TITLE: Suprapubic Needle Aspiration for Urine Sampling in Emergency Departments:

Safety and Guidelines

DATE: 4 March 2005
RESEARCH QUESTIONS:
1.

What is the comparative clinical safety and risks of urine sampling via suprapubic needle
aspiration versus urethral catheterization in infants and toddlers in the emergency
department?

2.

What are the guidelines for collection of urine samples in infants and toddlers in the
emergency department when conventional urethral catheterization has failed and what
form of sedation is recommended for these procedures?

3.

What are the guidelines for using urine samples for determination of disease causality in
infants and toddlers in emergency departments?

METHODS:
A limited literature search was conducted on key health technology assessment resources,
including PubMed, the Cochrane Library (Issue 2, 2010), University of York Centre for Reviews
and Dissemination (CRD) databases, ECRI, EuroScan, international health technology
agencies, and a focused Internet search. The search was limited to English language articles
published between 2005 and February 2010. Filters were applied to limit the retrieval to health
technology assessments, systematic reviews, meta-analyses, randomized controlled trials,
controlled clinical trials, and guidelines. Internet links were provided, where available.
The summary of findings was prepared from the abstracts of the relevant information. Please
note that data contained in abstracts may not always be an accurate reflection of the data
contained within the full article.

Disclaimer: The Health Technology Inquiry Service (HTIS) is an information service for those involved in planning and providing
health care in Canada. HTIS responses are based on a limited literature search and are not comprehensive, systematic reviews.
The intent is to provide a list of sources of the best evidence on the topic that CADTH could identify using all reasonable efforts
within the time allowed. HTIS responses should be considered along with other types of information and health care considerations.
The information included in this response is not intended to replace professional medical advice, nor should it be construed as a
recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality
evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for
which little information can be found, but which may in future prove to be effective. While CADTH has taken care in the preparation
of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect.
CADTH is not liable for any loss or damages resulting from use of the information in the report.
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RESULTS:
HTIS reports are organized so that the higher quality evidence is presented first. Therefore,
health technology assessment reports, systematic reviews, and meta-analyses are presented
first. These are followed by randomized controlled trials, controlled clinical trials, and evidencebased guidelines.
One health technology assessment and one randomized controlled trial were identified
regarding the comparative clinical safety and risks of urine sampling via suprapubic needle
aspiration versus urethral catheterization in infants and toddlers in the emergency department.
Four evidence-based guidelines were identified regarding the guidelines for collection of urine
samples in infants and toddlers in the emergency department, form of sedation recommended
for these procedures, and the use of urine samples for determination of disease causality in
infants and toddlers in emergency departments. No relevant systematic reviews, meta-analyses,
or controlled clinical trials were identified. Additional articles of potential interest can be found in
the appendix.
OVERALL SUMMARY OF FINDINGS:
Suprapubic aspiration (SPA) is an invasive method used to collect clean urine samples.1 The
diagnosis of urinary tract infection in children and infants is considered to be the most sensitive
when urine is collected using this method .3 A sensitive diagnosis of urinary tract infection can
also be made using urinary catheterization as the collection method, but there are risks of
contamination of the urine sample by the introduction of pathogens.3 Catheterization and SPA
should only be used when non-invasive collection methods are not practical or possible.4,5
Suprapubic aspiration should only be done on a full bladder.4,6 Ultrasound should be used to
verify bladder volume before the procedure.4
One randomized controlled trial compared pain experienced by infants less than two months of
age during catheterization and SPA.2 A topical anesthetic cream was applied one hour before
the procedure and parents were allowed to comfort the children in any way they wished.
Adequate urine samples were obtained in 66% of SPA procedures and 83.3% of
catheterizations.2 Pain scores observed in the SPA group were significantly higher than those of
the catheterization group.2 A study comparing specimen culture taken from diapers or urine
pads to SPA found good agreement between results from the invasive and non-invasive
samples, though there were limited data presented.1
The guidelines recommend a clean catch sample method for urine collection when possible.4,5
One guideline also recommended the use of urine collection pads for urine sampling.4 Urine
samples collected for the diagnosis of urinary tract infections in children less than three years of
age should be sent for microscopy or culture.4,5 Urine dipstick testing may also be useful to test
for the presence or absence of leukocyte esterase and nitrites.4,5
When possible, non-invasive urine specimen collection methods should be used in young
children.4,5 Suprapubic aspiration is more painful than catheterization2 but results in clean urine
samples for the diagnosis of urinary tract infections.1,3

Suprapubic Needle Aspiration for Urine Sampling in Emergency Departments

REFERENCES SUMMARIZED:
Health technology assessments
1.

Whiting P, Westwood M, Bojke L, Palmer S, Richardson G, Cooper J, et al. Clinical

effectiveness and cost-effectiveness of tests for the diagnosis and investigation of urinary
tract infection in children: a systematic review and economic model. Health Technol
Assess [Internet]. 2006 [cited 2010 Feb 19];10(36). Available from:
http://www.hta.ac.uk/fullmono/mon1036.pdf (Copy and paste URL into browser's URL
bar).

Systematic reviews and meta-analyses

No literature identified
Randomized controlled trials
2.

Kozer E, Rosenbloom E, Goldman D, Lavy G, Rosenfeld N, Goldman M. Pain in infants

who are younger than 2 months during suprapubic aspiration and transurethral bladder
catheterization: a randomized, controlled study. Pediatrics. 2006 Jul;118(1):e51-e56.
PubMed: PM16818537

Controlled clinical trials

No literature identified
Guidelines and recommendations
3.

Grabe M, Bishop MC, Bjerklund-Johansen TE, Botto H, ek M, Lobel B, et al. Guidelines

on urological infections [Internet]. Arnhem: European Association of Urology; 2009. [cited
2010 Feb 22]. Available from:
http://www.uroweb.org/fileadmin/tx_eauguidelines/2009/Full/Urological_Infections.pdf
Note: see Collection of urine, p. 40

4.

National Collaborating Centre for Womens and Childrens Health. Urinary tract infection in
children [Internet]. London (UK): National Institute for Clinical Excellence; 2007. [cited
2010 Feb 22]. Available from:
http://www.nice.org.uk/nicemedia/pdf/CG54NICEguideline.pdf
Note: see Urine collection, p. 6

5.

Cincinnati Children's Hospital Medical Center. Evidence-based care guideline for medical
management of first urinary tract infection in children 12 years of age or less [Internet].
Cincinnati: Cincinnati Children's Hospital Medical Center; 2006. [cited 2010 Feb 22].
Available from:
http://www.cincinnatichildrens.org/assets/0/78/1067/2709/2777/2793/9199/c2dda8f2-f1224cc4-9385-f02035d4f322.pdf
Note: see Laboratory studies, p. 2

6.

World Health Organization. Pocket book of hospital care for children: guidelines for the
management of common illnesses with limited resources [Internet]. Geneva: World Health

Suprapubic Needle Aspiration for Urine Sampling in Emergency Departments

Organization; 2005. [cited 2010 Feb 22]. Available from:

http://whqlibdoc.who.int/publications/2005/9241546700.pdf
Note: see A1.6 Supra-pubic aspiration, p. 320

PREPARED BY:
Health Technology Inquiry Service
Email: htis@cadth.ca
Tel: 1-866-898-8439

Suprapubic Needle Aspiration for Urine Sampling in Emergency Departments

APPENDIX FURTHER INFORMATION:

Observational studies
7.

Hosseini SMM, Ataei N, Sharifzadeh M, Khotaei GT. Urine culture obtained from bag
specimens and suprapubic aspiration in neonates. J Ped Infect Dis [Internet]. 2009 Nov
[cited 2010 Mar 3];4(3):289-293. Abstract available from:
http://iospress.metapress.com/content/g48030r07g677p63/

8.

Babl FE, Mandrawa C, O'Sullivan R, Crellin D. Procedural pain and distress in young
children as perceived by medical and nursing staff. Paediatr Anaesth. 2008
May;18(5):412-9. PubMed: PM18363627

9.

Luco M, Lizama M, Reichhard C, Hirsch T. Urine microscopy as screen for urinary tract
infections in a pediatric emergency unit in Chile. Pediatr Emerg Care. 2006
Oct;22(10):705-9. PubMed: PM17047469

Clinical practice guideline

10.

Investigation of urine: BSOP 41 [Internet]. London (UK): Department for Evaluations,

Standards and Training, Centre for Infections, Health Protection Agency; 2009. [cited
2010 Feb 22]. Available from: http://www.hpastandardmethods.org.uk/documents/bsop/pdf/bsop41.pdf
Note: see Specimen collection, p. 10 and 16

Review articles
11.

Phillips B. Towards evidence based medicine for paediatricians. Urethral catheter or

suprapubic aspiration to reduce contamination of urine samples in young children? Arch
Dis Child. 2009 Sep;94(9):736-9. PubMed: PM19700430

12.

Long E, Vince J. Evidence behind the WHO guidelines: Hospital Care for Children: what
are appropriate methods of urine collection in UTI? J Trop Pediatr [Internet]. 2007 Aug
[cited 2010 Feb 22];53(4):221-4. PubMed: PM17517815. Available from:
http://tropej.oxfordjournals.org/cgi/reprint/53/4/221

Suprapubic Needle Aspiration for Urine Sampling in Emergency Departments