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Following
the operation you will have to change your daily routine.
Although this may be difficult at the start, with time you
will learn to integrate these changes into your daily life.
This information brochure has been developed to assist you
with these changes and provide you with information regarding
your bladder substitute. If you remain uncertain and have
further questions after reading this please contact the nurses
specialized in long-term management of patients following
bladder substitution or the urologist.
What
is a "new" bladder ?
Following
removal of bladder a reservoir or neo-bladder is created to
store urine. There are many technique to design a neo-bladder
Mr Puri uses the Studer technique named after Urs Studer,
the surgeon who described this technique.
During
the operation a 55cm piece of bowel has been taken to construct
a bladder reservoir which allows urine to be stored. In the
beginning this bladder has a very small capacity (80-100ml).
With specific urethral sphincter muscle training and increasing
pressure the bladder stretches and increases in capacity.
In several weeks time the capacity will reach normal values
of 400-500ml. There are certain points one must be aware of
following a bladder substitution:
- Emptying
- Continence
- Hygiene
- Metabolic
changes
- Sexuality
- Miscellaneous
1.
Emptying
What
happens following discharge from hospital?
In
the beginning you should empty the neobladder every 2 hours.
This will take 6 to 8 minutes. To fully empty your bladder
you must actively assist with certain manoeuvres. At the beginning
you must sit down to urinate. Otherwise incomplete bladder
emptying may occur. Men can void standing in 3 to 6 months
time.
To
assist you in emptying your bladder:
■
Fold your hands over your lower abdomen
■
Relax your pelvic floor
■
Press your hands over the lower abdomen and bend your body
forward
■
Straighten up and repeat this procedure until the bladder
is empty
■
Following this bend your body in all direction
■
Massage the groin and lower abdomen regions with gentle movement
and pressure from outside. This often leads to further bladder
emptying.
When you
feel that your bladder is empty stand up and stretch. Sit
down again and repeat the above procedure again. With the
change of position and stretching further residual urine from
the bladder may be emptied.
Bladder
emptying at night
In
the beginning the bladder needs to be emptied twice during
the night. After a few weeks or months it can be done only
once. You must remember that the feeling of urgency that existed
before the operation and awakened you to void does not exist
anymore. Use a separate alarm clock for each void at night.
You can awaken to one alarm clock, empty the bladder and go
back to sleep again without having to reset the alarm clock.
The second alarm clock will already have been set. This makes
it easier to fall asleep again.
Post
void residual urine
If
you empty your neobladder insufficiently some urine will remain.
This residual urine is a breeding ground for bacteria resulting
in urine tract infections. These bacteria can pass through
the ureters up to the kidney and cause a kidney infection.
2.
Continence
Involuntary
loss of urine is quite normal in the beginning. This incontinence
will remain until your sphincter training has resulted in
sufficient muscle strength to withstand the pressure from
your neobladder. The strengthened sphincter muscle combined
with the increased capacity of the neobladder will eventually
result in continence. Effective sphincter training will be
demonstrated to you.
Where
is the pelvic floor and what are the differences between man
and women?
The
pelvic floor stretches across the pelvic opening like a sheet
of muscle extending from the pubic bone to the sacrum. It
is larger in women than it is in men. The muscle is penetrated
by the rectum and the urethra in men and additionally by the
vagina in women.
Pelvic
floor/sphincter exercises
Contract
your urethral sphincter muscle for a few seconds as if you
were preventing urine and stool from escaping. The abdominal
and buttock muscles should remain relaxed. Initially contract
your anal sphincter ten times an hour for six seconds each
time. This is an excellent exercise which can be performed
in every position without anyone being aware of it. Regular
practice, preferably when performing daily tasks such as brushing
your teeth, breakfast etc., increases success.
Sit slightly
forward , so that the pressure is applied to the front portion
of the pelvic floor. Contract as strongly and as long as possible.
Be very
conscious of your breathing when exercising. While contracting
your muscles you should breath out and while relaxing breath
in.
Reaching
adequate bladder capacity
As
soon as you can remain continent for 2 hours, you may increase
your voiding intervals by 30 minutes at a time until you reach
the 4 hour mark. It is important during this phase of your
training to withhold your urine by contracting your sphincter
muscle even if a little urine escapes. This is only way to
reach the desired capacity of 400-500ml.
Milking
the urethra
In
men urine may remain in the urethra following voiding. This
may dribble out into the underpants a short time later falsely
indicating incontinence. To prevent this from happening the
urethra should be milked from the base of the penis (perineum)
to the tip of the penis.
Sleeping
tablets
Sleeping
tablets will relax your muscles including the pelvic floor.
This may increase the risk of involuntary loss of urine.
Drinks/alcoholic
drinks
Cold
and alcoholic beverages can increase involuntary urine loss,
especially at night.
3.
HygieneThere
is a large selection of sanitary aids which can assist you
in your care.
Incontinence
pads
Migros
has a large selection of different pads under the name of
"Secure" as does Coop under the name of "Tena".
These are available in most branches. Drug stores and sanitary
stores all have similar products. Publicare AG in Dättwil
has a large selection of incontinence pads that are available
at reasonable prices. We are more than happy to give you advice
on these products and assist in ordering them.
4.
Metabolic changes
The
mucosa of the bladder reservoir continues to produce mucus
which can be seen as yellow turbidity in the urine.
Your neobladder
which has been constructed from small bowel retains residual
bowel functions which will diminish over the years.
The mucosa
of the neobladder can absorb substances from the urine and
secret them into the blood. Conversely, substances can be
taken from the blood and excreted in the urine. Subsequently
you can no longer determine the concentration of your urine
from the colour as there is a constant exchange substances
between the blood and the urine.
This process
is comparable with water absorption by a plant. Here the water
rises from the root to the leaves by a concentration differential.
A similar process occurs in the neobladder. A concentration
equilibrium is reached which results in the urine staying
the same colour irrespective of the amount you drink. For
this reason it is imperative that you drink at least 3 litres
a day for the first 3 to 6 months to reduce the chances that
this exchange phenomenon will have any serious consequences.
After a while you can reduce your daily fluid intake to 2
litres. You are free to drink any sort of beverage that you
wish. If you are not used to drinking a lot, a regulated drinking
schedule may help.
You must
be aware that you will lose salt via the neobladder. The salt
is bound to water which leads to excess urine production.
To compensate for this salt loss you should consume extra
salt and salt products during your meals (eg. Broth, dried
meats, salt pretzels) and snacks between meals.
Inadequate
fluid or salt intake could lead to a metabolic abnormality
which presents weight loss or tiredness. An acid base abnormality
in the blood could lead to metabolic acidosis resulting in
loss of appetite, nausea, dyspepsia and indigestion. In the
worst case it could lead to repeated nausea and vomiting.
Despite these difficulties one must urgently consume more
fluids to excrete these acid elements in the urine and correct
the acidosis.
Should
these symptoms occur call us immediately on . We can then
discuss this problem with you and institute the appropriate
measure.
5.
Sexuality
In
men the nerves responsible for erection may be impaired during
the operation resulting in erectile dysfunction. As a rule
it is possible with the use of appropriate measures and aids
to achieve erections again and subsequently perform intercourse.
We are more than ready to discuss any such difficulties encountered
and provide you with further information and therapy options.
Please do not hesitate to make use of this service.
The following
therapeutic options are available:
■
Injections into the penis shaft
■
MUSE is a preparation which is inserted into the urethra
■
Vacuum pump
■
Viagra and Uprima are oral tablets used for erectile dysfunction
In females
the vaginal length may be shortened and lubrication may be
reduced. Certain lubricants may be used for this (eg. KY Gel
– available through pharmacies or drug stores). Most larger
department stores will also stock lubricating gels.
Sexual
intercourse may be resumed 3 months following the operation.
6.
Miscellaneous
Eating
Following
the operation a stepwise increase in diet will occur. With
time you will be able to resume your normal diet. Foods which
tend to bloat should initially be avoided as they may induce
abdominal pain, cramps and possibly diarrhoea.
Bowel
habits
To ensure
optimal recovery during your hospital stay and immediately
following you will have been given several antibiotics. This
could lead to a disturbance of your intestinal flora and result
in changes in your bowel habits eg. constipation or diarrhoea.
To rebuild your bowel flora we would recommend eating unpasturised
yoghurt. If further antibiotic treatment is necessary it may
be taken with or following your meals/
In
the first few months following the operation you may suffer
from constipation or diarrhoea.
Activities
following the operation
The resumption
of physical activity can best be judged from your own feeling
of well-being and physical strength. For the first several
weeks you should avoid lifting heavy objects (over 10kg),
or exerting excessive pressure on your abdomen while emptying
your reservoir. Such actions could result in wound hernias.
It takes about 3 months for a complete wound healing.
Follow-up
and management
The first
follow up will take place one week after discharge from the
hospital. As a rule this consist of a blood test to determine
your blood acid level, a urine analysis as well as an ultrasonography
of the kidneys and neobladder. These results will determine
whether you will require a further short-term follow-up.
Otherwise
the routine follow-ups will occur at regular intervals. The
next 2 will take place in 3 and 6 months thereafter.
Don’t
forget:
For
your well being and for the flawless function of your neobladder
a regular follow up and your full co-operation are indispensable!
Individual
follow ups and management
If you
have questions or are uncertain about anything following discharge
from hospital you may contact the nurses specialized in long-term
management of patients following bladder substitution by telephone
number. If on exception this number if not answered you may
request to speak to the doctor on call in the Urology Department
on telephone number .
We hope
that this pamphlet has clarified any questions you may have
had and wish you and your family all the best for the future.
Life
after bladder reconstruction
Useful
addresses and telephone numbers
Website www.urol.co.uk
Email rp@urol.co.uk
Website www.urol.co.uk
Email rp@urol.co.uk
Uro-oncology
nurse specialists
BRI Yorkshire
Clinic
Mr
David Tyson 01274 382079 Mrs Lyn Taylor 01274 550600
Miss
Zoe Scaife
Ward
14 Ward 1
Bradford
Royal Infirmary Yorkshire Clinic
Tel
(01274) 364383 Tel (01274) 560311
Secretary
to Mr R. Puri
Bradford
Royal Infirmary Yorkshire Clinic
Duckworth
Lane Bradford Road
Bradford
BD9 6RJ Bingley BD16 1TW
Tel
(01274) 382655 Tel (01274) 564521
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