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Suprapubic Bladder Aspiration

Jennifer R. Marin, M.D., Nader Shaikh, M.D., Steven G. Docimo, M.D.,
Robert W. Hickey, M.D., and Alejandro Hoberman, M.D.

The following text summarizes information provided in the video.

Overview
This summary reviews suprapubic bladder aspiration in children, both with and From the Departments of Pediatrics
without the use of ultrasound guidance. Familiarity with this procedure is impor- (J.R.M., N.S., S.G.D., R.W.H., A.H.) and
Emergency Medicine (J.R.M.), University
tant when neither a clean-catch urine sample nor a specimen from a urethral cath- of Pittsburgh, Pittsburgh. Address re-
eter can be obtained. print requests to Dr. Marin at Children’s
Hospital of Pittsburgh, 4401 Penn Ave.,
AOB, Suite 2400, Pittsburgh, PA 15224,
Indications or at jennifer.marin@chp.edu.
Suprapubic bladder aspiration is performed to obtain a sterile urine sample from
N Engl J Med 2014;371:e13.
children when the urethra cannot be adequately visualized, such as in girls with DOI: 10.1056/NEJMvcm1209888
labial adhesions or labial edema, in uncircumcised boys with unretractable fore- Copyright © 2014 Massachusetts Medical Society.

skins, in children with conditions such as severe, protracted diarrhea that may
make it difficult to obtain a sterile specimen, in children in whom multiple unsuc-
cessful attempts have been made to obtain urine through urethral catheterization,
and in children with a history of urethral or introital surgery in whom it may be
difficult to perform catheterization.
Before the procedure is performed, its purpose and its risks and benefits should
be explained to a family member or guardian, and that person should be given the
opportunity to ask questions. Some institutions may require written documenta-
tion of informed consent.

Contraindications
Contraindications to suprapubic bladder aspiration include major genitourinary
abnormalities, infections of the abdominal wall, clinically significant bleeding dis-
orders, and massive organomegaly.

Equipment
To perform suprapubic bladder aspiration, you will need topical anesthetic cream
and an adhesive bandage, 1% lidocaine (with or without epinephrine), a 25-gauge
5/8-in. or 1-in. needle, a 22-gauge or 23-gauge 1.5-in. needle, two sterile 5-ml sy-
ringes, sterile gloves, a sterile drape or towel, antiseptic solution with sterile gauze,
a sterile specimen container, and a bandage.

Analgesia
Apply the topical anesthetic to the skin 1 to 2 cm superior to the pubic symphysis
and cover with an adhesive bandage. The anesthetic will be most effective if applied
approximately 20 to 30 minutes before the procedure begins.
If you are performing the procedure in an infant, dip a pacifier into an oral
sucrose solution and allow the infant to suck the pacifier during the procedure to
decrease discomfort. Alternatively, the care provider can dip a finger into the solu-

n engl j med 371;10 nejm.org september 4, 2014 e13(1)

The New England Journal of Medicine
Downloaded from nejm.org at UNIFOR on June 11, 2015. For personal use only. No other uses without permission.
Copyright © 2014 Massachusetts Medical Society. All rights reserved.
 The new england journal of medicine

tion. In older children, who have thicker abdominal walls, use a subcutaneous
injection of lidocaine.

Anatomy
To perform the procedure safely and successfully, you must have a clear under-
standing of pelvic anatomy. The bladder lies posterior to the pubic symphysis and
anterior to the uterus in girls and anterior to the rectum in boys.

Procedure
The procedure can be performed with or without ultrasound guidance. Both ap-
proaches are described.

Without Ultrasound Guidance

Place the child on his or her back, in the frog-leg position. You will need one as-
sistant positioned at the child’s head to maintain control of the arms and a second
assistant to restrain the legs.
Wash your hands with soap and water, and don sterile gloves. Cleanse the
child’s skin from the umbilicus to the pubic symphysis, using an antiseptic solu-
tion. You may choose to leave the diaper on during the procedure to capture
spontaneous urination. Drape the area to avoid contamination.
Next, infiltrate the subcutaneous tissues approximately 1 to 2 cm above the
pubic symphysis with 1 ml of lidocaine. Use the 1.5-in. needle to perform bladder
Figure 1. First Attempt at Bladder aspiration. The needle should be placed at an angle that is perpendicular to the
­Aspiration.
ICM AUTHOR Marin RETAKE 1st abdominal wall, which means the needle will be approximately 10 to 20 degrees
REG F FIGURE 1 2nd
In the
CASE first
TITLE
attempt at bladder aspira-
Revised
3rd from true vertical (Fig. 1).
tion,Enonthe needle should
EMail Line be 4-C placed at
SIZE Penetrate the skin and immediately apply negative pressure to the syringe as
ARTIST: mst H/T H/T
an angle that is perpendicular to the
16p6
FILL Combo
you advance the needle through the skin until urine is visible. You may feel a
abdominal wall,
AUTHOR, which means the
PLEASE NOTE:
Figure has been redrawn and type has been reset.
needle will bePlease approximately
check carefully. 10 to change in resistance as the needle penetrates the bladder wall.
20 degrees
JOB: 37110 from true vertical. ISSUE: 9-4-14 If no urine is obtained after the initial attempt, withdraw the needle to the edge
of the needle tip, but do not remove the needle from the skin. Then change the
angle of needle entry so that the needle tip is more caudad. The needle should be
oriented in a true vertical position (Fig. 2). Once you have collected sufficient urine
in the syringe, immediately transfer the urine to a sterile container.

With Ultrasound Guidance

Ultrasonography is increasingly used for diagnostic and procedural guidance. The
use of ultrasonography to assess bladder volume and to guide aspiration can in-
crease the likelihood that the procedure will be successful.1-3
The most common reason for failing to obtain urine with suprapubic bladder
Figure 2. Second Attempt at Bladder aspiration is a lack of sufficient urine in the bladder, which may be the case if the
Aspiration.
ICM AUTHOR Marin RETAKE 1st child has urinated within the past hour or if the child is dehydrated. Performing
REG F FIGURE 2
If no
CASEurine
TITLEis obtained after the
2nd
initial
3rd ultrasonographic evaluation of the bladder to ensure an adequate urine volume
Revised
attempt,
EMail
Enon
withdraw the
ARTIST: mst
Line needle
H/T
4-C
H/T
toSIZEthe before attempting the procedure can increase the likelihood that urine will be
edgeFILLof the needle Combo tip, but do 16p6 not obtained. A high-frequency (5- to 10-MHz) linear-array transducer is ideal for
remove the needle from the skin. Then
AUTHOR, PLEASE NOTE:
Figure has been redrawn and type has been reset. imaging the superficial pediatric bladder. Obtain a transverse view and measure
change the angle of needle entry so
Please check carefully.

thatJOB:
the 37110
needle tip is more ISSUE:caudad.
9-4-14
the size of the bladder. Measurements of at least 2 cm in each dimension will
The needle should be oriented in a provide sufficient volume for analysis.2
true vertical position. If there is an inadequate amount of urine in the bladder, provide the patient
with oral or intravenous hydration, as appropriate to the patient’s clinical state,
and try using ultrasound guidance to locate the bladder 30 minutes afterward. The
amount of fluid you administer will depend on the size of the patient, the level of
dehydration, if present, and whether there is any known cardiac or renal disease.

e13(2) n engl j med 371;10 nejm.org september 4, 2014

The New England Journal of Medicine

Downloaded from nejm.org at UNIFOR on June 11, 2015. For personal use only. No other uses without permission.
Copyright © 2014 Massachusetts Medical Society. All rights reserved.
 Supr apubic Bladder Aspir ation

Once there is sufficient urine in the bladder, you may begin the procedure.
Prepare a small amount of sterile gel and put on sterile gloves. Cleanse the skin
with antiseptic solution, and place a sterile cover on the ultrasound probe.
Locate the bladder again. If you are not using ultrasonography for real-time
Needle
guidance of bladder aspiration, use a sterile pen to mark the skin site where the
bladder is best visualized and proceed with bladder aspiration (as described above).
When performing real-time ultrasound guidance, leave the probe on the abdo- Patient’s
right
Patient’s
left
men and insert the needle midline and just inferior to the edge of the probe at an
angle that is perpendicular to the abdominal wall. You should see the needle tip
clearly on the ultrasound screen as it advances through the skin and into the an-
terior wall of the bladder. Once you see the needle in the bladder, aspirate the urine
(Fig. 3). The procedure can also be performed with the transducer positioned along
the long axis of the needle, such that the length of the needle is visualized (Fig. 4). Figure 3. Transverse Sonographic
View through the Bladder.
Complications In this view, the patient’s right side
Complications of suprapubic bladder aspiration are rare. They include gross hema- can be seen on the left side of the
screen, and the patient’s left side
turia, cellulitis of the abdominal wall, and perforation of the bowel, which may
appears on the right side of the screen.
occur when a loop of bowel overlies the bladder. The use of ultrasound guidance Once the needle is visualized in the
decreases the likelihood of bowel perforation. bladder, the urine can be aspirated.
If you suspect bowel perforation, withdraw the needle and reattempt the proce-
dure with a fresh needle and syringe. Intestinal penetration is usually not clini-
cally significant and generally requires no follow-up.

Summary
Knowing how to perform suprapubic bladder aspiration is important for clinicians
who care for children who are not toilet-trained or who are unable to provide a Needle

clean-catch urine specimen. When a sterile urine specimen from a patient is re-
quired and the performance of urethral catheterization is difficult or unfeasible, Patient’s
head
suprapubic bladder aspiration is the next preferred method. Patient’s
feet

Dr. Hoberman reports receiving fees for providing expert testimony in a neonatal hypoglycemia case. No
other potential conflict of interest relevant to this article was reported.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

Figure 4. Longitudinal Sonographic

View through the Bladder.
In this view, the left side of the screen
is oriented to the patient’s head and
the right side of the screen is oriented
to the patient’s feet.

References
1. Chen L, Hsiao AL, Moore CL, Dziura
JD, Santucci KA. Utility of bedside blad-
der ultrasound before urethral catheter-
ization in young children. Pediatrics
2005;115:108-11.
2. Gochman RF, Karasic RB, Heller MB.
Use of portable ultrasound to assist urine
collection by suprapubic aspiration. Ann
Emerg Med 1991;20:631-5.
3. Witt M, Baumann BM, McCans K.
Bladder ultrasound increases catheteriza-
tion success in pediatric patients. Acad
Emerg Med 2005;12:371-4.
Copyright © 2014 Massachusetts Medical Society.

n engl j med 371;10 nejm.org september 4, 2014 e13(3)

The New England Journal of Medicine
Downloaded from nejm.org at UNIFOR on June 11, 2015. For personal use only. No other uses without permission.
Copyright © 2014 Massachusetts Medical Society. All rights reserved.