MANAGING YOUR NEOBLADDER

Your neobladder (“new” bladder) is a storage pouch for urine.  It is made from a segment of intestine.  The ureters are connected to it, so that urine can drain down from the kidneys.  The urethra is connected to it, so that you can pass urine from the neobladder to the outside world.  A catheter is left in the neobladder for 2-3 weeks after surgery, to keep the system decompressed until all of the connections heal.  Once your catheter is removed, you will need to train your neobladder to work properly.

The following pages contain instructions and tips to help you manage your neobladder.  You don’t have to memorize the material…you won’t be quizzed on it!  You may feel a little overwhelmed at first, but eventually you will adapt to the surgical changes and develop your own routine. 

How to pass urine
The process of passing urine will be different now that your bladder has been removed and a new one created.  To safely and efficiently pass urine from your neobladder, you must do two important things:
1)Relax your pelvic floor.
2)Exert pressure on the neobladder by either contracting your abdominal muscles or by pushing down on the neobladder, through the abdominal wall, using your hands (Credé maneuver).

Your pelvic floor is the surface of your body that touches the seat of the chair when you are sitting.  The pelvic floor muscles support the urinary and reproductive organs and surround the urethra. 

When the pelvic floor muscles are contracted, the urethra is pinched off and urine cannot pass through.  When the pelvic floor muscles are relaxed, there is little resistance to passing urine from the neobladder.  Try the following exercise to relax your pelvic floor.

Once you have relaxed your pelvic floor, you should exert pressure on your neobladder by either contracting your abdominal muscles or by pushing down on your neobladder with your hands.  Patients can often empty more efficiently when sitting, however, you can try emptying your neobladder while standing if you prefer.

PROPER POSTURE/TECHNIQUE TO EMPTY YOUR BLADDER:

• Sit on toilet and lean forward, resting forearms on thighs.  Lift heels and rest them on the base of the toilet or place feet on a stool in front of the toilet.
• Keeping lips, jaw, and mouth open will facilitate relaxation of the pelvic floor during urination.
• Breathe in through nose and exhale through mouth or perform gentle hissing through the teeth.  Gently direct the air down and forward towards your neobladder, while contracting your abdominal muscles (bearing down).

   4.  If unsuccessful with emptying your neobladder by contracting
        your abdominal muscles, try the Credé Maneuver.  See
        instructions on the next page.

When to pass urine (void)
In the beginning, the capacity of your neobladder is small.  You will need to follow the steps outlined below, to gradually increase your neobladder’s storage capacity.  You should start this program immediately following removal of your urinary catheter, 2-3 weeks after surgery.

• Week 1 – Urinate every two hours around the clock (you will need to set the alarm to wake you at night)
• Week 2 – Urinate every three hours around the clock (you will   

     need to set the alarm to wake you at night)

• Week 3 – Urinate every three hours while awake and every four hours at night (if you urinate right before going to bed and first thing in the morning, you should only have to get up once in the night)

• Week 4 – Urinate every four hours during the day and night (if you urinate right before going to bed and first thing in the morning, you should only have to get up once in the night)

• After Week 4 – Continue on a four hour schedule during the day, you may want to get up at least once during the night in order to help you keep a little drier. If you do not get up at night, you will not injure the neobladder, but you are likely to be wet in the morning.

Once you have completed this program, your goal is to store no more than 400-500 cc (about 14 ounces) of urine before emptying your neobladder.  The frequency at which you pass urine should be determined by volume.  Chronic overdistension of the neobladder may impair your ability to empty it.

If you were not taught how to catheterize yourself prior to surgery, you will be taught to do so immediately after your surgically placed catheter is removed.  You will need to pass a catheter into your neobladder for the following reasons:
1)  To drain urine if you are unable to pass urine on your own.
2)  To irrigate your neobladder.   
3) To check how efficiently you are emptying your neobladder.  Urinate on your own until you think your neobladder is completely empty.  Then pass the catheter into the neobladder, to drain any remaining (residual) urine.  For the first six weeks after your catheter has been removed, you should check for residual urine  just before you go to bed.  You will need to measure the residual volume and keep a record of it.  If your residual volumes are consistently less than 100 cc, you may then catheterize at bedtime, twice weekly, for a total of 3 months.

You will be given a patient education brochure which outlines the steps for self-catheterization and provides illustrations to help you learn.  You will be given a curve-tip catheter (Coudé) and straight-tip catheter to try.  Use whichever one inserts the easiest.  If you are using a curve-tip catheter (Coude'), remember to insert it with the tip curving up.  If you are using a straight-tip catheter, you need not be concerned about this.  Never force the catheter in because you may cause injury.  If you meet resistance with insertion, pull back a bit, try to relax by taking some deep breaths, and then gently continue insertion.  

You can re-use your catheter as long as you wash it with antibacterial soap and water, rinse it well, and allow it to completely air dry. We recommend that you use a new catheter each week.  If your insurance will cover use of a new catheter daily, do so.

If the catheter isn’t draining well, mucus may be plugging the tip.  You can try irrigating (instructions to follow).  If irrigating doesn’t help, you will have to pull the catheter out, clean off the mucus, and then reinsert it.

This chart is a very important part of evaluating your neobladder function and of assessing your recovery from surgery.  For the first two weeks following catheter removal, you will be keeping a frequency and volume chart.  Our clinic nurses will give you the form.  Instructions for completing it are detailed on the next two pages.  Call us at the conclusion of week #1, to review the results.  We may adjust your directions, depending upon how efficiently you are emptying your neobladder.  Bring the results of week #2 with you to your clinic visit.

The chart allows us to assess how much you normally drink (fluid intake), how much urine you make (urine output), and how often you empty your neobladder on a daily basis.  It will document the storage capacity of your neobladder and tell us how efficiently you are emptying.  There is space to record episodes of urinary leakage (incontinence) as well.  In general, be sure that the volume of fluid you drink exceeds the volume of urine that you void.  If the volume of urine that you void consistently exceeds the volume of fluid that you drink, you will become dehydrated.

Keep the chart with you and fill it out as completely as possible.  You will be given a measuring container that fits right under the toilet seat.  You can also purchase an inexpensive measuring cup if you are going to be away from home and need to measure urine. 

INSTRUCTIONS:

• Record the time for each event 
• Measure and record the volume of fluid intake and urine output in either ounces or cc’s (1cc=1ml).
• Measure and record the catheterized residual volume of urine in your neobladder.  You will do this once daily, at bedtime, for the first six weeks.
• When recording a leak - please record the amount you leaked. 
• Please put your name and date of birth on each page (back and front) of the chart. 

For the first year, we request that you measure and record your fluid intake and urine output for two full days prior to each clinic visit.  Pick days which will be convenient for you.  They DO NOT have to be two days in a row.  On the days that you measure and record, you should pass the catheter, at bedtime, to check for residual urine.  The numbers that you provide will help us to identify problems early on and will allow us to take active measures to correct them.   It is essential that you complete the chart and bring it with you to each appointment, whether it be with the physician or nurse practitioner. 

Urinary incontinence is experienced by all patients initially.  This improves, over time, as your body heals.  Urinary incontinence typically resolves during the daytime hours but may persist, to some degree, at night when you are very relaxed. 

You will need to purchase pads or briefs to protect your clothing.  Pads adhere to your undergarments and are not noticeable through your clothing.  There are several brands of incontinence pads and briefs, including Poise and Depends.  At night, you may initially need a larger superabsorbent pad or combination of pad and brief. 

You can do exercises (“Kegel”) to strengthen and tone your pelvic floor muscles.  “Kegel” exercises can help improve your urinary control and reduce incontinence.  Initially, we encourage you to set aside dedicated times to exercise.  Once you have gained expertise, you will find that you can do these exercises virtually at any time and in any place, even while doing other activities. 

The muscles of your inner thighs and buttocks are NOT the main muscle groups to target.  When you squeeze or tighten your pelvic floor muscles, think of it as pulling your muscles up and in.  Perform both Endurance and Short/Quick Kegel exercises three times daily.

Endurance Kegels
1)Contract (tighten) your pelvic floor muscles and hold the contraction for 3-5 seconds.  Remember to exhale while you are doing this.  Relax for 3-5 seconds.
2)Contract your muscles then relax your muscles, as described above, for a total of 10 repetitions.
3)As your strength and control improve, you will be able to hold the contraction for a longer time interval.  Gradually, try to work your way up to tightening your pelvic floor muscles and holding the contraction for 10 seconds followed by resting your pelvic floor muscles for 10 seconds.  It may take several weeks to work up to a 10 second hold.
4)Once you are able to hold the contraction for a longer time interval, try to increase the number of repetitions from 10 to 15.

Short/Quick Kegels
Each session of Endurance Kegels should be followed by a session of Short/Quick Kegels.
1)Contract your pelvic floor muscles and hold the contraction for 1-2 seconds.  Relax your pelvic floor muscles for 1-2 seconds.
2)Contract your muscles then relax your muscles, as described above, for a total of 5 repetitions.

Your neobladder is constructed from a segment of intestine.  The cells which line the intestines produce mucus.  For this reason, you will notice mucus draining out with your urine.  The mucus may become so thick that it actually prevents you from passing urine.  To prevent obstruction from mucus, we advise the following:
1)Drink plenty of fluids to keep the urine dilute and draining well.
2)Consider using over-the-counter Zantac 150 mg, twice daily.  Some studies suggest that this may reduce mucus production.
3)Irrigate your neobladder.  For the first six weeks following catheter removal, you should irrigate your neobladder each time you pass the catheter to check your residual urine volume.

The following procedure should be used to irrigate your neobladder.  You may use either sterile water or sterile normal saline.  Pass the catheter into your neobladder, as described above.

• Wash your hands.
• Draw up 40 to 60 cc of sterile water/saline in the syringe provided for you.
• Insert the catheter into your neobladder.
• Place the tip of the syringe into the funnel-shaped end of the  catheter.
• Steadily inject the sterile water/saline into the catheter.  Do not force the water in as this can cause discomfort.

• Withdraw the water/saline from your neobladder with the syringe.

          Watch for mucus (mucus is what you want to see).

• This process may be repeated several times. Once you can no

          longer withdraw mucus, you may stop for that particular irrigation.

• After you have completed each irrigation, wash the syringe with anti-

         bacterial soap and hot water, Take the plunger out of the barrel and
         clean all surfaces well.  Let all surfaces airdry.  Reassemble, wipe       
         the tip with alcohol, and recap it.

• If your catheterized residuals are more than 100 cc, call us.   
• Constipation makes it more difficult to empty your neobladder.  Do what you can to keep your stools soft and formed.  You may require use of stool softeners or fiber.  Keep yourself well-hydrated.  Natural juices and prunes are good to help with softening your stool, check with your doctor if you are diabetic.  Walking is an excellent way to stimulate bowel activity. 
• Relaxing your pelvic floor muscles is key to emptying your neobladder completely.  Sitting on the toilet seat, as opposed to standing to urinate, may help you to relax better.  For women, facing the back of the toilet seat, as opposed to facing forward, may help you to relax better.  Don’t be afraid to experiment.
• Be vigilant about bladder habits, particularly within the first year of your recovery.  Overdistension of your neobladder should be avoided.  Empty your neobladder routinely and completely.
• Keep yourself well-hydrated to keep the mucous thin.  Irrigate your neobladder when you notice that mucous production has increased or if you have to strain more to evacuate urine. 

• If you develop fever (101˚F or higher) or chills
• If you have persistent pelvic or back pain
• If your urine becomes foul-smelling
• If you notice blood in the urine
• If you can’t empty your neobladder or drain it with the catheter

If you have any questions or concerns, please do not hesitate to call:
Clinic Nurses                         (734)647-8903
Sharon Clow
Vicki Davidowitz
Julie Derossett
Vic Hola

Nurse Practitioners
Deb Crider                             (734)615-3766
Kathleen Fasing                    (734)647-3248
Opal Lesse                                      (734)904-5709
Staci Mitchell                         (734)615-4340
Nancy Rodriguez-Galano    (734)615-4831

Urgent matters that arise during non-business hours can be addressed with the urology doctor on-call, through the paging operator (734)936-4000.

The illustrations and photographs in this booklet are by Wendy Baker, R.N.

© Team 3 Urology Staff and Pelvic Floor Physical Therapists  July 2009, revised August 2010.