How To Do Suprapubic Aspiration of the Bladder in a Child

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

Empty bladder

Major genitourinary abnormalities

Bleeding disorder

Massive hepatosplenomegaly

Previous abdominal surgery

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.

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

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

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

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

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, cleanse 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 vertically into the abdominal wall about the breadth of 2 fingers above the pubic bone in the midline. (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 closer to the pubic bone in a downwards direction.

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.

Place a bandage over the puncture site.

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

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.