (Hibiclens®)is used. The patient is thendraped with sterile linen ifrequested by the urologist.

The urologist dons sterilegloves and palpates the suprapu-bic area feeling for a distendedbladder. Once the bladder islocated, a local anesthetic is usedper physician preference. Theurologist uses the Stamey to pushthrough the skin, pre-vesiclespace, and into the bladder. Aurine specimen may be obtained

for urinalysis and culture at thistime if ordered by the physician.The obturator is then removedand the catheter secured as rec-ommended by the manufacturer.

The suprapubic catheter mayhave a balloon or pigtail thatholds it in the bladder dependingon the manufacturer (see Figures1 and 2). The urologist may alsoplace a suture to help reinforcethe security of the catheter. Thearea around the catheter iscleaned and dressed with a 4x4and taped in an occlusive fash-ion. An additional piece of tapecan also be placed on the catheteroutside of the dressing, attachingto the abdomen or thigh for extrasecurity. A urinary drainage bag,either a leg bag or night bag, isthen applied. If a leg bag isapplied, a larger volume night

bag is also offered. This allowsfor uninterrupted patient sleep atnight without getting up toempty a smaller bag.

Lowsley™ InsertionThe second method involves

insertion of the suprapubic cathe -ter under anesthesia or moderatesedation, which also uses cleantechnique. This method is usedin non-emergent cases in which

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Figure 1.Suprapubic Catheter with

Pigtail End

Source: Reprinted with permissionfrom Cook Medical.

Figure 2.Rutner Suprapubic Balloon

Catheter

Source: Reprinted with permissionfrom Cook Medical.

Anesthesia – Drug induced state of unconsciousness.

Clean Technique – Practice that reduces the number of infectious agents(Northern Territory Government: Department of Health and Families, 2010).

Local Anesthesia – Technique used to induce the absence of sensation in anypart of the body.

Lowsley™ Tractor – Metal surgical instrument designed to facilitate suprapubiccatheter placement.

Meatotomy – An incision into the meatus to enlarge it.

Moderate Sedation – A drug-induced depression of consciousness duringwhich patients respond purposefully to verbal commands, either alone oraccompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate.

Obturator – Metal piece that occludes the needle, which introduces a suprapubic cystostomy.

Prevesicle Space (or Space of Retizus) – Space between pubic symphysis andurinary bladder that is the retropubic space in front of the bladder.

Sound – Curved metal instrument used to dilate the urethra.

Stamey Catheter – Style of suprapubic catheter used for initial placement.

Sterile Technique – Aims to eliminate micro-organisms from areas and objectssuch as surgical incisions or wounds (Northern Territory Government:Department of Health and Families, 2010).

Suprapubic Catheter – Also known as a suprapubic cystostomy; created connection between urinary bladder and the skin used to drain urine from thebody.

Urethral Dilation – Procedure performed by the urologist that opens a urethra.

Table 1.Definition of Terms

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the patient is not in acute reten-tion. The patient’s abdomen isprepped and draped in the samemanner as discussed with theStamey method. The perinealarea is prepped with chlorhexi-dine gluconate and water on a 4x4.This method of insertion requiresthe use of a Lowsley™ tractor forplacement (see Figure 3).

The Lowsley™ tractor is ametal instrument resembling asound or curved dilator. Theinstrument goes through the ure-thra and into the bladder. Thetractor is used to “tent up” thebladder. This is a process thatpushes the tractor up against thebladder wall into the pre-vesiclespace. The tractor can usually befelt through the abdominal walldepending on the thickness of

the patient’s abdominal wall. Ascalpel or cautery pencil is usedto cut through the abdomen tothe Lowsley™ tractor, which willthen come up through the pre-vesicle space and out of theabdomen. The tractor is thenopened up to grasp the catheterthat will be used for placement(see Figure 4). Once the catheteris firmly grasped, it is broughtback through the pre-vesiclespace into the bladder and outthe urethra. A cystoscope is usedto follow the catheter back intothe bladder. The catheter shouldbe plugged to allow the bladderto fill. Once placement is veri-fied, the catheter balloon is theninflated. Dressings and drainagebag are applied as with theStamey method.

Complicated Suprapubic CatheterInsertion

At times, additional helpmay be needed in placing thesecatheters. If the patient is unableto be catheterized, a urethral dila-tion or a meatotomy may berequired. It is not uncommon toadditionally use fluoroscopy (X-ray) or ultrasound when placingsuprapubic catheters. If it is aparticularly difficult case, a cys-togram may be performed to ver-ify placement. Patients requiringadditional diagnostic and or pro-cedural interventions may beadmitted overnight to the hospi-tal for observation.

Potential complications re lat -ed to insertion of suprapubic cath -eters include hemorrhage, perfo-ration into the bowel, catheterwith poor or no urine drainage,and infection (Ramakrishnan &Mold, 2005). Astute nursingassessment of these complicationsis particularly important after ini-tial insertion.

Changing a Suprapubic Catheter

Formation of a well-estab-lished tract for the suprapubiccatheter takes approximately sixweeks to six months to develop.Until then, the suprapubiccatheter change is performed bythe urologist. Once the tract isestablished and optimal cathetersize has been achieved, a trainednurse can perform this proce-dure. Patients usually tolerategoing up one catheter size (forexample, from 16 Fr to 18 Fr)without difficulty. The physiciangenerally increases the size of thecatheter at each visit until a sizeis reached that allows for optimaldrainage. It is not unusual to seesome blood in the urinary drain -age bag after a catheter is chang -ed to a larger size. Patients areencouraged to increase theirfluid intake. Minimal bleeding atthe stoma site may also be noted.However, the bleeding shouldnot last for more than a day ateither the stoma site or in theurine. Figure 5 outlines the sup-

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Figure 3.Lowsley™ Tractor

Source: Image Courtesy of Gyrus ACMI Inc.

Figure 4.Lowsley™ Tractor Grasping Catheter

Source: Image Courtesy of Gyrus ACMI Inc.

262 UROLOGIC NURSING / September-October 2011 / Volume 31 Number 5

plies necessary and the steps ofchanging a suprapubic catheter.

If the patient has cloudyurine, the urologist may want thecatheter irrigated to ensure theflow of urine is optimal. Cath et ersare routinely changed per physi-cian choice. In the author’s facili-ty, this is anywhere from three tosix weeks. If the patient experi-ences catheter-related problems(such as not draining adequatelyor stone material forming on thetube), then a more frequentchange is preferable.

Care of Suprapubic Catheters/Patient Family Teaching

It is vital for the patient and/or family to be taught how to carefor the suprapubic catheter priorto discharge, either as an inpa-tient or outpatient. Teachingaspects would include dressingchanges, stoma site care (includ-ing signs and symptoms of infec-tion), fluid intake, monitoring ofurine output for volume, andsigns of a bladder infection.Frequency of catheter change is

also important to discuss. Gen -erally, soap and water to cleanthe stoma area is sufficient.Petroleum-based ointments shouldnot be used because they couldharm the catheter (if it is latex-based) and could also lead toinfection.

The patient is encouraged todrink adequate fluids to keep theurine clear and free-flowing.Suprapubic catheters chronical-ly leave some residual urine inthe bladder, which can lead tostone formation. Therefore, theimportance of drinking fluidsshould be stressed. Somepatients may note that theirurine looks cloudy or sometimes“milky.” This can be sedimentfrom stone formation caused byinfection (Basler, Catrill, Lucas,& Ghobriel, 2009). The nurseshould notify the urologist if thisis a new finding. The urologistwill need to assess the situation.Reviewing the patient’s historyand noting whether this is achronic problem or an acuteissue will help direct furtherinvestigation. The urologist mayadvise gentle irrigation of thebladder as a first step. This canbe done with either sterile wateror normal saline solution (perphysician preference) and a bulbor Toomey syringe. Proper in -struction by the nurse with suc-cessful return demonstration bythe patient or family is requiredif this procedure is to be contin-ued at home. If a urinary tractinfection is suspected, the pa -tient may be placed on an antibi-otic. Antispasmodic medicationcan be prescribed if bladderspasms become problematic(Ramakrishnan & Mold, 2005). Acystoscopy may be performed toexamine the bladder more fullyif further investigation is war-ranted.

In the event the suprapubiccatheter becomes dislodged, it isimportant for the patient to havethe catheter reinserted as soon aspossible. This may involve call-ing the urologist’s office or com-ing to the emergency room unless

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Figure 5.Supplies Needed and Steps for Changing a Suprapubic Catheter

Supplies Needed

• 10 cc syringe to deflate the balloon on the existing catheter.• Under pad to protect patient from getting soiled.• New suprapubic catheter.• Filled 10 cc syringe to inflate new balloon.• Urinary drainage bag.• Graduate container.• Gloves – Sterile in appropriate size.• Culturette.• 4x4s with chlorhexidine gluconate and warm water.• Water-soluble lubrication.• Dressing.• Tape.

Steps for Changing a Suprapubic Catheter

• Place the patient in a supine position. • Place underpad under the suprapubic catheter to protect the patient from

becoming soiled. • Remove the old dressing. • Assess the insertion site for redness and drainage. If there is inflammation

or drainage, a culture may be obtained.• Prep with 4x4s with chlorhexidine gluconate and warm water. • Lubricate the new catheter. • Deflate the balloon of the old catheter to remove. • Grasp the old catheter at the skin level and remove at a steady rate. • Measure the new catheter to the old catheter and insert to the same level.

(This is particularly important in males to avoid placing the catheter in theurethra where the balloon may get inflated, causing pain and trauma.)

• Insert the new catheter. When removing or inserting the catheter, there maybe some slight resistance. This resistance is similar to catheterizing a malepatient as the catheter passes through the prostatic urethra.

• Inflate balloon.• Apply drainage bag.• Clean patient and apply dressing.

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the patient/ caregiver has beenproperly instructed on how toreinsert the suprapubic catheter.The site of insertion can closefairly quickly, so prompt atten-tion is needed. Anecdotally, thisclinician has observed a signifi-cant decrease in the stoma open-ing size in as little as eight hours.If the site has begun to close, andthe catheter cannot be safelyreinserted, then the urologist isnotified. A stoma site dilationmay be indicated. Flouroscopyand a cystogram may also need tobe performed.

It is important for the nurse toassess the psychosocial needs ofpatients requiring suprapubiccatheter insertion. Anger issuesdue to the loss of control anddecreased self-esteem related tochanges in body image or diagno-sis may need further exploration.In the author’s practice, many

patients have different ways ofapplying their dressings and sta-bilizing their catheters. To foster asense of control, it is important toallow these differences as long asit does not compromise theintegrity of the catheter system.Generally, after a few visits,patients are not as angry becausethey feel they have regained somecontrol and are more comfortablewith their altered body image.

Conclusion

As health care delivery con-tinues to change, nurses need toprepare for the possible increasein numbers of outpatients requir-ing suprapubic catheters, whichcan impact their practice set-tings. In the author’s facility,there has been a rise in the num-ber of patients who have supra-pubic catheters in the home set-

ting. Requests for educational in-services regarding suprapubiccatheter care and managementhave increased as well. Edu -cating ourselves, our patients,and their families is vital for suc-cessful outpatient patient supra-pubic catheter management andprevention of complications.

ReferencesBasler, J., Cantrill, C.H., Lucas, J.J., &

Ghobriel, A. (2009). Bladder stones.Re trieved from http:// e medicine.med scape. com/ article/ 44 06 57-overview # show all

Northern Territory Government: De part -ment of Health and Families. (2010).Aseptic technique. Re triev ed fromhttp:// remote health atlas. nt. gov. au/aseptic _ technique. pdf

Ramakrishnan, K., & Mold, J.W. (2005).Urinary catheters: A review. TheInternet Journal of Family Practice,3, 2.