Caring For an Indiana Pouch

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for an excellent patient guide from the NHS on what to expect during and after surgery for the “continent diversion (internal pouch or reservoir), see this booklet:

Bladder Reconstruction-Continent diversion

{/niftybox}(These instructions are basic, and not intended to be the primary source of information.  Please follow the instructions and guidelines as set forth by your physician for your situation)

Important note: After cystectomy, please carry medical identification with you at all times. A bracelet or necklace with the information engraved on it is one option. I wear a medical alert bracelet engraved with, “continent urinary reservoir.” You can also indicate continent urostomy. I also keep a card with this info in the glove compartment of my car and all family members know what to communicate in case of emergency. Please check with your physician.

Catheterization (Intubation) of Indiana Pouch
The creation of a continent urinary reservoir, or pouch, will mean several things to you in terms of care and what to expect. It is important to know and understand that it will take several weeks, perhaps even months, before your pouch is functioning in a predictable fashion. Some of the common adjustment phases of the pouch might be:

1. Leaking:  It is not unusual that while the pouch is learning to hold urine, it may leak. This is normal.

2. Irritability: There may be times when you have been on a somewhat regular schedule for several days/weeks and then you find you have to catheterize yourself with increasing frequency. This is not unusual. The cause is usually one of two things: a). The pouch is learning it’s new function, or b). A mild infection, both of which can be treated.

3. Difficulty passing the catheter: Often, with frequent catheterizations, the stoma and channel leading to the pouch will have some swelling. This is normal. It may take more time to catheterize yourself, but will eventually resolve.

When passing the catheter, you may feel the contours of the “limb” as it passes around corners. Once it enters the pouch, you may feel a “pop”.  If you encounter difficulty advancing the catheter, rolling it between your fingers as you push it sometimes facilitates insertion.

Another reason the catheter is difficult to advance is due to a straining, or bearing down.  If you relax and assume a different position, often the catheter will slip in more easily. The intra-abdominal pressure you generate compresses the limb and makes the catheter difficult to pass.

The channel through which the catheter passes will sometimes contract and grip the catheter (what I call going native, in essence it’s acting like an intestine). You should relax and wait for this to pass, then continue. Or, you can use a water-soluble lubricant such as K-Y jelly, Surgilube or Lubrafax. Do not use vaseline – it could plug the catheter. The stoma and channel stays moist so most people, in time, do not need to use a lubricant. But, I never leave home without it!

4. Occasional flecks of blood in the urine. This is normal. You may also see it on the pad covering your stoma. The stoma and/or channel sometimes gets irritated or scraped from the catheter.

5. Failure to adequately empty pouch. This is normal. It takes time, practice and patience to know when the pouch has been completely emptied. The position used (standing, sitting, etc.) may have some effect as well. You should try different positions to determine the best for you. Gentle pressure on your abdomen will sometimes help in draining the pouch. If the pouch isn’t completely emptied, that means it fills that much more quickly and also you are keeping urine in your pouch, which can become stagnant.

6. Thick mucus: Usually from not drinking enough water/fluids. Try to drink 8-10 glasses of water/fluids per day. (I drink 15 glasses per day; it makes a huge difference in the clarity and consistency of the urine and dramatically decreased the mucus.)

7. Leaking at night: Often due to drinking up until bedtime. Don’t drink much after 7-8 p.m.

It is essential, while the pouch is learning to grow, that catheterization occurs by the clock. This allows a steady, progressive enlarging of the pouch.

Irrigation of Indiana Pouch

The purpose of irrigation is:

  •  To flush the pouch to minimize the build-up of mucus** so urine continues to drain freely
  •  Help prevent the formation of stones
  •  Help prevent infection

Maintenance Procedure: (1 – 2 times per day…more often if mucus build-up)

1. Gather all the necessary equipment

2. Wash your hands thoroughly (antibacterial soap preferred)

3. Cleanse the end of the catheter with 70% alcohol; rinse off under warm water and shake off the excess.

4. Lubricate catheter, if desired. (With time this may not be necessary)

5. Insert catheter into the stoma and advance until there is a return of urine. If the catheter drains slowly, or not at all, remove the catheter and run under hot water to remove the mucus plug. Reinsert the catheter to finish draining the pouch

6. With a Toomey (piston or catheter tip) syringe, draw up 60cc of saline and instill into the pouch via the catheter/stoma

7. Fluid in the pouch can drain by gravity, the same as your routine intubation

8. Once the drainage has stopped, rotate the catheter about ¼ turn and withdraw it about 2 – 3 inches. Push the catheter back into the pouch and continue to do this until you have “swept” the pouch at least twice. By doing this, pockets of collected urine are drained.

9. Remove the catheter from the pouch, first by folding the catheter on itself to prevent leaking

10. Clean the catheter if possible. If not, keep in a ziploc bag until cleaning/disinfecting can be carried out.  Do not mix clean and dirty catheters

Keep all equipment clean. I microwave the catheters once per week. Glass of water in the microwave, and heat on high for about 10 minutes, but do one at a time, I’ve had a few melt together.

To make saline: 1T saline, 1-quart water. Boil water, add salt. Store in the refrigerator and discard after 48 hours. I keep a few pre-packaged bottles of saline solution for travel. I save the small bottles of Evian (or whatever) to store the saline I make at home.

**Note:  It is the normal function of the bowel to secrete mucus. Irrigating the pouch allows the “flushing” of mucus to ensure good drainage of urine and to reduce the possibility of infection and/or stones.

Please notify your physician if:

1. Urine is thick, cloudy and foul smelling

2. Chills and/or fever

3. Persistent nausea and vomiting

4. Persistent abdominal/flank (kidney) pain

5. Gross blood in the urine

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This page contributed by Kathy Leslie