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Urostomy management in the community

Community nurses may be asked to assist a person with urostomy care after hospital discharge or the urostomist may seek advice because of urostomy-related problems. This article aims to enable primary care nurses to update their knowledge of urostomy care, appliances and  awareness of complications

Linda Nazarko
MSc PgDip BSc(Hons) RN OBE FRCN
Nurse Consultant Ealing Primary Care Trust
Visiting Fellow London South Bank University
Visiting Lecturer King's College
London

Urostomies are uncommon and there are only an estimated 7,500 urostomists (people with urostomies) in the UK. Around 1,770 urostomy operations are performed annually.1 Urostomy is usually performed when a person has cancer of the bladder or urethra, congenital bladder abnormalities or spinal problems. When urostomy is performed because of bladder cancer recurrence rates are high.2

Urostomy surgery
The word "urostomy" is derived from two Greek words: "uros", meaning urine and "stoma", meaning mouth or opening.
Urostomy is an opening created on the abdominal wall to enable urine to drain. A traditional urostomy may be referred to as an "ileal conduit". A section of the ileum (small bowel), around 16–21 cm in size, is removed and used to create the urostomy.
The rest of the ileum is then reconnected to the large bowel.
The ureters are detached from the bladder and attached to the ileal segment that was removed. The bladder may or may not be removed. The far end of the ileal segment is brought through the abdominal wall to form a stoma on the abdomen.

The urine output is not controlled and the patient will have to wear a collection pouch, attached to the abdomen, at all times. The small intestine produces mucous naturally. The segment of intestine that forms the ileal conduit or urostomy will continue to produce mucus. The urine that drains into the bag will contain mucous. This mucous can make the urine look cloudy and string like strands of mucous can be seen in the urine. This is normal and not indicative of infection.

Complications of urostomy
The person with a urostomy may experience problems relating to the stoma, skin problems and renal and bladder infection.3 

Stomal complications
Around 55% of people who have a urostomy experience stoma complications.3 Good stoma care and using a suitable appliance can avoid complications. If the person requires help to manage urostomy care it is important to work with formal and informal caregivers to prevent complications.4 If the urostomist is frail, or his or her health is declining, the person may be receiving a package of care at home. Often, home care agencies are reluctant to instruct staff to assist with urostomy care because they are unfamiliar with urostomies. Primary care nurses can teach home care workers how to provide simple urostomy care and provide information about when the community nurse should be consulted.

Stomal stenosis
Stenosis is the narrowing of the lumen of the stomal outlet. Stomal stenosis affects 2–15% of all stoma patients.5 Stomal stenosis often occurs postoperatively but in 10% of cases it affects established stomas.6 Urostomy stenosis affects the ability of the stoma to drain urine. When stenosis occurs the urine can be can dark-coloured and malodorous. The urine can spurt out in a projectile fashion. The urostomist may develop recurrent urinary infections and loin pain.7 

Stenosis should be treated surgically.8 Some people are not fit for surgery. In such circumstances, the stoma may be dilated daily over a period of time. Nurses with specialist expertise normally demonstrate this procedure to self-caring urostomists.
If the urostomist is unable to perform stomal dilation, community-based nurses may be required to carry out this procedure after training. Dilation of the stoma can cause bleeding and scarring and so this procedure is now normally reserved for people who require palliative care and those who are not fit for surgery.9

Retraction
A urostomy should have a "spout" that is around
2 inches long.10 The spout projects urine into the bag, protects the skin and enables the person to apply a urostomy bag snuggly. This reduces the risk of leaks. A retracted stoma is where the stoma has sunk into a skin fold or dip in the abdomen. Retraction may be caused by poor healing that causes the stoma to slide back into the abdomen. It may retract because the person has gained weight and changed shape. If the person has gained weight, losing weight may help.
Sometimes if the person is obese the stoma sinks into skin folds. In this case, using a special pouch known as a convex pouch may help. In some cases the stoma has retracted so much that it will require refashioning.11

Prolapse
Prolapse is a rare complication of urostomy and affects less than 1% of ostomists.12 Prolapse develops because the abdominal muscles weaken and the bowel telescopes out, increasing the length of the urostomy spout. Patients and professionals can find the sight of a prolapsed stoma very concerning. Prolapse is harmless and does not cause pain. The prolapse can be surgically repaired although many people do manage without surgery.

Large prolapsed stomas can make it difficult to fit a pouch; however, some large pouches are now available to accommodate prolapse. The prolapsed stoma can be heavy and the weight of the prolapse can cause the drainage bag to slip off. Semicircular hydrocolloid wafers (known as flange extenders) can be used to help the pouch to adhere.

Herniation
A parastomal hernia is caused by the bowel under the stoma protruding. Around 15% of people with urostomy develop parastomal hernias.12 Parastomal hernias can be surgically repaired but this is a major procedure and may be unsuccessful.11 Parastomal hernias cause three problems: difficulty fitting the bag; leakage; and discomfort. The hernia can make it difficult to fit a urostomy bag and the bag can leak.
A specially designed bag with a flexible flange, for example, the Curvex from Clinmed, can resolve such problems.

Parastomal hernias can be uncomfortable. The person may complain of dragging, heaviness and general discomfort. Some ostomists find that a light support girdle (adapted to accommodate the urostomy) helps relieve this discomfort. Specially made support garments are available on prescription and are fitted by surgical fitters.

Bleeding
The stoma is formed from the small bowel. The small bowel has a good blood supply and bleeds easily, sometimes because of rigorous cleaning. Ensuring that the stoma is cleaned gently may resolve the problem.

The stoma may also develop overgranulation tissue. This is red, friable tissue and bleeds easily. The urostomist may find this distressing. Various treatments are used to treat overgranulation tissue. These include steroid creams, silver nitrate and cauterisation. Haelan tape contains a moderately potent steroid and is used in dermatology to treat inflammatory conditions. It is now also being used to treat overgranulation around stoma sites.13 In my experience, Haelan tape, unlike steroid cream, does not interfere with adhesion of
urostomy bags.

If the stoma is bleeding you should consult your local wound care policy for treatments and seek the advice of stoma care and tissue viability specialists. If blood is leaking from inside the stoma you should seek urgent medical advice.

Odour
Many urostomists fear smelling of urine. This should not be a problem as modern urostomy pouches are made from an odour-proof plastic. If the person is concerned it is important to check that the appliance fits well and there is no leakage. If odour, or the perception of odour, persists, ostomy deodorants may help. A few drops can be added to the pouch before applying it.

Cranberry juice has also been used to reduce urine odour and to prevent infection. The urostomist should be advised to drink two 200 ml glasses a day.14 Since 2003, there have been a number of reports of serious interactions between warfarin and cranberry juice.15,16 In 2003, it was reported that a patient who had been taking warfarin and who had eaten virtually nothing for six weeks except cranberry juice had died from a haemorrhage.17 The Committee on Safety of Medicines reported four cases where warfarin and cranberry juice had interacted and issued a safety warning. They stated that people on warfarin should not drink more than one glass of cranberry juice a day.18 In view of these reports, cranberry juice should be avoided when warfarin
is prescribed.

Urinary tract infection
People with a urostomy have an open and shortened urinary tract system that is vulnerable to infection. Around 23% of urostomists develop urinary tract infections.19 Scrupulous handwashing before changing the pouch can reduce infection risk. The person may choose to drink two 200 ml glasses of cranberry juice daily (if not on warfarin). Cranberry juice acts by preventing bacteria from adhering to the mucosa.14 If an infection is suspected a urine specimen should be sent for culture and sensitivity.

Skin problems
Around 50% of urostomists experience skin problems.20 Pouches can occlude, macerate and irritate the skin. Removal of pouches strips away the epidermal layer. Barrier creams, gels, lotions, sprays and wipes can make a real difference and improve quality of life.

If leakage occurs, appliances should be changed immediately. Appliances should be changed regularly as advised. Stoma care should be carried out carefully and without hurry to reduce complications. If the flange is removed by pulling this can damage skin. Peeling the flange off breaks the seal between the hydrocolloid flange and the skin and minimises damage.21 

Soap is alkaline and is normally pH 9. Soap can dry and damage delicate skin, especially peristomal skin. Some clinicians recommend limiting the use of soap and using foam cleansers and liquid soap to protect peristomal skin.22 In my experience, sore peristomal skin is best cleaned with plain warm water. The skin should be dried carefully with a soft cloth (like an old cut-up cotton t-shirt), which is less abrasive than rough towels and is gentler on the skin. A silicone-based barrier should be applied to protect the skin. When the barrier has dried the appliance can be fitted.

Urostomy appliances
Many urostomy-related complications can be prevented if the urostomist uses an appliance suited to his her needs and abilities. The person's ability to use an appliance may change and the characteristics of the stoma may change. The person may gain or lose weight or develop a parastomal hernia. Advice on appliances should be based on a holistic assessment of the patient. Box 1 outlines information required to inform
appliance choice.

[[Box 1 uros]]

Urostomy appliances are available as one- or two-piece items in either clear or opaque materials. Table 1 outlines some of reasons for choosing a one- or two-piece system. Urostomy may be performed in people who have cancer. Some people with cancer may feel exhausted and prefer an appliance that is easy to manage such as a one-piece appliance.

[[Tab 1 uros]]
 
The urostomist's ability to manage an appliance will be affected by eyesight and manual dexterity. People with poor eyesight or dexterity may find a one-piece appliance most suitable. If the person is dependent on others then the level of support available at home will influence appliance selection.

All appliances have a non-return valve. This prevents urine from retuning to the top of the bag and potentially causing phosphate deposits around the urostomy.10 Urine is drained from the pouch using either a tap or bung system. People with poor dexterity or vision may find the taps easier to manage. People who are more active may prefer the bung system as the bung can be tucked into a pocket on the back of many bags and this makes it less noticeable under clothing.

Urostomy bags have a maximum capacity of around 400 ml so they need to be emptied regularly. If a person is
travelling, he or she may attach the urostomy pouch to a urine leg bag using an adaptor. Appliances may be changed daily or every few days. Urine can corrode flanges and cause leakage and skin problems so appliances are normally changed at least every third day.

Night drainage
Adults normally produce smaller volumes of concentrated urine at night; however, ageing reduces the ability to concentrate urine and older people may produce larger volumes of urine at night. Some urostomists use a night drainage system to ensure that they do not have to get up in the night to empty their pouch. Most appliance systems produce night drainage bags. These are usually connected to the urostomy appliance using a connector.23 Extension kits are available to extend tubing. People who are restless in bed and who turn over a lot may find these helpful. Some people with dexterity or visual problems can find connectors fiddly and bothersome.

The decision to use a night drainage system is an individual one. Some people find them a real boon and appreciate being able to sleep through the night without worry. The primary care nurse's role is to inform the urostomist of available options and to offer the urostomist support in using the preferred system.

Conclusion
Urostomies are often carried out when a person has cancer or a long-term condition such as paraplegia. People who have a urostomy may be in poor health and at some point require support, advice or palliative care. Primary care nurses who are up to date with urostomy care can work with the urostomist and formal or informal carers to ensure that the urostomist enjoys the best possible quality of life.

If the nurse requires advice and guidance on caring and supporting a person with urostomy, the stoma care nurse specialist should be consulted.

References
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2. Catto JW, Abbod MF, Linkens DA, Larré S, Rosario DJ, Hamdy FC. Neurofuzzy modeling to determine recurrence risk following radical cystectomy for nonmetastatic urothelial carcinoma of the bladder. Clin Cancer Res 2009;15(9):3150–5.
3. Lyon C, Smith A (eds). Abdominal Stomas and their Skin Disorders: An atlas of diagnosis and management. London: Martin Dunitz; 2001.
4. McGrath A, Johnson A. Accessories used in stoma care. In: Porrett T, McGrath A, eds. Essential Clinical Skills for Nurses; Stoma Care. Oxford: Blackwell Publishing Ltd; 2005.
5. Beraldo S, Titley G, Allan A. Use of W-plasty in stenotic stoma: a new solution for an old problem. Colorectal Dis 2006;8(8):715–16.
6. Johnson A, Porrett T. Stomal stenosis, a complex stoma complication: case study. Gastrointestinal Nursing 2007;5(1):17–22.
7. Breckman B. Stoma Care and Rehabilitation. Elsevier Church Livingstone, London: 280–1; 2007.
8. Efron J. Ostomists and Stomal Therapy. American Society of Colon and Rectal Surgeons; 2003.
9. Barr JE. Part 1: Assessment and management of stomal complications: a framework for clinical decision making. Ostomy Wound Manage 2004;50(9):50–67.
10. Birch J, Sica J. Urostomy products: an update of recent developments. Br J Community Nurs 2004;9(11): 482–6.
11. Taylor P. Care of patients with complications following formation of a stoma. Prof Nurse 2001;17(4):252–4.
12. Kouba E, Sands M, Lentz A, Wallen E, Pruthi RS. Incidence and risk factors of stomal complications in patients undergoing cystectomy with ileal conduit urinary diversion for bladder cancer. J Urol 2007;178(3):950–4.
13. Johnson S. Haelan Tape for the treatment of overgranulation tissue. Wounds UK 2007;3:3.
14. Nazarko L. Infection control. The therapeutic uses of cranberry juice. Nurs Stand 1995;9(34):33–5.
15. Griffiths AP, Beddall A, Pegler S. Fatal haemopericardium and gastrointestinal haemorrhage due to possible interaction of cranberry juice with warfarin. J R Soc Promot Health 2008;128(6):324-326.
16. Paeng CH, Sprague M, Jackevicius CA. Interaction between warfarin and cranberry juice. Clin Ther 2007;29(8):1730–55.
17. Suvarna R, Pirmohamed M, Henderson L. Possible interaction between warfarin and cranberry juice. BMJ 2003;327:1454.
18. Committee on Safety of Medicines. Possible interaction between warfarin and cranberry juice. Current Problems in Pharmacovigilance 2003;29:8.
19. Madersbacher S, Schmidt J, Eberle JM, Thoeny HC, Burkhard F, Hochreiter W, Studer UE. Long-term outcome of ileal conduit diversion. J Urol 2003;169(3):985–90.
20. Herlufsen P, Olsen AG, Carlsen B, Nybaek H, Karlsmark T, Laursen TN, Jemec GB. Study of peristomal skin disorders in patients with permanent stomas. Br J Nursing 2006;15(16):854–62.
21. Black P. Peristomal skin care: an overview of available products. Br J Nurs 2007;16(17):1048,105,1052–4.
22. Fore J. A review of skin and the effects of aging on skin structure and function. Ostomy Wound Manage 2006;52(9):24–35.
23. Gallagher T. Night Drainage Systems For Use with a Urostomy. Available from: www.ostomates.org/night.html

Resources
Coloplast
The company has developed a peristomal assessment tool to enable nurses to assess and treat peristomal skin problems, the Ostomy Skin Tool: a Peristomal Skin Assessment Tool. 
W: www.coloplast.com

Clinimed
Although mainly aimed at people who have had bowel surgery, this website is also relevant to urostomists
W: www.clinimed.co.uk

Urostomy Association
W: www.uagbi.org