Information for the patient following bladder substitution

Information for
Patients with a
Bladder
Substitution
Dr Celi Varol MB BS FRACS (Urology) Elizabeth Marshall Dip Health Sc (Nursing) 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 Liz or Professor
Varol.
How does the “new” bladder work?
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 to be aware of
following a bladder substitution:
1. Emptying
What happens following discharge from hospital?
In the beginning you should empty the neobladder every 2
hours. This will take 6-8 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  straighten up and repeat this procedure until the bladder is  following this bend your body in all directions  Massage the groin and lower abdominal 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 for you to fall asleep again.
Post void residual urine
If you empty you 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 into the kidney and cause a kidney
infection.
2. Continence

Involuntary loss of urine is 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. This strengthened sphincter muscle
combined with 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 is the difference between
men 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. This muscle is penetrated by
the rectum and the urethra in men and additionally by the
vagina in women.
The great advantage of pelvic floor and urethral sphincter
training is that it can be continued and performed regularly at
home.
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 five 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 routine daily tasks such as
brushing your teeth or having breakfast will increase your
success.
Sit leaning 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 breathe out and while
relaxing breath in.
Reaching adequate bladder capacity
As soon as you can remain continent for two 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 the only way to
reach the desired capacity of 400-500ml.
Milking the urethra
In men residual 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. Continence Products

There is a large selection of aids which can assist you in your
care.
Incontinence pads
Your pharmacist has a large selection of different pads. Some
supermarkets may have similar brands available at reasonable
prices. We are more than happy to help and give you advice on
these products and assist you in ordering them.
4. Metabolic changes

The mucosa of the bladder reservoir continues to produce
mucus which can be seen 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 color as there is a constant exchange of
substances between the blood and urine.

For this reason it is important 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.
You must also 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, (e.g.
Bonox soup, dried meats, salt chips, etc) and snacks between
meals.
Inadequate fluid or salt intake could lead to a metabolic
abnormality which presents as weight loss, tiredness, loss of
appetite, nausea with indigestion. In the worst case it could lead
to repeated nausea and vomiting. Despite of these difficulties
one must urgently consume more fluids to excrete these acid
elements in the urine and correct the acidosis.
Should these symptoms worsen please call your urologist
immediately or the casualty department. We can then discuss
this problem with you and institute the appropriate measures.

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:  Viagra, Cialis and Levitra® are oral tablets used for  Surgical Implantation of Penile Prosthesis
In females the vaginal length may be shortened and lubrication
may be reduced. Certain lubricants may be used for this e.g. K-
Y Gel (available through pharmacies or supermarkets).
Sexual intercourse may be resumed 3 months following the
operation.
6. Miscellaneous

Eating
Following the operation a slow increase in your diet will occur.
Slowly you will be able to resume your normal diet. Foods,
which tend to cause bloating, should initially be avoided as they
may induce abdominal pain, cramps and possibly diarrhoea.
Bowel habits
To insure 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 a change in your bowel habits e.g.
constipation or diarrhoea. To rebuild your bowel flora we would
recommend consuming yoghurt/milk products containing
bifidus. 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 however 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 consists of a blood test to determine
your blood acid level, a urine analysis as well as an
ultrasonography of the kidneys and your neobladder. These
results will determine whether you will require further short term
follow-up.
Otherwise the routine follow-ups will occur at regular intervals.
The next two will take place in 3 and 6 months.
Don’t forget:
For your well being and for flawless function of your
neobladder a regular follow up and your full cooperation
are mandatory!

Individual follow up and management
If you have questions or are uncertain about anything following
discharge from hospital you may call Liz, our practice nurse on
0432 160 543. If on exception this number is not answered you
may request to speak to the doctor on call for the Urology
Department at your local hospital or the casualty department in
emergencies.
We hope that this pamphlet has clarified any questions you may
have had.

Source: http://www.macquarieurology.com.au/pdf/information-for-patients-with-a-bladder-substitution.pdf