7.1 Urostomy Management: Mucus, Stents, Night Drainage & Specimen Collection

Urostomy Management: Mucus, Stents, Night Drainage & Specimen Collection

Quick Summary: A urinary diversion never stops draining, which changes almost every practical rule the nurse learned on fecal stomas. The pouch has different engineering, the change technique requires continuous wicking, and the single most consequential piece of patient teaching — mucus is normal — is the one most often skipped.

The Urostomy Pouching System Is Purpose-Built

Empty at one-third to one-half full. Fluid is dense, and an over-full pouch pulls the wafer off the abdomen under its own weight.

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Mucus: The Teaching Point Patients Are Never Warned About

The conduit or reservoir is made of bowel, and transposed intestinal segments retain their goblet cells. They secrete mucus for life. Patients who are not warned reliably interpret white shreds in the pouch as pus and present to emergency departments convinced they are infected.

Teach explicitly:

• Mucus strands and cloudy flecks in urine are normal and permanent.
• Fluid intake of 2 to 3 litres daily dilutes mucus so it cannot thicken, plug a catheter, or encrust.
• Mucus production is usually heaviest in the early postoperative months and then settles.
• What is not normal: fever, chills, flank or back pain, foul odour with systemic symptoms, frank blood, or a marked drop in output.

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Ureteral Stents

After the ureters are anastomosed to the conduit, soft ureteral stents are usually left in place to maintain patency and decompress the renal pelvis while the anastomoses heal. Typically:

• One stent per ureter, so each drains one kidney.
• They exit through the stoma lumen and are often secured with a suture at the mucocutaneous junction.
• They remain in place roughly 7 to 14 days, then are removed by the surgical team — sometimes simply sliding out spontaneously.

Nursing responsibilities:

• Never pull, reposition, or trim a stent.
• Cut the barrier aperture generously so the stents are not kinked or compressed by the wafer edge, and consider a two-piece system so the pouch can be removed to inspect without disturbing the wafer.
• Monitor drainage from each stent. Mucus can occlude a stent. A sudden reduction in overall output, or output that appears to come from only one stent, needs prompt reporting — obstruction of a single kidney is silent until it is not.
• Track hourly output postoperatively. Sustained output below roughly 30 mL/hour warrants notification.
• If a stent falls out, do not attempt reinsertion; secure it, note the time, and notify the surgeon.

Important: Do not confuse stents with the conduit. Stents drain the ureters temporarily. The conduit is permanent. Once stents are removed, urine simply drains from the ureteral anastomoses into the conduit, and output should not fall.

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Night Drainage

Overnight, urine accumulates faster than the pouch capacity, and the weight of an over-full pouch is one of the leading causes of nocturnal leakage and 3 a.m. bed changes.

Setup:

1. Empty the pouch before connecting.
2. Attach the drainage tubing to the pouch outlet using the adapter supplied with the system.
3. Hang or place the collection bag below the level of the stoma — on a bedside frame, a stand, or in a basin on the floor — so gravity drains and urine cannot reflux.
4. Ensure the tubing is not kinked, trapped under the patient, or looped above the level of the stoma, where a fluid lock will stop flow.
5. Leave a small amount of urine in the pouch when connecting, which helps prevent the anti-reflux valve from sealing shut against an empty pouch.

Cleaning the night bag: rinse with cool water after each use, then wash with a solution of 1 part white vinegar to 3 parts water — or per manufacturer instruction — to control odour and crystal deposits, and hang to air dry. Replace the drainage system per manufacturer guidance, commonly every 2 to 4 weeks.

A leg bag serves the same function for daytime use in patients with high output or limited mobility.

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Alkaline Urine and Encrustation

Urea-splitting organisms such as Proteus raise urinary pH above 7, and phosphate crystals then precipitate onto the stoma and peristomal skin. The result feels gritty or like sandpaper, may bleed on contact, and progresses to pseudoverrucous lesions if unaddressed.

Management is the same triad used for pseudoverrucous lesions: increase fluid to 2 to 3 litres daily, apply dilute white vinegar compresses of 1 part vinegar to 3 parts water for 5 to 10 minutes at appliance changes, and verify that the aperture is correctly sized so skin is not chronically bathed. Culture the urine if pH remains high.

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Obtaining a Urine Specimen from an Ileal Conduit

This is a named blueprint skill and a reliable exam item.

Warning: Never send urine collected from the pouch. The pouch is colonized within hours of application, and a pouch specimen will grow organisms regardless of whether the patient has an infection. Acting on that result exposes the patient to unnecessary antibiotics and resistance.

Procedure — catheterized (double-barrelled) specimen:

1. Explain the procedure and position the patient supine or semi-recumbent.
2. Perform hand hygiene and set up a sterile field; use sterile gloves.
3. Remove the pouch. Cleanse the stoma and surrounding skin with water or normal saline — antiseptics that run into the conduit can contaminate the sample and irritate mucosa.
4. Wick the stoma with sterile gauze and discard the first urine, which is contaminated by the pouch surface.
5. Lubricate a sterile straight catheter, commonly 14 French, with water-soluble lubricant.
6. Insert gently about 5 cm (2 inches) into the stoma lumen, following the direction of the conduit. Never force. If resistance is met, withdraw slightly, redirect, and try again; if it still will not pass, stop and escalate.
7. Allow urine to drip into a sterile container. Collection is slow — 5 to 10 mL may take several minutes, and that is expected.
8. Remove the catheter, reapply a new pouching system, and label and transport the specimen promptly.

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Colonization Versus Infection

Every urinary diversion is colonized. Asymptomatic bacteriuria in a urostomy is not treated. Treating it selects resistant organisms without benefit.

Upper-tract symptoms carry the weight, because in a diversion there is no bladder to buffer an ascending infection — a conduit infection reaches the kidneys quickly. Teach patients to report fever, flank pain, and chills rather than to judge by appearance of the urine.