7.3 Continent Diversion Management: Catheterization, Irrigation & Troubleshooting

Continent Diversion Management: Catheterization, Irrigation & Troubleshooting

Quick Summary: A continent diversion trades an external pouch for a schedule and a catheter. The nurse's job shifts from appliance engineering to teaching a lifelong routine, recognizing when the routine is failing, and knowing which failures are emergencies.

The Common Architecture

Every continent diversion has three parts: a detubularized low-pressure reservoir built from bowel, a continence mechanism that resists outflow, and a catheterizable channel ending in a small, flush, skin-level stoma — or, for an orthotopic neobladder, an anastomosis to the native urethra.

Important: IPAA is frequently miscategorized. It is a continent reconstruction, but it is not catheterized. Patients defecate per anus, typically 4 to 8 times daily, and the characteristic complication is pouchitis, treated first-line with ciprofloxacin or metronidazole.

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Catheterization Schedules

Schedules start tight and lengthen as the reservoir stretches and its capacity increases.

Continent urinary reservoirs (Indiana, Mainz):

• Initially every 2 to 3 hours around the clock, including at least once overnight.
• Progressing over roughly 3 to 6 months to every 4 to 6 hours.
• Catheter size commonly 14 to 18 French; larger bore resists mucus occlusion.

Continent ileostomies (Kock, BCIR):

• Initially every 2 to 3 hours, lengthening as the pouch matures.
• Eventually 3 to 4 times daily for most patients.
• Catheter size commonly 28 to 30 French, because fecal effluent is far thicker than urine.

Warning: Never allow the reservoir to over-distend. These are surgically constructed pouches without the compliance or sensation of a native bladder. Over-distension stretches suture lines and risks spontaneous perforation, which presents as abdominal pain, distension, fever, and sepsis, and carries significant mortality. Patients must catheterize on the clock, not on sensation — the sensation may be a vague fullness or nothing at all.

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Irrigation: Mucus Is the Enemy

Reservoirs built from bowel produce mucus continuously. Mucus thickens, plugs catheters, and can obstruct the outflow channel.

Routine irrigation:

• Instil 30 to 60 mL of normal saline or tap water through the catheter after emptying, then allow it to drain by gravity or withdraw it gently.
• Repeat until the return runs clear.
• Perform once or twice daily routinely, and additionally any time drainage slows or the return looks thick.
• Maintain fluid intake of 2 to 3 litres daily — dilution is the cheapest mucus control there is.

For a continent ileostomy, irrigation with 30 to 50 mL of water or saline is used both to clear mucus and to soften thick effluent that will not drain.

Stoma care between catheterizations: the stoma is small and flush and is covered with a simple absorbent pad, gauze dressing, or stoma cap, not a pouching system. It should stay clean and dry; a small amount of mucus on the pad is normal.

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Troubleshooting Difficult Catheterization

Work through this sequence, and teach it to the patient explicitly.

1. Relax and reposition. Sit, breathe out, relax the abdominal wall. Change the angle of insertion — the channel usually has a curve.
2. Re-lubricate generously. Under-lubrication is the commonest simple cause.
3. Rotate the catheter gently as it advances; do not push harder.
4. Try a fresh catheter, in case the tip is deformed or plugged.
5. Try the next size, if the patient has been taught this and it is within their surgeon's instructions — a larger catheter often passes better through a mucus-filled channel than a smaller one.
6. If it still will not pass, stop.

Warning: Failure to intubate a continent diversion is an emergency. The reservoir has no other way to empty. The patient must never force the catheter, because forcing risks perforating the channel or the pouch. They must contact the surgeon or go to an emergency department immediately, and they should carry a card explaining that only someone familiar with the diversion should attempt catheterization. The usual cause is valve slippage or desusception of the nipple valve, which requires operative repair.

Patients must be taught to carry catheters, lubricant, and syringes at all times, keep a spare set in a car or workplace, and wear medical alert identification describing the diversion.

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The Orthotopic Neobladder

A neobladder is anastomosed to the native urethra, so the patient voids per urethra — but the physiology is entirely different from a native bladder.

• There is no detrusor contraction. Emptying is achieved by relaxing the pelvic floor and applying gentle Valsalva, ideally seated.
• There is no normal sensation of fullness, so voiding is timed: roughly every 2 to 3 hours during the day and every 3 to 4 hours at night, with an alarm set overnight.
• Nocturnal incontinence is common and expected, particularly in the first year, because the reflex arc that wakes a person with a native bladder is absent and the pelvic floor relaxes in sleep. Continence improves over 6 to 12 months with pelvic floor muscle training.
• Mucus must be cleared; some patients need intermittent catheterization and irrigation to do so.
• Incomplete emptying produces retention, infection, and stone formation, and may require clean intermittent self-catheterization long-term. Patients must be taught this possibility before surgery, because discovering it afterward is a major source of regret.

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Long-Term Surveillance

Exam Tip: When an item describes a patient with a continent diversion who "cannot get the catheter in," the correct answer is never a nursing manoeuvre repeated with more force. It is to stop, not force, and escalate urgently.