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How To Do Suprapubic Aspiration of the Bladder in a Child

By

Keara N. DeCotiis

, MD, Nemours/Alfred I. duPont Hospital for Children

Last full review/revision Dec 2020| Content last modified Dec 2020
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Suprapubic aspiration is obtaining a urine sample using a needle inserted into the bladder in the suprapubic region, typically to obtain an uncontaminated urine sample for culture.

Indications

Suprapubic aspiration is done when a clean-catch urine sample cannot be obtained and transurethral bladder catheterization was unsuccessful or not possible. Suprapubic aspiration is done most often in children but can also be done in adults.

Contraindications

Absolute contraindications

  • Skin or soft tissue infection* of the abdominal wall over the bladder

* Cellulitis or significant abdominal wall infection, not diaper rash or eczema.

Relative contraindications

  • Empty bladder

  • Major genitourinary abnormalities

  • Bleeding disorder

  • Massive hepatosplenomegaly

  • Previous abdominal surgery

Complications

Suprapubic aspiration is typically safe. Possible complications include

  • Bleeding

  • Infection

  • Bowel perforation (rare, usually in patients with bowel distention from a gastrointestinal disorder). In these patients, ultrasound guidance can reduce the risk of bowel perforation.

Equipment

  • Sterile drapes and gloves

  • An absorbent underpad

  • Antiseptic solution (eg, povidone iodine, chlorhexidine) with applicator sticks, cotton balls, or gauze pads

  • Lidocaine (1% with or without epinephrine), 25-gauge needle, and 5-mL syringe

  • For aspiration, a 5-mL syringe, 22-gauge 1.5-inch needle

  • Sterile cup for urine specimen

  • Washcloth for removing povidone iodine after the procedure

  • Sterile bandage

Additional Considerations

  • The bladder should be relatively full (confirmed by physical examination and/or ultrasonography).

Relevant Anatomy

  • The bladder lies posterior to the pubic bone and anterior to the uterus in girls and anterior to the rectum in boys.

Positioning

  • Place the patient in a supine, frog position (hips and knees partially flexed, heels on the bed, hips comfortably abducted).

Step-by-Step Description of Procedure

  • Locate the bladder by percussion and palpation or using ultrasound.

  • Locate the point of entry, which is 1 to 2 cm cephalad to the superior edge of the symphysis pubis in the midline.

  • Cleanse the area from the pubic symphysis to the umbilicus with antiseptic solution. Begin at the planned entry site and use a circular motion outward. If using povidone iodine, clean 3 times then allow the area to dry and remove the iodine with an alcohol swab.

  • Place sterile drapes around the area or use a fenestrated sterile drape.

  • Inject local anesthetic subcutaneously and into the dermis at the planned entry site.

  • Insert the 22-gauge needle attached to a 5-mL syringe into the entry site perpendicular to the abdominal wall (this is typically pointing 10 to 20° caudally from the true vertical because the abdominal wall in children slopes down to the symphysis pubis).

  • Aspirate while advancing. Urine will appear in the syringe.

  • If urine is not obtained, withdraw the needle to the subcutaneous tissue but do not withdraw completely. Then redirect the needle in a more caudad direction, this time keeping the needle and syringe vertical to the abdominal wall.

  • Consider using ultrasound to identify the bladder for real-time ultrasound guidance. Place a sterile cover on the ultrasound probe. Place the probe on the abdominal wall just inferior to the planned needle-insertion site. Follow the needle as it advances through the anterior abdominal wall and into the bladder. When the needle is in the bladder, aspirate the urine.

  • After collecting adequate urine, withdraw the syringe and needle.

Aftercare

  • Place a bandage over the puncture site.

Warnings and Common Errors

  • Microscopic hematuria is common after the procedure; gross hematuria is uncommon.

Tips and Tricks

  • Frequently the child may spontaneously urinate stimulated by the procedure. Be prepared to collect this urine in a sterile container.

  • During pre-procedure examination or ultrasound, apply minimal pressure to the abdominal wall to avoid triggering urination.

  • If the bladder appears as a hypoechoic area 2 cm in each dimension, it is possible to obtain about 2 mL of urine.

  • If the bladder cannot be visualized with ultrasound, there is probably not enough urine due to dehydration or recent voiding. Provide hydration if permitted by the patient's clinical condition and repeat the ultrasound after a few minutes.

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