21. Urinary Diversions - Prevention and Management of Complications

In this class, we're going to discuss prevention and management of complications and adults who have urinary diversion. So we're going to talk about the complications that are associated with urinary diversion. We're going to focus on prevention measures, but also discuss management because sometimes you'll be in the position where you have to actually manage a complication. So urinary tract infection, probably the most common complication associated with urinary diversion. Why? Well, first of all, we have either removed or bypassed the bladder. And if you remember, there is a very effective anti-reflex mechanism built into the base of the bladder. So you have the trigonal muscle that surrounds the urators. You also have the oblique angle at which the urators insert at the base of the bladder. When the bladder contracts, that trigonal muscle contracts right around the urators to close the urators to seal them and to protect them against reflux, but the bladder's gone. Now the urators are connected to a segment of bowel, the ilial conduit, rather than to the bladder. And the enastomosis between urators and that section of ilium is typically freely refluxy. So we do not have built-in protection against urinary tract infection. We do not have an anti-reflex mechanism. So that's one thing that places the individual at risk that freely refluxing enastomosis between the urators and the ilial conduit. The fact that the stoma empties onto the abdominal wall so bacteria can migrate through the stoma into the conduit, up the urators and into the kidneys. If the urine is concentrated, the patient's higher risk because concentrated urine promotes bacterial growth as does alkaline urine. So individuals with a city dilute urine or lower risk individuals with concentrated alkaline urine at higher risk. Our focus is prevention. We start talking to patients about prevention during the preoperative visit. And we talk to them primarily about bullet point two, the critical importance of adequate volume of fluid intake. You need a minimum of two liters a day, the average adult does, and you should be drinking throughout the day so you're constantly flushing the system, flushing any bacteria out. We also teach them careful hygienic care, so before you change your pouch and you have your hands close to the stoma opening, you're going to wash your hands. You're going to then get out your equipment so everything is clean. And then we want to teach them the early signs and symptoms of a urinary tract infection because it's very different when you have an ilial conduit as opposed to when you have a bladder. If you have a bladder signs and symptoms or frequency and urgency and discomfort with urination, none of those are relevant to a patient with an ilial conduit. For that patient is going to be malaise, flank pain, nausea, possibly vomiting, possibly fever, and their urine might be cloudy and malodorous. If the patient has any reason to suspect a urinary tract infection, if we have any reason to be concerned about urinary tract infection, we want to get a culture and sensitivity. Now, remember we do this only for symptomatic UTIs. We do not go around catarising conduits, getting cultures just to screen for urinary tract infection. This is done only for a symptomatic individual. In this situation, we do need to use sterile technique because we don't want to introduce bacteria into this specimen. We want to know if bacteria are already there. Now we are going to remove the pouch, drape the patient, then we're going to set up our sterile tray and we're going to apply sterile gloves. We're going to clean the stoma with our prep solution. Typically, you clean three times and you have two choices. You can come straight down over the stoma with the first wipe, second, third, three cotton balls soaked with the antibacterial solution or you can start at the center of the stoma and come around in a circular motion and do that three times. The next point is critical. After you do your prep, you want to take a dry cotton ball or dry sterile gauze. You want to wipe over the stoma to remove as much of the prep solution as possible. If you leave prep solution on and in the stoma, it can mix with the urine, kill the bacteria before they ever get to the lab. So yes, it's important to do your prep but it's equally important to remove excess prep solution and to allow urine to flow before you collect your specimen. The initial urine flow will flush out any prep solution that got left behind. One thing I didn't mention, it is on the slide but I just want to mention it out loud because it's so important. Before you do your prep, squeeze out your prep balls, you don't want excess fluid. So you want your prep ball to have the antibacterial solution so that when you wipe over the stoma, you're effectively cleansing the stoma but you don't want to be dripping solution into the stoma because then it will do just what we said mix with the urine, sterilize the urine before it ever gets to lab. Okay. So we've squeezed out our excess prep, we've cleaned our stoma three times, we've taken a dry cotton ball or dry gauze, taken off the excess prep, we've allowed some urine to flow out of the stoma to flush out any residual prep and then we're going to insert our sterile lubricated catheter into the conduit, we're going to wait until urine flows through the catheter into our specimen cup. If we're waiting, nothing's happening, you can have the patient call for a bear down to see if abdominal pressure can mobilize any urine in the conduit. Now there is an alternative, if you are not in a good position to catheterize the stoma if you don't have all the equipment, then what you can do is you can again wash your hands, remove the old pouch, again wash your hands, set up your sterile kit, put on sterile gloves, squeeze out your cotton balls, prep your stoma, take your dry cotton ball, dry gauze, wipe off the excess prep, allow a little bit of urine to flow out and then hold a sterile cup underneath the stoma and get your specimen via the drip method, either is considered appropriate and acceptable. Then you wait until you get your results back. If colony counts are greater than 100,000 colony forming units per milliliter that is indicative of clinical infection and the patient should be treated based on sensitivity results. If it is less than 100,000 colony forming units per milliliter, the patient is considered to be colonized, not infected, and again you have to weigh in how symptomatic is the patient and that will sometimes affect the decision as to whether or not that patient should be treated. What if you have a patient with a u-reader rustomy and they have signs of your near-tracked infection, then how do you get a specimen? Well, you are going to do the same thing, wash your hands, take off the pouch, set up your tray, squeeze out the excess prep, prep your stoma, take a dry cotton bowl, take off the excess prep, but instead of a 12/14/16" red rubber catheter or plastic catheter, you are going to get a number 5 or a number 8" feeding tube, which is very tiny to feed into the u-reader rustomy. What if they want you to get a culture from the u-reader rustamps? This is uncommon, but it does happen. So if they want you to get a specimen from the stance. You're going to wash your hands, put on sterile gloves, get your prep balls, clean off the end of the stints, then dry the end of the stints. Then allow some urine to flow, and then collect your specimen in a sterile cup. We very briefly mentioned in a previous class that if they have a turmball loop, stoma, that's what you see on the bottom, and because the insertion point of the urtors was cut off, we put two little arrows there to indicate where the urtors would be connected. So if you're catheterizing a turmball loop stoma, you want to be sure that you pass the catheter into the proximal side of the loop where the uridural anesthmoses are and where the urine will be. Very occasionally, it's difficult to get your catheter to go into the conduit. You can get through the stoma, but you can't seem to find the channel to get your catheter down into the conduit. You have on sterile gloves, so you can do a very gentle digital with your small finger to see, okay, what's the pathway, and then slide your catheter past that into the conduit. So urinary tract infection, go number one, prevention, fluid intake, careful hygiene. Go number two, prompt detection, so if the patient feels bad, if they're running attempt, if they have any degree of flank pain, nausea and vomiting, then we want to obtain a sterile specimen, get a culture and sensitivity and treat based on results. The second complication we're going to discuss, and we've talked a little bit about it in previous classes, is renal calculine, kidney cells, which, as we've said before, and as you know, can occur in anyone, among patients with an allial conduit, the ones who are at increased risk, anyone who has a history of kidney stones. So have you ever had a kidney stone in the past? Any patient with known metabolic or renal disease that would alter mineral levels in the urine? So what if this patient is known to have chronic kidney disease? Okay, they're higher risk. Anytime you see that the patient has concentrated urine, an adequate fluid intake, that is definitely a modifiable risk factor that we should be focused on very heavily with our patient education. Any patient with recurrent urinary tract infections, is it increased risk? Especially if the infecting organism is a urease-producing organism like proteus or pseudomonas. In that case, when the organism is producing urease, you almost always get alkaline urine, and that places you at high risk for staghorn calculi. So if you look at the illustration on bottom, you see that a staghorn calculus can essentially fill the renal pelvis. They're a very dangerous type of renal stone, they require open surgery for removal in many situations. So any patient with recurrent UTIs, especially if it's with proteus or pseudomonas, and any patient who's wheelchair bound, who's immobile, paralyzed, because those individuals begin to de-mineralize their bones and they're dumping excess calcium into the urine, which of course can then crystallize out to form stones. We've talked about prevention, but the more we tell patients to drink fluids, hopefully the more likely they are to hear us, so hopefully the more times we tell you how important fluid intake is for your urinary diversion patient. Hopefully that's going to translate into teaching to your patients. So adequate fluid intake, prevention strategy number one, prompt treatment of any symptomatic urinary tract infection is also important. Now selected patients may benefit from measures to control the pH of the urine. Since I have a patient who said, "Oh, yeah, I've had, gosh, I lost count. I can't even tell you how many kidney stones I've had." They're awful. Okay, do you know what kind? Oh, yeah, I know what kind I had. They're calcium oxalator, they're calcium phosphate. Okay, well, if we know what kind of stone a patient is prone to develop, then we can manipulate the urinary pH in a way to make the pH hostile to development of that stone type. Also, if we have patients who are complaining of my urine smells bad, it seems like every six months I'm developing a urinary tract infection, it can be very helpful to check the pH of the urine to make sure that it is remaining in the acidic range. As acidic urine has less odor and is less prone to infection. So if I want to monitor urinary pH either because of odor issues, because of frequent UTIs or because of a history of stone formation, I need to get nitrazine paper, which I can get over the counter in the drugstore. I want to teach the patient every time you change your pouch, I want you to put up all your stuff, wash your hands, get a little cup, come back, drain your urine into the cup and use your nitrazine paper to test that urine. I do not want you to dip the nitrazine paper. I don't want you to touch it to the stomach, I don't want you to touch it to the skin. I want you to dip it into the cup of freshly formed urine and compare it to the pH chart. Now, if I'm trying to minimize urinary odor, if I'm trying to reduce the risk of UTI, I want the pH to be acidic. If I have a patient with a history of uric acid stones, I want the pH to be alkaline. If I have a patient with a history of calcium based stones, calcium phosphate stones, I want the urine to be acidic. And if I have a patient with a history of oxalate stones, again, I want the urine to be acidic. And I also want to teach the patient to reduce intake of dietary oxalate, such as tea. And I should know the signs and symptoms of kidney stones, and most people do, I can guarantee you that any patient who's ever had a kidney stone knows the symptoms and will not forget them, severe flank pain, abdominal pain, nausea, vomiting, blood in the urine. Management, hydration, obviously, management of pain in nausea. And then what are we going to do to get that stone out of there? Well, some people pass the stones spontaneously, many people will require lithotrypsy or surgery. That's going to be determined by the urologists. Okay, the last thing we're going to talk about is skin complications that are more likely to occur in the patient with a urostomy. Now general peristomal skin problems will be discussed in a later class. Right now we're talking about skin complications somewhat unique to patients with a urinary diversion. And there's three things we're going to talk about, maceration, where the skin appears waterlogged, pseudo verucous lesions. These are a grayish white, wart-like lesions that can develop on the skin and/or on the stoma, and crystal formation, which is pretty unlikely, but does sometimes occur if the urine is alkaline. The etiology for all three of these complications is prolonged contact between the skin and the urine. It only happens if the skin is in prolonged contact with the urine. So who's at risk? Well you can figure this out. Any patient whose pouch does not fit them well? If my pouch is lifting right around the stoma, allowing urine to pull on the skin, or if my barrier is becoming saturated with urine, and then I have a urine soap sponge sitting on the skin. Any patient who's using a pouch that does not have an anti-reflex valve? Anyone who's trying to get just an extra day or two out of each pouch. So sometimes you'll have a patient who comes in and they're like, "Wow, I'm doing so well. I can make this last for two weeks." And then you see they've got all this tape on the outside edge, duct tape, whatever. And when you take off the pouch, you find. that the barrier is completely waterlogged with urine. Okay, so the patient thinks they're doing well because they can keep the pouch on, but in reality the pouch is not providing a secure seal. It is not providing protection of the peristoma skin. So we've got to educate the patient, we've got to talk about why they're trying to go two weeks without changing their pouches at an insurance issue, a funding issue, how can we help? And then any patient who has concentrated or alkaline urine, higher risk for peristoma skin complications, dilute urine much less irritating to the skin, acidic urine much less irritating to the skin. So prevention, we want to get the very best match possible between the peristoma skin surface and the surface of the pouch and barrier. So again, we're looking at our contours, we're looking at our stomach, we're looking at our options in terms of pouching systems. If we're dealing with deep creases, then we probably need a pouch that's very flexible and will fold into the creases. If we have concave defect like you see middle of the screen, then you're going to need a pouch with a convex surface that will fit into that recessed area. If you have a stoma that empties at skin level again, you're going to need a pouch with a convex curve that will put pressure right around the stoma and help force the urine to project into the pouch. Also, sometimes it can be very helpful to add a barrier ring right around the stoma, or if you have a specific defect, you can fill it with two paste or two paste so that you get a flat pouching surface, then put a pouch on top of that. Critical to teach the patient to change the pouch own schedule, but also PRN. If they notice that it's starting to leak out, don't add tape, change the pouch. If they're developing itching or burning or discomfort of the peristoma skin, time to change the pouch. Also, when they take the pouch off, they should look at the barrier to see, is that barrier saturated? Is it eroding? Is it waterlogged? If so, they need to change the pouch more often or make a change in the pouching system. And once again, what are we talking to the patient about? An adequate fluid intake, keeping the urine dilute and ideally acidic. So we know that if you're trying to manage any complication related to any disease process, go number one is to correct causative factors. And this situation, the causative factors are prolonged contact between the skin and the urine. So how do I correct that? I'm going to assure a good match between my pouch surface and my skin surface. If the skin sinks in, my pouch is going to have an outward curve, a convex curve that fits into that depression. I may need to add a barrier ring right around the stomach so that I have added protection and I reduce the risk of undermining. I might need to add a belt. I might need to add adhesive to the surface of the pouching system to give a more secure seal. And I want to make sure my pouch has an anti-reflex valve to help keep urine off the skin. Everything I know needs to be done, I have to teach the patient because the patient is providing care on a routine basis. So I want to make sure the patient understands recommended pouch change frequency. I want to make sure they're following the right procedure when they size the opening. I want to make sure they have dry skin before they put the pouch down. I want to make sure that they're routinely checking the barrier for saturation and erosion when they're taking it off. I want to make sure they're drinking enough to keep the urine dilute and hopefully acidic. Now, when you have peristomal skin damage when the skin is water logged, when you have these lesions crusting can be helpful. So you clean the skin, you drive the skin. When it's really wet, you can sprinkle on a little bit of powder dust off the excess. You can then pouch on top of that or you can spray our blot over the powder with a liquid skin barrier. So in summary, urinary tract infection is probably the most common complication. Prevention primarily relates to fluid volume intake but also to careful hygiene, hygienic care when changing the pouch. Renal Calculi slight increase in risk among patients with urinary divergence if the patient fails to drink enough fluid if the patient fails to maintain a city urine. If the patient develops chronic UTIs that may alter the pH of the urine and increase the risk of stone formation. If I have a patient with a history of Calculi, if I have a patient who develops a stone, I want to get that stone analyzed and then I want to look at modifying the pH to hopefully prevent further stone formation. And then finally, peristomo skin complications, the three that are unique to urinary diversion, maceration, pseudovarucous lesions, and crystal formation in the patient with concentrated alkaline urine. Prevention of those complications is all about getting a very good fit between the pouch and the skin, making sure that the patient changes the pouching system at appropriate intervals, making sure the patient knows to monitor the back of the pouching system for saturation and erosion. Thank you very much.