Atlas of Procedures in Neonatology, 4th Edition

Miscellaneous Sampling

18

Suprapubic Bladder Aspiration

  1. Lee Woods
  2. Indications (1,2,3,4,5,6,7,8 and 9)
  3. To obtain urine for culture

Suprapubic bladder aspiration is considered the most reliable method of obtaining urine for culture in infants and children <2 years old. In this age group, the distended bladder is located intra-abdominally. Any number of bacteria in urine obtained by this method is considered significant and likely to be indicative of urinary tract infection. Contamination with skin flora can occur, with a false-positive rate of 1% reported (10), but should be avoidable with careful skin preparation. Although bladder catheterization has a higher success rate, it also has a much higher false-positive rate than suprapubic aspiration (11,12). Reported success rates for suprapubic aspiration vary widely, from 25% to 100% (13). With careful attention to performing the procedure when the infant has a full bladder, success is generally 89% to 95%, even in very low-birthweight infants (3,4,7,8 and 9). The use of portable ultrasound (13,14,15,16,17 and 18) or transillumination (19) to determine bladder size can greatly increase the chance of success.

  1. Contraindications (1,2,4,6,20)
  2. Empty bladder as a result of recent void or dehydration

A full bladder is essential for success of the procedure and avoidance of complications.

  1. Skin infection over the puncture site
  2. Distention or enlargement of abdominal viscera (e.g., dilated loops of bowel, massive hepatomegaly)
  3. Genitourinary anomaly or enlargement of pelvic structures (e.g., ovarian cyst, distention of vagina or uterus)
  4. Uncorrected thrombocytopenia or bleeding diathesis
  5. Equipment

All equipment must be sterile, except transillumination light or ultrasound equipment.

  1. Gloves
  2. Gauze sponges and cup with iodophor antiseptic solution or
  3. Prepared antiseptic-impregnated swabs
  4. 3-mL syringe
  5. 21- or 22-gauge x 1½-in needle
  6. Transillumination light or portable ultrasound (optional)
  7. Precautions
  8. Use strict aseptic technique.
  9. Delay the procedure if the infant has urinated in the last hour.

If the infant is systemically ill, do not delay antibiotic therapy to wait for further urine production.

  1. Correct bleeding diathesis before the procedure. Consider catheterization as an alternative.
  2. Be certain of landmarks. Do not insert the needle over the pubic bone or off the midline.
  3. Aspirate urine using only gentle suction. The use of too much suction can draw the bladder mucosa to the needle, obstructing the collection of urine and increasing the risk of injury to the bladder.
  4. Technique (2,3,4,5 and 6,9,20)
  5. Have an assistant restrain the infant in the supine, frog-leg position.
  6. To avoid reflex urination, ask assistant to:
  7. Place the tip of a finger in the anus and apply pressure anteriorly in a female infant, or
  8. Pinch the base of the penis gently in a male infant.
  9. Determine the presence of urine in the bladder.
  10. Verify that the diaper has been dry for at least 1 hour.
  11. Palpate or percuss the bladder.
  12. Optionally, use transillumination light (19), or portable ultrasound guidance (13,14,15,16,17 and 18).
  13. Locate landmarks. Palpate the top of the pubic bone. The site for needle insertion is 1 to 2 cm above the symphysis pubis in the midline (Fig. 18.1).
  14. Wash hands thoroughly and put on gloves.
  15. Clean the suprapubic area (including the area over pubic bone) three times with antiseptic solution. Blot dry with sterile gauze.

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FIG. 18.1. The bladder in the neonate, with immediate anatomical relations. An asterisk indicates approximate site for needle insertion.

Generally, anesthesia is not required, but local injection of lidocaine at this time or application of topical anesthetic cream prior to cleaning the area can be used for local anesthesia at the puncture sites (21).

  1. Palpate the symphysis pubis, and insert the needle (with syringe attached) 1 to 2 cm above the pubic symphysis in the midline (Fig. 18.2).
 

FIG. 18.2. A: Insertion of needle 1 to 2 cm above symphysis pubis. B: Midline sagittal section to emphasize the intra-abdominal position of the full bladder in the neonate and its posterior anatomic relations.

  1. Maintain the needle perpendicular to table or directed slightly caudad.
  2. Advance the needle 2 to 3 cm. A slight decrease in resistance may be felt when the bladder is penetrated.
  3. Aspirate gently as the needle is slowly advanced until urine enters the syringe. Do not advance the needle more than 1 in.
  4. Withdraw the needle if no urine is obtained.
  5. Do not probe with the needle or attempt to redirect it to obtain urine.

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  1. Wait at least 1 hour before attempting to repeat the procedure.
  2. Withdraw the needle after urine is obtained. Apply gentle pressure over the puncture site with sterile gauze to stop any bleeding.
  3. Remove the needle and place a sterile cap on the syringe or transfer urine to a sterile container to send for culture.
  4. Complications

Minor transient hematuria is the most commonly reported complication, occurring in 0.6% to 10% of cases (3,7,8 and 9). Serious complications are very rare, occurring in 0.2% of cases or less (4,6).

  1. Bleeding
  2. Transient macroscopic hematuria (blood-tinged urine) (3,7,8 and 9)
  3. Gross hematuria (7,8 and 9,22,23 and 24)
  4. Abdominal wall hematoma (25)
  5. Bladder wall hematoma (7,26)
  6. Pelvic hematoma (27)
  7. Infection
  8. Abdominal wall abscess (28,29)
  9. Sepsis (30,31)
  10. Osteomyelitis of pubic bone (32,33)
  11. Perforation
  12. Bowel (28,31,34,35)
  13. Pelvic organ (34)

References

  1. Long SS, Klein JO.Bacterial infections of the urinary tract. In: Remington JS, Klein JO, Wilson CB, Baker CJ, eds. Infectious Diseases of the Fetus and Newborn. 6th ed. Philadelphia: Saunders; 2006:335.
  2. Shilkofski N.Procedures. In: Robertson J, Shilkofski N, eds. The Harriet Lane Handbook. 17th ed. St. Louis, MO: Mosby; 2005:73.
  3. Buescher ES.Immunology and infectious diseases procedures and tests. In: Taeusch HW, Christiansen RO, Buescher ES, eds.Pediatric and Neonatal Tests and Procedures. Philadelphia: Saunders; 1996:625.
  4. Barkemeyer BM.Suprapubic aspiration of urine in very low birth weight infants. Pediatrics. 1993;92:457.
  5. Stevens DC, Schreiner RL, Gresham EL.Suprapubic bladder aspiration in the neonate. Perinatol Neonatol. 1981;5:47.
  6. Abbott GD, Shannon FT.How to aspirate urine suprapubically in infants and children. Clin Pediatr. 1970;9:277.
  7. Saccharow L, Pryles CV.Further experience with the use of percutaneous suprapubic aspiration of the urinary bladder. Pediatrics.1969;43:1018.
  8. Shannon FT, Sepp E, Rose GR.The diagnosis of bacteriuria by bladder puncture in infancy and childhood. Aust Paediatr J.1969;5:97.
  9. Nelson JD, Peters PC.Suprapubic aspiration of urine in premature and term infants. Pediatrics. 1965;36:132.
  10. Pierog S, Parthasarathy S, Rojanaphruk S, et al. Incidence of bacteriuria in high-risk neonate. NY State J Med.1975;75:2152.
  11. Austin BJ, Bollard C, Gunn TR.Is urethral catheterization a successful alternative to suprapubic aspiration in neonates? J PaediatrChild Health. 1999;35:34.
  12. Tobiansky R, Evans N.A randomized controlled trial of two methods for collection of sterile urine in neonates. J Paediatr Child Health. 1998;43:460.
  13. Gochman RF, Karasic RB, Heller MB.Use of the portable ultrasound to assist urine collection by suprapubic aspiration. Ann Emerg Med. 1991;20:6.
  14. Chu RW, Wong YC, Luk SH, et al. Comparing suprapubic urine aspiration under real time ultrasound guidance with conventional blind aspiration. Acta Paediatr.2002;91:512.
  15. Munir V, Barnett P, South M.Does the use of volumetric bladder ultrasound improve the success rate of suprapubic aspiration of urine? Pediatr Emerg Care. 2002;18:346.
  16. Ozkan B, Kaya O, Akdag R, et al. Suprapubic bladder aspiration with or without ultrasound guidance. Clin Pediatr (Phila.).2000;39:625.
  17. Garcia-Neito VG, Navarro JF, Sanchez-Almeida ES, et al. Standards for ultrasound guidance of suprapubic bladder aspiration.Pediatr Nephrol.1997;11:607.
  18. Kiernan SC, Pinckert TL, Keszler M.Ultrasound guidance of suprapubic bladder aspiration in neonates. J Pediatr. 1993;123:789.
  19. Buck JR, Weintraub WH, Coran AG, et al. Fiberoptic transillumination: a new tool for the pediatric surgeon. J Pediatr Surg.1977;12:451.
  20. Barone MA.Pediatric procedures. In: McMillan JA, Feigin RD, DeAngelis CD, et al., eds. Oski's Pediatrics: Principles and Practice. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2006:2671.
  21. Anand KJ, Johnston CC, Oberlander TF, et al. Analgesia and local anesthesia during invasive procedures in the neonate. Clin Ther.2005;27:844.
  22. Carlson KP, Pullon DHH.Bladder hemorrhage following transcutaneous bladder aspiration. Pediatrics. 1977;60:765.
  23. Lanier B, Daeschner CW.Serious complication of suprapubic aspiration of the urinary bladder. J Pediatr. 1971;79:711.
  24. Rockoff AS.Hemorrhage after suprapubic bladder aspiration. J Pediatr. 1976;89:327.
  25. Kunz HH, Sieberth HG, Freiberg J, et al. Zur Bedeutung der Blasenpunktion fur den sicheren Nachweis einer Bakteriurie. Dtsch Med Wochenschr.1975;100:2252.
  26. Morell RE, Duritz G, Oltorf C.Suprapubic aspiration associated with hematoma. Pediatrics. 1982;69:455.
  27. Mandell J, Stevens P.Supravesical hematoma following suprapubic urine aspiration. J Urol. 1978;119:286.

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  1. Polnay, L, Fraser AM, Lewis JM.Complication of suprapubic bladder aspiration. Arch Dis Child. 1975;50:80.
  2. Uhari M, Remes M.Suprapubic abscess—a complication of suprapubic bladder aspiration. Arch Dis Child. 1977;52:985.
  3. Mustonen A, Uhari M.Is there bacteremia after suprapubic aspiration in children with urinary tract infection? J Urol. 1978;119:822.
  4. Pass RF, Waldo FB.Anaerobic bacteremia following suprapubic bladder aspiration. J Pediatr. 1979;94:748.
  5. Wald ER.Risk factors for osteomyelitis. Am J Med. 1985;78:206.
  6. Kalager T, Digranes A.Unusual complication after suprapubic bladder puncture. Br Med J. 1979;1:91.
  7. Weathers WT, Wenzel JE.Suprapubic aspiration: perforation of a viscus other than the bladder. Am J Dis Child. 1969;117:590.
  8. Schreiner RL, Skafish P.Complications of suprapubic bladder aspiration. Am J Dis Child. 1978;132:98.