US Pharm. 2013;8(38):27-30.

ABSTRACT: Given the number of catheterizations and urostomies being performed today, it is essential for the community pharmacist to fully understand urostomy and catheterization procedures and to be proficient in recommending related products and counseling patients. Community pharmacists need to become well versed in such topics as reasons for catheterization and urostomy, how both of these procedures are performed, types of catheterization, available products, and how to change a urostomy bag.

A thorough knowledge of catheterization and urostomy products is particularly important because of the number of these procedures being performed and the need for related products. It is essential for community pharmacists to be familiar with reasons for catheterization and urostomy; how these procedures are performed; types of catheterization; available products; and how to change a urostomy bag. Traditionally, there has been a lack of pharmacist education on these topics. It is anticipated that the pharmacist will become knowledgeable about durable medical equipment for catheterization and urostomy by reviewing these topics in detail.

UROSTOMY

Urostomy is a rerouting of the ureters that is necessitated by a damaged or diseased urinary system.^1,2 In this procedure, the bladder is removed or bypassed and the ureters are connected to an opening in the abdominal wall.^1,3 Urine is then collected in a pouch worn outside the body.^1,2

Reasons for Urostomy

There are several conditions that may warrant urostomy. One of these is bladder cancer, in which case the bladder may have to be removed entirely to keep the cancer from spreading.^2,3 A defective bladder arising from a birth defect, spinal injury, or surgery may be another reason for urostomy.³ Nerve damage, exstrophy, chronic pyelonephritis, and trauma are other specific circumstances that may require urostomy.^1,2 Ultimately, any condition that causes a blockage of urine flow and results in accumulation in the ureters and kidneys may necessitate this procedure.^2,3

Urostomy Procedures

In one urostomy process, an ileal conduit is constructed from a piece of the ileum in the small intestine.^2,3 This is the standard urostomy procedure.² The ureters are detached from the bladder and connected to one end of the ileal conduit.^1,2 A stoma (opening) is formed by bringing the other end of the ileal conduit through the abdominal wall (FIGURE 1).^2,3 At this point, urine output is no longer controlled, and a pouch is necessary to collect the urine.^1,2 Another available option is the ureterostomy. In this procedure, no ileal conduit is used, and the ureters are directly connected to the abdominal wall to create a stoma. A collecting pouch is still needed.³

Changing a Urostomy Pouch

Patients need to be well educated on how to change their urostomy pouch. Patients receive information before leaving the hospital, but reinforcement in the community setting is often necessary.

First, the patient should wash his or her hands thoroughly before changing the pouch.^1,2 The next step is to clean the stoma and the skin around it with a wet towel or washcloth.^1,3,4 Once the skin is dry, a skin barrier is applied to protect the skin from urine.^3-5 The skin barrier may be precut or may require a hole cut out for the stoma.² If a hole needs to be cut, the stoma should be measured using a guide, traced on the back of the skin barrier, and cut accordingly.^4,5 The skin barrier should be no more than one-eighth of an inch larger than the stoma.² To apply the skin barrier, the paper backing should be removed and the skin barrier centered over the stoma and firmly held in place for at least 30 seconds.^4,5 If the product is a one-piece urostomy pouch, the bag is attached to the skin barrier; if a two-piece pouch is used, however, the bag must be attached separately.² In this case, the bag should be opened to let in a small amount of air and lined up with the skin barrier for attachment.⁵

Urine should be emptied from the pouch prior to removal. To remove a pouching system, the skin barrier should be held taut and pulled downward while the skin is pushed away from the skin barrier.^4,5 It is important to change the pouching system when fluids have been limited for several hours; the best time is the morning.^1,2

Urostomy Products

Many different urostomy brands and products are available.² When a patient is choosing a product, factors that should be taken into consideration are stoma length and location, abdominal firmness and shape, scars and folds near the stoma, and the patient’s height and weight.

A good pouch should be flush to the skin to allow easy passage of urine, last 3 to 7 days, and protect the skin around the stoma.^2,6 It also should be easy to attach and remove and should be nearly invisible under clothing. As previously mentioned, there are two main urostomy pouching systems. Both systems include the adhesive skin barrier and a collection pouch. One type is the one-piece pouch, which attaches directly to the skin barrier. In the two-piece system, the pouch can be detached from the skin barrier.²

Ostomy belts and tape, while not necessary, are other products that patients may be interested in obtaining. A belt provides support by attaching to the pouching system and wrapping around the waist. Tape is used around the outside edge of the skin barrier for additional comfort. Skin wipes and ostomy powder may be used to further protect the skin around the stoma.² Caulking material may be applied to the skin barrier to fill gaps between the skin barrier and the stoma.⁵ Finally, night-drainage systems are convenient because the pouch does not have to be emptied during the night.²

Counseling for Urostomy

The patient should be counseled to check for signs of possible infection: dark or foul-smelling urine, back pain, poor appetite, nausea, and vomiting. If any of these symptoms are present, the physician should be contacted.^1,3 The collection pouch should be emptied at regular intervals, generally when it is about one-third full.^1,2 The pouch needs to be changed every 5 to 7 days, and more often if leakage occurs.¹ If a night-drainage system is used, the container should be vented with the tubing secure at the top. The pouch should be cleaned every morning.² Dietary changes generally are not necessary, unless kidney problems are present.^2,3 Lastly, seams and waistbands should not be placed directly over the stoma.¹

CATHETERIZATION

The use of a catheter may be necessary for diagnostic or therapeutic purposes.^7,8 A catheter is inserted through the urethra into the bladder to permit the drainage of urine.^7,9 Two minimally invasive procedures are indwelling catheterization and intermittent catheterization.⁹

Reasons for Catheterization

As mentioned, there are diagnostic and therapeutic reasons that catheter insertion may be necessary. Diagnostic situations include instilling medication, obtaining urine specimens, monitoring urine output, and measuring residual volume after voiding. Catheterization may be used therapeutically for acute or chronic urinary retention and for the removal of blood and/or clots from the bladder.^7,8

Types of Catheterization

Different circumstances require different types of catheterization. One type, intermittent catheterization, is the brief insertion of a catheter on one occasion or at regular intervals. The second type, indwelling catheterization, is the insertion of a catheter for a longer period of time, and the catheter is held in place by an inflated balloon in the bladder. Intermittent catheterization is used to obtain urine samples, empty the bladder, measure residual volume, instill medication, and instill contrast media into the bladder. Indwelling catheterization may be necessary for accurately measuring urine output, managing incontinence when other methods have failed, maintaining continuous urine output after surgery, and maintaining continuous urine output in patients with voiding difficulties resulting from neurologic disorders, as well as for immediate treatment of acute urinary retention.^9,10

Male Catheterization Procedure

The patient should lie on a flat surface in the supine position.⁸ Catheterization should always be performed under sterile conditions.^8,11 Sterile gloves should be worn and the pubic region and inner thighs covered with sterile drapes.^8,11 Approximately 10 to 15 mL of viscous lidocaine should be injected into the urethra to anesthetize the area and distend the urethra for catheterization. Next, the penis should be grasped and held perpendicular to the body plane; the tip should be cleansed in a circular motion with cotton balls soaked in antiseptic solution.⁸ The catheter tip should be lubricated with sterile jelly or viscous lidocaine prior to insertion.^8,11 Then, the catheter should be gently introduced into the urethra and slowly advanced. Some resistance may be encountered near the external sphincter at around 16 to 20 cm. The catheter should be advanced until the return of urine is observed. This indicates proper positioning.⁸ If no urine is seen, the catheter may be obstructed by lidocaine or the bladder may be empty.^8,11 In this situation, the catheter should be flushed with saline to ensure free flow and appropriate placement.⁸

If an indwelling catheter is being used, the balloon should be inflated with 10 mL of sterile water. No air or saline should be used.^8,11 Once the balloon is inflated, the catheter should be pulled back to set the balloon against the bladder.⁸ Then, the catheter should be anchored to the medial thigh and attached to a collection bag.^8,11 The collection bag should be placed below the level of the bladder in a dependent position.⁸

Female Catheterization Procedure

The patient should lie on a flat surface in the supine position prior to catheter insertion. The legs should be apart and the feet together in a frog-legged position.⁷ Catheterization should always be performed under sterile conditions.^7,11 An absorbent pad should be placed under the patient’s buttocks before sterile gloves are donned.⁷ The abdomen and superior pubic region should be covered with sterile drapes, antiseptic poured on preparation swabs, and the catheter tip lubricated.^7,11 The nondominant hand should be used to locate the urethra. The opening should be cleansed with the presoaked antiseptic swabs in a circular motion. Next, the catheter should be held in the dominant hand, gently introduced into the urethra, and slowly advanced. At about 4 cm in length, the female urethra is much shorter than the male urethra. Once urine starts to flow, the catheter should be inserted another 3 to 5 cm.⁷ If the flow of urine is slow or nonexistent, the catheter may be obstructed or placed in the wrong site, or the bladder may be empty. If this occurs, the catheter should be flushed with saline. If the saline returns freely, the catheter is properly placed.

If an indwelling catheter is used, the balloon should be filled with 10 mL of sterile water and the catheter gently pulled downward to set it in place.^7,11 No saline or air should be used.⁷ At this point, the catheter should be secured to the inner thigh and attached to a collection bag, which should be placed below the bladder in a convenient location.^7,11

Catheterization Products

Products for catheterization are available commercially in prepackaged kits.^7,8 Usually, most needed items are included in the kit, with the exception of viscous lidocaine, a tape or device to secure the catheter to the patient, and antiseptic solution.

Many types and sizes of catheters are available (FIGURE 2).⁸ The most common material is latex, although silicone catheters are available for patients with latex allergies. The Foley catheter, the most frequently used type, is a double-lumen, straight-tipped catheter with a balloon at the end.^7,8 The Coudé catheter is helpful for facilitating placement in patients with prostatic enlargement. Its semirigid, curved tip should be pointed upward in the 12 o’clock position before insertion.⁸ For intermittent or one-time catheterization, a straight catheter is generally used.⁷ The triple-lumen catheter, which has an additional port for irrigation, is used to remove blood and/or clots.

Catheters are sized according to the French gauge system (French units [F]).^7,8 A size of 14-F to 16-F is appropriate for most females, although smaller units may be required for narrow urethras and larger units may be required if luminal obstruction is suspected (e.g., gross hematuria with clots).⁷ For males, 16-F to 18-F is generally acceptable; 12-F to 14-F may be needed if urethral stricture is observed, and 20-F to 24-F may be appropriate for patients with prostatic enlargement or hematuria.⁸

Silver-alloy catheters have been shown to resist bacterial growth in indwelling catheters and should be considered for patients at high risk for infection.^7,8 In intermittent catheterization, there is no significant difference between catheter types in risk of urinary tract infections.

Clear, noncoated catheters are the most cost-effective, but other options also should be offered and considered.¹²

Various collection systems are available. The leg-drainage system, night-drainage system, and urimeter-drainage system are typically for daytime use, nighttime use, and accurate measurement of urine output, respectively.¹³

Complications of Catheterization

The main complication arising from catheterization is urinary tract infection, especially with the use of indwelling catheters.^7,8 The chance of infection increases by 3% to 10% per day of catheter use. With time, pyelonephritis, bacteremia, and urosepsis may develop.⁸ Urinary tract infections are less common with intermittent catheterization than with indwelling catheterization.^9,11 Trauma to the urethra or bladder, dislodgement, and blockage are other possible complications.^7-9

Certain patient populations may be at increased risk for complications, such as the elderly and patients with diabetes, underlying renal insufficiency, or advanced, life-threatening illnesses.⁸ Thus, catheterization should be avoided unless absolutely necessary.^7,8,11 If catheterization is implemented, strict aseptic technique, maintenance of a closed collection system, and reduced duration are essential to minimize complications.^7,8

CONCLUSION

It is critical for the community pharmacist to be conversant with catheterization and urostomy procedures and to be proficient in recommending related products and counseling patients. A broad awareness of the reasons for catheterization and urostomy, the performance of these procedures, types of catheterization, available products, and how to change a urostomy bag is necessary. Traditionally, there has been a lack of education of pharmacists in this area; however, a thorough knowledge of catheterization and urostomy products is essential because of the number of these procedures being performed and the need for related products.

REFERENCES

1. Toth JM. When your patient faces a urostomy: he’ll be frightened by changes in his anatomy and self-image. You can ease his fear by telling him what to expect and teaching him how to manage his new urinary system. RN. 1985;48:50-55,64.
2. American Cancer Society. Urostomy: a guide. www.cancer.org/acs/groups/cid/documents/webcontent/002931-pdf.pdf. Accessed March 31, 2013.
3. Urostomy and Continent Urinary Diversion. Bethesda, MD: National Kidney and Urologic Diseases Information Clearinghouse; 2006. NIH Publication No. 06–5629.
4. Pullen RL Jr. Replacing a urostomy drainage pouch. Nursing. 2007;37:14.
5. SUR-FIT product information. Skillman, NJ: ConvaTec Inc; 2009.
6. United States Patent. Urostomy device. Patent number 3822704. Filed November 20, 1972; issued July 9, 1974.
7. Ortega R, Ng L, Sekhar P, Song M. Female urethral catheterization. N Engl J Med. 2008;358:15-18.
8. Thomsen TW, Setnik GS. Male urethral catheterization. N Engl J Med. 2006;354:22-24.
9. Herter R, Kazer MW. Best practices in urinary catheter care. Home Healthc Nurse. 2010;28:342-349.
10. Robinson J. Urinary catheterisation: assessing the best options for patients. Nurs Stand. 2009;23:40-45.
11. Hart S. Urinary catheterisation. Nurs Stand. 2008;22:44-48.
12. Bermingham SL, Hodgkinson S, Wright S, et al. Intermittent self catheterisation with hydrophilic, gel reservoir, and non-coated catheters: a systematic review and cost effectiveness analysis. BMJ. 2013;346:e8639.
13. Emr K, Ryan R. Best practice for indwelling catheter in the home setting. Home Healthc Nurse. 2004;22:820-828.

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