1. SUPRA-PUBIC CATHETERISATION

2. 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

3. 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

4. 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

5. 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

6. 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)

7. 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

8. 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

10. COMPLICATIONS  Bowel injury  Migration  Haematuria  Rectal injury and Vascular injury  Very rare  Stay in the midline to avoid

11. WATCH THE VIDEO  https://www.youtube.com/watch?v=xa0CtwHToRk