Bladder Managment for Adults with Spinal Cord Injury - 39

CLINICAL PRACTICE GUIDELINE

Individuals should be advised that these are highly technical procedures and should be performed only at centers with experienced surgeons and excellent ancillary support.

Medications. Normal saline is used to irrigate the augmented bladder to rid the augmented segment of mucus and a nidus for infection. An anticholinergic medication may be needed if pressures within the bladder are not within the normal range. Reversibility. This procedure is not reversible.
Adapted from Joseph, A.C., A. Hixon, J. Giroux, D. Briggs, M. Gardenhire, D. Diaz, and J. Wells. Nursing clinical practice guideline: neurogenic bladder management. Spinal Cord Injury Nursing 15 (2) (1998): 21–56.

Nursing Considerations for Bladder Augm entation
The success of this bladder management option hinges on both objective and subjective assessments of the individual’s and caretaker’s ability to provide the necessary follow-up care. Preoperative. The individual and his or her family are assessed to make sure they understand the procedure and the changes in lifestyle that will be necessary. The family’s ability to accommodate these changes is critical if bladder management is going to succeed (Hicken, Putzke, and Richards, 2001). Perioperative. Prior to surgery, the individual will receive bowel cleansing, antibiotics, a lowresidue diet, adequate hydration, and confirmation of the site (if applicable), as determined by the surgeon and by institution procedure and policy. If the individual will have a stoma, a wound and continence therapist or other qualified health-care provider will mark the site, the location of which will depend on body physique (bony prominences or skin creases), old abdominal scars, hand function, and usual beltline of clothing. The individual will be evaluated both lying down and sitting up in a chair; self-care is easier when the individual can see the stoma. Postoperative. The focus is on maintenance of homeostasis through adequate hydration and fluid elimination. Assistance required. Adequate hand function and sufficient cognitive ability are needed to insert the catheter and irrigate the augmented bladder, or a caregiver must be available to do so. Cosmesis. There will be an abdominal incision and scar. If the individual is unable to use the urethra for catheterization, an abdominal stoma will be created in the right or left lower quadrant, about the size of a small cherry; the bladder neck may or may not be closed, and the individual will catheterize through the stoma. Interference with social/sexual function. Body image issues may need to be addressed if an abdominal stoma is created.

Continent Urinary Diversion
Continent urinary diversion employs the same principles as those used for bladder augmentation, except these cases require total diversion of urine with or without complete removal of the bladder. The most common procedures used for continent urinary diversion are: (a) the Kock pouch, which is based on the concept of an intussuscepted nipple at both the afferent and efferent limbs of a detubularized segment of ileum, or (b) a modification of the Indiana pouch using a tapered segment of ileum as a continent stoma and a detubularized segment of colon. 1. Consider a continent urinary diversion for: Individuals in whom it is not feasible to augment the native bladder. Individuals who cannot access their native urethra because of congenital abnormalities, spasticity, obesity, contracture, or tetraplegia, or who require closure of an incompetent bladder neck. Females with tetraplegia in whom a chronic indwelling catheter has caused urethral erosion. Males with SCI with unsalvageable bladders secondary to urethral fistula and sacral pressure ulcers. Individuals with bladder cancer requiring cystectomy.
(Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Rationale: Clinical studies have shown improved quality of life, particularly in the area of sexuality of females with tetraplegia, following continent diversion (Moreno et al., 1995; Plancke, Delaere, and Pons, 1999). A continent stoma may

Bladder Managment for Adults with Spinal Cord Injury

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