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Suprapubic Catheterization (SPC)-Related Complications and Problems

The complication rate for cystostomy (surgical procedure for insertion of a suprapubic catheter (SPC)) ranges from 1.6% to 2.4%. The first few catheter changes after the initial SPC insertion should be performed using a guidewire as acute complications can occur.

Problems and adverse events usually occur with long-term SPCs and are similar to those seen with indwelling urethral catheter (IUC, foleys). They include:

  • Catheter blockage
  • Urine bypassing (urine leaks around the catheter
  • Bladder spasms
  • Accidental catheter dislodgement
  • Non-deflating balloon
Hobbs and colleagues (2022)11 retrospectively analyzed the database (National Spinal Injuries Centre in Stoke Mandeville Hospital, UK) of 1000 consecutive SPC insertions from 1998 to 2015 in a population primarily of spinal cord injury patients. They reported on short (occurring within 30 days of SPC insertion and) and long-term complications (occurring beyond 30 days of SPC insertion). Short term complications were seen in 176/ 1000 cases (17.6%), with the most common, febrile UTI, occurring in 56/1000 cases (5.6%), hematuria lasting longer than 48 hours was seen in 42/1000 cases (4.2%0, posterior bladder wall injury occurred in 2 cases, small bowel obstruction diagnosed on CT scan occurred in 3 patients. Long-term complications recorded in this population included:

  • Tract losses in 136/866 cases (15.7%)
  • Difficult changes requiring re-visits in 43/866 cases (5%)
  • Tract stenosis requiring dilatation in 19/866 cases (2.2%)
  • Urethral leakage (male-71.1%, female 28.9%) reported by 76/866 cases (8.8%), with 8/ 76 (10.5%) opting to have their SPC removed in favor of a urethral catheter.
However, there are additional complications that may occur with SPCs and here is a list of those seen:

  1. Catheter-associated UTIs (CAUTI): All indwelling urinary catheters rapidly become colonized by bacteria, with almost 100% of catheters colonized after 28 days. Bacterial colonization is not the same as a CAUTI. Bacteria in the urine and without symptoms is known as asymptomatic bacteriuria and does not require antibiotics. Bacterial colonization occurs as a consequence of the catheter interfering with the natural flushing action of urine which usually eliminates bacterial microorganisms from the bladder. The impact of catheterization method, urethral or suprapubic, on CAUTI frequency, has not been investigated but it is thought to be occurring less in patients with a SPC. Buehrle and colleagues (2020)3 demonstrated that SPCs were associated with significantly lower rates of CAUTI and fewer days of antibiotic therapy for CAUTI or for CAUTI plus asymptomatic bacteriuria than indwelling urethral catheters among VA nursing home residents. Both urethral and suprapubic catheters can develop bacterial biofilms on the interior or exterior of the catheter lumen. Biofilm leads to the formation of urease, which breaks down urinary urea to release ammonia which turns the urine alkaline. The alkalinity of the urine causes the formation of apatite (a hydroxylated form of calcium phosphate) and struvite (magnesium ammonium phosphate). These are ‘gritty’ crystals that attach to the lumen of the catheter and block the drainage eyelets. On removal of the catheter, these crystals can be shed into the bladder, which may result in the formation of bladder stones.
  2. Abdominal and lower urinary tract injury, including bowel and bladder complications: complications including small bowel perforation and injury, peritonitis, bleeding, wound infection and cellulitis, and bladder injury can occur with initial SPC placement, although less common with routine SPC changes, these complications can present at any time, even months following the procedure. Misplacement of the catheter during routine SPC replacement can contribute to bladder and/or small bowel injuries or perforations. Inflating the catheter balloon prior to the catheter reaching the bladder can contribute to tract injury.
  3. Overgranulation at the cystostomy site The site of catheter insertion is highly vascularized but lacks a protective epithelial layer, causing the area to remain moist and unable to withstand trauma, especially from rubbing. This can cause overgranulation of tissue (as seen in this figure) leading to bleeding and discomfort when changing the SPC. Overgranulation can be precipitated by an inflammatory response from specific catheter material (e.g. latex). According to English (2017),18 removal of overgranulated tissue includes the use of topical silver nitrate to cauterize the overgranulation tissue. Reducing pressure on the stomal opening can prevent occurrence. Also, low dose hydrocortisone cream can be used to reduce redness and granulation tissue around the SPC tract.
  4. Difficulty with catheter insertion: Causes of difficulty during SPC change include: loss of the suprapubic tract or an inflammatory reaction of the vascularized tract to catheter material or from the presence of hard stool in the bowel in a patient with severe constipation. If overgranulation occurs, this tissue may cover the insertion site and narrow the tract thus making insertion of the catheter difficult.
  5. Bleeding: A small amount of bleeding may occur with the first few SPC changes. Patients on anticoagulant therapy are at greater risk for bleeding. Prolonged bleeding after insertion may indicate a bowel injury
  6. Discharge around the catheter: Discharge around the SPC exit site is a common complaint. This usually does not require treatment. Swabs are not helpful and antibiotics are not needed. Use of gauze dressings is recommended.
  7. Pain: Removal of an existing SPC may be painful if there is ridge formation on the catheter balloon.
  8. Trauma: Tissue trauma of the suprapubic tract may occur if the catheter is not adequately advanced into the bladder and the retaining balloon is inflated in the stomal tract. This can be prevented by avoiding insertion of the catheter too far, since it may result in advancement of the catheter into the urethra, resulting in trauma when the clinician attempts to inflate the balloon.
  9. Bladder calculi incidence is the same in both IUC and SPC methods of bladder drainage. Hunter et al (2013)12 noted that the presence of the catheter and the resultant bacteria and high urinary pH that occur may be the causes.
  10. Catheter migration: This can occur with first few catheter changes after the initial insertion or in long-term SPC patients. Elmoheen and colleagues (2021)5 reported on a case of a 30-year-old man who presented with migration of the catheter into the vesicoureteral junction causing moderate to severe hydronephosis on the left side. He was 1 month post-cystostomy for SPC placement and had been changed 5 days prior to this episode. Mekayten and colleagues (2021)17 reported on a 34-year-old male who had uneventful SPC replacements for 15 yrs. However, after a replacement with a whistle tip 24 Fr catheter, a CT test demonstrated bilateral hydronephrosis, an empty bladder, and a catheter tip in the ureteral orifice with the catheter drainage holes (eyelets) in the distal left ureter.
Written by: Diane K. Newman, DNP FAAN BCB-PMD, Urologic Nurse Practitioner, Adjunct Professor of Urology in Surgery, Senior Research Investigator, Perelman School of Medicine, University of Pennsylvania

References:

  1. Ahluwalia, R. S., Johal, N., Kouriefs, C., Kooiman, G., Montgomery, B. S., & Plail, R. O. (2006). The surgical risk of suprapubic catheter insertion and long-term sequelae. Annals of the Royal College of Surgeons of England, 88, 210–213.
  2. Bonkat, G., Widmer, A.F., Rieken, M., van der Merwe, A., Braissant, O., Muller, G. et al. (2013) Microbial biofilm formation and catheter-associated bacteriuria in patients with suprapubic catheterisation. World journal of urology, 31(3): 565–571. https://doi.org/10.1007/s00345-012-0930-1 PMID: 22926265
  3. Buehrle DJ, Clancy CJ, Decker BK Suprapubic catheter placement improves antimicrobial stewardship among Veterans Affairs nursing care facility residents. American Journal of Infection Control. 2020,48, 10, 1264-1266. doi: 10.1016/j.ajic.2020.01.005
  4. Corder CJ, LaGrange CA. Suprapubic Bladder Catheterization. [Updated 2020 Feb 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK482179
  5. Elmoheen A, Saqr M, Salem W, Bashir K, Hagras A. (2021) Suprapubic Catheter Migration: A Review of a Rare Complication. Case Rep Urol. Jan 5;2021:8816213. doi: 10.1155/2021/8816213.
  6. Gibson, K.E., Neill, S., Tuma, E., Meddings, J., & Mody, L. (2019). Indwelling urethral versus suprapubic catheters in nursing home residents: determining the safest option for long-term use. J Hosp Infect. 02(2):219-225. doi: 10.1016/j.jhin.2018.07.027
  7. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, HICPAC. (2010) Guideline for prevention of catheter associated urinary tract infections 2009. Infect Control Hosp Epidemiol, 31,319-26. https://doi: 10.1086/651091.
  8. Hall, S.J., Harrison, S., Harding, C., Reid, S., & Parkinson, R. (2020). British Association of Urological Surgeons’ suprapubic catheter practice guidelines – revised. (2020) BJU International. May. doi: 10.1111/BJU.15123
  9. Hall, S., Ahmed, S., Reid, S., Thiruchewam, N., Sahai, A., Hamid, R., …Parkinson, R. (2019). A national UK audit of suprapubic catheter insertion practice and rate of bowel injury with comparison to a systematic review and meta-analysis of available research. Neurourol Urodyn, 38(8),2194-2199. https://doi: 10.1002/nau.24114.
  10. Harrison, S.C.W., Lawrence, W.T., Morley, R., Pearce, I., & Taylor, J. (2011). British Association of Urological Surgeons’ suprapubic catheter practice guidelines. BJU Int, 107(1),77-85. https://doi: 10.1111/j.1464-410X.2010.09762.x.
  11. Hobbs C, Howles S, Derry F, Reynard J. (2022) Suprapubic catheterisation: a study of 1000 elective procedures. BJU Int. Jun;129(6):760-767. doi: 10.1111/bju.15727
  12. Hunter, K.F, Bharmal, A., & Moore, K.N. (2013) Long-term bladder drainage: Suprapubic catheter versus other methods: a scoping review. Neurourology Urodynamics, 32(7),944-51. https://doi: 10.1002/nau.22356.
  13. Katsumi, H.K., Kalisvaart, J.F., Ronningen, L.D., & Hovey, R.M. (2010). Urethral versus suprapubic catheter: choosing the best bladder management for male spinal cord injury patients with indwelling catheters. Spinal Cord. 48:325-9. doi:10.1038/sc.2009.134;
  14. Khan, A. & Abrams, P. (2009) Suprapubic catheter insertion is an outpatient procedure: cost savings resultant on closing an audit loop. BJU Int, 103(5),640‐644. https//doi: 10.1111/j.1464-410X.2008.08125.x
  15. Kidd, E.A., Stewart, F., Kassis, N.C., Hom, E., Oma,r M.I. (2015). Urethral (indwelling or intermittent) or suprapubic routes for short-term catheterisation in hospitalised adults. Cochrane Database Syst Rev. Dec 10;(12):CD004203.
  16. Li, Z., Li, K., Wu, W., Wang, Q., Ma, X., Lin, C., …Huang, H. (2019). The comparison of transurethral versus suprapubic catheter after robot-assisted radical prostatectomy: a systematic review and meta-analysis. Transl Androl Urol, 8(5),476-488. https://doi: 10.21037/tau.2019.08.25.
  17. Mekayten M, Duvdevani M. (2021) Obstruction of a ureter orifice by suprapubic catheter. Urol Case Rep. Jun 15;39:101756. doi: 10.1016/j.eucr.2021.101756. eCollection 2021 Nov.PMID: 34195006
  18. Newman, D.K. (2017). Devices, products, catheters, and catheter-associated urinary tract infections. In: D.K. Newman, J.F. Wyman, V.W.Welch (Eds). Core Curriculum for Urologic Nursing (pp. 429-466). Pitman, New Jersey: Society of Urologic Nurses and Associates, Inc.
  19. Newman, D.K., Cumbee, R.P., & Rovner, E.S. (2018). Indwelling (transurethral and suprapubic) catheters. In: D.K. Newman, E.S. Rovner, A.J. Wein, (Eds). Clinical Application of Urologic Catheters and Products. (pp. 47-77) Switzerland: Springer International Publishing.
  20. Prattley, S., New, F., & Davies, M. (2019). Malignancies of suprapubic catheter (SPC) tracts in spinal cord injury patients: a case series and review of literature. Spinal Cord Ser Cases. 15;5:34. https://doi: 10.1038/s41394-019-0177-9.
  21. Reid S, Brocksom J, Hamid R et al. (2021) British Association of Urological Surgeons (BAUS) and nurses (BAUN) consensus document: management of the complications of long-term indwelling catheters. BJU Int. 128:667–77. https://doi.org/10.1111/bju.15406
  22. Romo, P.G.B., Smith, C.P., Cox, A., Averbeck, M.A., Dowling, C., Beckford, C., Manohar, P., Duran, S., Cameron, A.P. (2018) Non-surgical urologic management of neurogenic bladder after spinal cord injury. World J Urol. 36(10):1555-1568
  23. Warriner, L. & Spruce, P. (2012). Managing overgranulation tissue around gastrostomy sites. Br J Nurs. Mar 8-21;21(5):S14-6, S18, S20 passim. doi: 10.12968/bjon.2012.21.Sup5.S14
  24. Yates, A. (2016). The risks and benefits of suprapubic catheters. Nursing Times, 112;6/7,19-22.
Written by: Diane K. Newman, DNP, ANP-BC, FAAN
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