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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:
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.
