Safer insertion of suprapubic catheters: summary of a safety report from the National Patient Safety Agency

Suprapubic catheters are used when urethral catheterisation is not possible or desirable because of, for example, urethral stricture, prostatic enlargement, or urethral trauma.1 In some cases the procedure may be carried out as an emergency on the ward. Elective indications include postoperative drainage after lower urinary tract or bowel surgery and the management of the neuropathic bladder. Many patients with conditions such as multiple sclerosis and spinal cord injury use long term suprapubic catheter drainage, to simplify catheter management and minimise risks of urethral damage.

Anecdotal evidence suggests that a typical hospital will carry out more than 100 suprapubic catheterisations each year. The doctors who undertake suprapubic catheterisation may lack experience: unless they are urologists, they may rarely perform the procedure. Suprapubic catheterisation is often delegated to junior medical staff.

The procedure involves passing a urinary catheter directly into the bladder through the lower abdominal wall, sometimes guided by ultrasound. Most are done safely, but important risks associated with catheter insertion include haemorrhage and infection of the urine or catheter track, and serious complication from intestinal injury. Bowel damage can lead to fatal peritonitis and is a particular risk in patients with contracted bladders that fail to distend sufficiently for safe catheter passage and in those with adhesions from previous lower abdominal surgery tethering bowel loops to the lower abdominal wall.

From September 2005 to June 2009, staff in England and Wales reported three deaths and seven cases of severe harm relating to insertion of suprapubic catheters. A further 249 incidents related to problems in suprapubic catheter use. Complications are likely to be under-reported, given 30 day mortality rates, in relatively small studies, ranging from 0.82 to 1.8.3

A typical incident report reads: “Patient underwent insertion …