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Minimising risks of suprapubic catheter insertion (adults only)

Reference number
Central Alert System (CAS) reference
Issue date29 July 2009
Action date (if applicable) (date field)29 April 2010
DH Gateway reference

This Rapid Response Report alerts healthcare organisations to the risks of intestinal injury and bowel perforation following incorrect placement of suprapubic catheters in adults.


Suprapubic catheterisation should be used when urethral catheterisation is contraindicated or where it is technically not possible to relieve urinary retention in both acute and chronic conditions. In addition, it may be chosen to improve patient comfort, dignity or convenience, and to prevent complications such as catheter-induced urethral injury.


The Reporting and Learning System has identified three incidents of death and seven causing severe harm from suprapubic catheter placement between September 2005 and June 2009, nine of which involved bowel perforation. There were also 249 other incidents reported relating to suprapubic catheters causing lesser degrees of harm.


NHS and independent acute and community hospitals should:

  1. Immediately distribute information about the risk of this procedure to all staff who may insert or request the insertion of a suprapubic catheter
  2. Identify a named lead for training and develop a training plan
  3. Review or develop local guidelines/policies in the light of this report and forthcoming standards
  4. Use ultrasound wherever possible to visualise the bladder and guide the insertion of the catheter
  5. Review local incident data and take appropriate action, and encourage staff to report further incidents

Clarification: September 2009

The National Reporting and Learning Service (NRLS) has received a number of enquiries from community nursing services questioning whether the advice in the RRR applies to the initial insertion of a suprapubic catheter or to subsequent changes of catheter – a procedure that is often carried out in a patient’s home.


The NRLS would like to clarify as follows: the advice contained in this Rapid Response Report (RRR) relates to the initial insertion of a suprapubic catheter.  All but one of the serious incidents referred to in the RRR were related to the initial insertion.


If there is any doubt about the patency of an existing tract at change of catheter or there are problems with the reinsertion then urgent advice should be sought from urology / urogynaecolgy teams and the advice in the RRR should be taken into account.

Suprapubic catheter | Rapid Response Report
Suprapubic catheter | Rapid Response Report - 47 KB 1088 - Suprapubic catheter - Rapid Response Report - 2009-07-29 - V1
Suprapubic catheter | supporting Information
Suprapubic catheter | supporting Information - 79 KB 1088A - Suprapubic catheter supporting Information - 2009-07-29 - V1
Suprapubic catheter | clinician questions
Suprapubic catheter | clinician questions - 35 KB 1088B - Suprapubic catheter clinician questions - 2009-07-29 - V1