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Living With A Urostomy
This article discusses ileal conduit, Kock pouch, and neobladder procedures (with diagrams); care and maintenance of an ileal conduit stoma; potential drawbacks, such as impotency for the male urostomate, and life as a urostomate in general.
• Article added July 27, 2003
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Outlook on Life
It is not essential to have a urinary bladder to sustain life, but it is essential to maintain an uninterrupted flow of urine from the body. Fortunately, this can be accomplished with one of the urinary diversion procedures. The urostomy resulting from this surgery is not the end of life but rather a means of prolonging life, a second chance for those whose bladders must be removed.
Understanding the critical role of ostomy surgery, however, is essential to both the physical and psychological adjustment to the altered body function and diminished self-esteem that routinely accompany most ostomy surgeries. As body strength is regained following surgery, the physical and mechanical problems of dealing with any ostomy moderate and even become routine, but the psychological adjustment often takes a much longer period of time. Each urostomy patient will have his/her own set of physical and psychological problems with which to contend. Some will have the support of a caring family and/or friends to help them through the period of adjustment (and others may turn to support groups, such as LDOA). Whatever the circumstance, each urostomate's attitude is ultimately the key to life with a urinary diversion. Although a urinary diversion definitely alters body function and requires daily maintenance, it need not permanently limit a person's activities, abilities, interests or horizons. [Top]
Urinary Diversions
There are three main types of urinary diversions which are discussed in this article:
ileal conduit • incontinent urinary diversion; attaching a piece of the small intestine ( ileal) to the two ureters and requiring a stoma
Kock pouch • internal continent reservoir with a stoma
bladder reconstruction (neobladder) • internal continent reservoir that is reconnected to the urethra to provide normal urination
Other types of urinary diversion include:
nephrostomy • urine is diverted from the kidney to a stoma
cystostomy • urine is diverted from the bladder to a stoma
ureterostomy • redirecting one (single uterostomy) or both (bilateral uterostomy) of the ureters from the kidney(s) to an ostomy(ies) created on the side(s) of the abdomen. [Top]
Ileal Conduit
The ileal conduit procedure (also known as an incontinent urinary diversion, Bricker's loop, and ileal loop) was developed in the 1950s and rapidly became the gold standard for urinary diversion. It is still the most frequently performed urinary diversion, primarily because it is a relatively uncomplicated procedure. Although the majority work reasonably well, the ileal conduit is far from the perfect solution because of the high incidence of ureter and stoma strictures and urinary reflux to the kidneys. These strictures frequently impair, or even block, urine flow and may require surgical revision.
The ileal conduit is made from a 6 to 10 inch long segment of ileum which is separated from the small intestine with its blood and nerve supply carefully preserved. One end of the conduit is closed with stitches or staples, and the other end is brought to the surface of the abdomen to form a stoma. The ureters are implanted into the closed end of the conduit which serves as a pipeline for a steady flow of urine from the ureters through the stoma and into an external appliance attached to the abdomen. After the section of ileum is removed to create the conduit and stoma, the cut ends of the ileum are joined and the intestinal tract will soon function the same as before the surgery. Ideally, urine should flow continuously through the stoma at approximately 12 to 15 drops per minute. A healthy stoma is pink to red in colour and also excretes mucus and moisture, both normal excretions of the ileum. Fortunately, the mucus flows easily with the urine. [Top]
Ileal Conduits and Peristomal Skin Care
It is not uncommon for urostomates with ileal conduits to have leakage around the appli- ance faceplate and/or a variety of peristomal skin problems. Urostomates need to be aware that stoma size and shape may change, especially with weight gain or loss or an increase in physical activity, that leaking may occur, and a different type of faceplate and appliance may be required. Although this is particularly common during the first few months after surgery, it can happen at any time. Fortunately, a variety of urinary appliances is available, ranging from a one-piece disposable with a soft, flexible faceplate to a two piece re-usable appliance with a semi-rigid or rigid plastic faceplate. If the stoma is flush with the abdomen or located in a body fold, it may be necessary to use an appliance with a semi-rigid convex faceplate and a belt to help make the stoma protrude in order to prevent leakage. The faceplate opening should fit within 1/8 to 1/16 of an inch around the stoma.
Common peristomal skin problems include yeast and fungus infections, pimples, ulcerations, warty looking, gray, raised encrustations and/or white crystal deposits on the peristomal skin and/or stoma. These conditions require prompt and appropriate treatment by an ET. Prescription medications may be required for severe skin conditions. Preparations that contain cortisone must be used sparingly because they have the potential to cause skin to become thin and fragile with prolonged use. Urostomates should check with an ET or physician for specific directions before using any skin products. [Top]
The two most common causes of skin irritation are chemical and mechanical that are caused by leaky urine and rough treatment of the skin. Chemical irritation results from the exposure of peri- stomal skin to urine, adhesives, solvents, cleansers, and soap. Since allergic skin reactions are always a possibility, new products should always be tried out on a small area of skin outside of the faceplate. Peristomal skin and stomas that are awash in urine are prime targets for leaks, skin irritations, and crystal build-up around the stoma, especially during the post-operative period when the greatest change in stoma size and shape occurs.
Mechanical irritations are usually caused by improper appliance removal and/or close shaving, which may strip protective layers off of the peristomal skin. To minimize damage, the faceplate should be removed gently by carefully pushing the skin away from the adhesive, instead of pulling the adhesive away from the skin. Also, starting at the top of the faceplate and slowly working toward the bottom reduces tearing and pulling on the skin as well as the hair follicles, which grow in the same downward direction. Vigorous scrubbing or use of abrasive cleansers also damages the skin. Adhesive removers may be used sparingly and gently if necessary. Body hair on the peristomal skin occasionally needs to be carefully shaved or clipped with scissors to further reduce pulling of the hair and skin. An electric razor can be used, but disposable razors are not recommended because they may damage the top layer of skin. [Top]
Occasionally, it is necessary to air the peristomal skin. It helps to find a warm, private, comfortable place to sit and read or watch TV, and to place a waterproof pad or a towel underneath. The contin- ually flowing urine can be absorbed with a clean folded washcloth carefully positioned under the stoma. A hair dryer set on cool, held at least one foot away from the stoma, will speed drying time. Any urine that gets onto the skin during the airing process should be gently washed off with a warm cloth.
Since it is imperative to insure a constant flow of urine away from the stoma, the appliance needs to be connected to a long thin tube that drains into a collection jug at night or when lying down for a few hours. The tube and jug need to be cleaned daily with one of the germicidal solutions. The re-usable appliances also need to be cleaned in a similar manner when changed, typically every 3 to 6 days. Many people find it is easier to change an appliance in the morning before drinking liquids, and it also helps to bend over a few times to help expel urine from the conduit. A wall mirror and a dissolvable paper guide strip (the half-inch paper strip fits inside the faceplate opening) make it easier to center the appliance over the stoma. It is important to always have a backup appliance ready and available at all times. [Top]
Kock Pouch Urinary Diversion
In the early 1970s, Dr. Nils Kock introduced his innovative Kock continent ileostomy pouch, an internal reservoir for ileostomates who required colon removal. This also opened the door for the development of continent urinary reservoirs. This means that you do not have to wear a pouch to collect your urine, however, it is a more difficult operation technically than the ileal conduit. Because the operation is more complicated, its failure rate is much higher. About 1 in 5 people will require further operations to correct problems after the initial procedure.
The Kock pouch (pronounced "coke") is made from approximately two feet of ileum. At each end of the pouch an intussuscepted valve (folded back on itself like a turtleneck to prevent leakage and/or reflux) is created. The ureters are connected to the internal valve which prevents reflux to the kidneys, and the end of the other valve is brought to the abdominal surface to form a small continent stoma.
The Kock pouch is emptied by inserting a soft silicone catheter with a firm tip into the stoma 4 to 8 times a day. Catheterization is convenient, easy and painless, and maintenance is minimal. The Indiana pouch and several other varieties, including the Mainz, Miami, Studer, and Mitrofanoff, are also internal continent reservoirs that are catheterized. They are much simpler to construct than the Kock pouch, however, they hold a smaller volume of urine. All of these continent pouches have a moist stoma that needs to be covered by a small waterproof pad to protect clothing. A third of a Maxi-Thin pad, held in place with two pieces of micropore tape, works quite well as a stoma cover.
Although catheterization is not a sterile procedure, the catheters should be rinsed and cleaned with a germicidal solution after each use. Again, it is wise to check with an ET for directions. Catheters fit easily into a small plastic ziploc bag, as well as a pocket, purse, backpack, or glove compartment and should always be available. [Top]
Bladder Reconstruction (Neobladder)
This is the newest operation for bladder cancer. At the moment it is only possible for you to have this operation if you are a low risk of your cancer coming back and your cancer did not affect your urethra. In this procedure, a neobladder can be reconnected to the urethra to provide normal urination. There are several ways of performing this operation, but usually part of the small bowel is used. It is formed into a new bladder which is then sewn to the ureters and the remains of the urethra. The urine can then collect in the new bladder. If the cancer does return in the urethra, it is not too extensive an operation to remove the urethra and make an ileal conduit with a stoma.
These reconnects require a lot of patience and retraining of muscles to control urine flow, and some individuals never achieve 100% continence. When you need to pass urine, you hold your breath and push down into your abdomen. It is a bit like pushing to open your bowels, but you are pushing into your abdomen instead of into your rectum. You have to remember to do this regularly though, as you will not have the nerve supply that used to tell you your bladder was full.
The majority find continence is easily maintained during the daytime, but may need to wear a pad as a safety measure. Nighttime incontinence, however, remains a problem for many. Some people wear Depends, some get up a few times during the night, and some men use a penile sheath with a tube connected to a collection jug. [Top]
Urostomy and Impotency
In most cases, removal of the bladder renders the male impotent, an understandably frightening and psychologically intimidating prospect for even the most stoic individual to contemplate. In appropriate cases, however, a nerve-sparing technique can be used to maintain erectile function. Once again, the skill and experience of the surgeon is critical. Over the past two decades, medicine and engineering have combined to develop a variety of penile prostheses which provide acceptable alternatives to impotence. The three-piece inflatable prostheses are the most comfortable, unobtrusive and satisfactory. As a result, sexual rehabilitation for men is an integral part of treatment when the bladder is removed, an important step that plays a major role in restoring both self-image and an acceptable quality of life to the male urostomate. Although none of the prostheses provide an exact duplication of a natural erection, the penile implants are sufficiently similar to allow the patient to resume sexual activity close to what he enjoyed prior to the surgery. Also, since 1982, the use of vasodilatory drugs and penile injections have produced satisfactory results for a large number of men. [Top]
Conclusion
People around the world are alive today because they have had ostomy surgery. In the majority of cases, ostomy surgery is performed as a life-saving alternative to a life-threatening physical condition. Nonetheless, most new osto- mates find life with an ostomy overwhelmingly unpleasant for the first few months. Even those individuals who have had the advantage of specialized care before, during and after surgery will most likely have to work their way through a difficult period before they finally adjust to their ostomies. With few exceptions, an ostomy is viewed as an unnatural and very offensive alternative to the natural process of physical elimination. This is a perfectly normal response that typically requires a period of adjustment. Once health and strength are regained and the ostomy is under control, however, there is no good reason to dwell on the misfortune of diversionary surgery. Ostomates are not only able to do anything they have always done, but a majority take on tasks and adventures they had not even thought of prior to surgery. [Top]
Sources and Credits
Excerpts and definitions in this article were obtained from:
Bladder Cancer WebCafé web site
Random Thoughts and Tips on Urinary Diversions
Article made available December 3, 2002
by Roni Olsen. Excerpted from her book
A Guide to Bladder Cancer, Urostomy and Impotence
A Guide to Bladder Cancer, Urostomy and Impotence
Author • Roni Olsen
Publisher • Highline Editions
6400 Southwood Drive, Littleton, Colorado, USA 80121
• $12.00 USD (includes shipping in the U.S.)
• $14.50 USD (includes shipping to Canada)
As a patient advocate and volunteer for the United Ostomy Association, Roni Olsen has written a helpful guide based on her husband's experience and their own extensive research. Valuable insights, tips and information from someone who has been there. For those comtemplating or facing a urinary diversion, Roni's guide can empower the ostomate, help to avoid pitfalls and live as comfortably as possible with a urostomy, as well as provide information which may help male patients conquer impotence.Cancer Help, UK web site
Types of Surgery (for invasive bladder cancer)The CancerWEB Project web site
Dept. of Medical Oncology, University of Newcastle, UK
Online Medical Dictionary
Disclaimer • This site and its contents are presented expressly for informational purposes only about London & District Ostomy Association (LDOA) and gastrointestinal and/or urinary diversions in general. In no way are any of the materials presented here meant to be a substitute for professional medical care or proper attention by a qualified physician, nor should they be construed as such. Always check with your doctor or ET if you have any questions or concerns about your condition or before starting a new program or treatment. The Webmaster and LDOA are not responsible or liable, directly or indirectly, for any form of damages whatsoever resulting from the use (or misuse) of information contained in or implied by this site.
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