Urinary Diversion, Stoma, and Continence Care
This domain tests your ability to distinguish diversion types, assess a stoma for viability, teach pouching, and anticipate the metabolic consequences of rerouting urine.
Diversion types
- Ileal conduit: incontinent, right lower quadrant stoma, continuous output with mucus, and the most common diversion.
- Continent cutaneous reservoir (for example an Indiana pouch): catheterizable stoma, capacity typically 400-500 mL, irrigated every 4-6 hours.
- Orthotopic neobladder: urethral voiding by Valsalva, frequent nighttime incontinence, sometimes needing night drainage.
- Nephrostomy and suprapubic catheter for drainage rather than diversion.
Stoma assessment
A healthy stoma is rosy red, moist, and budded. A dusky, pale, or black stoma signals ischemia and is reported immediately. Also watch for retraction, stenosis, prolapse, mucocutaneous separation, parastomal hernia, and peristomal skin breakdown.
Pouching rules
- Measure the stoma and cut the opening about 1/8 inch larger; re-measure because postoperative edema resolves and the stoma shrinks.
- Change every 3-7 days or whenever leakage occurs; use convexity or paste for flat and retracted stomas.
- Clean with water or mild residue-free soap; avoid alcohol, oils, and lotions.
- Empty the pouch at one-third to one-half full.
Continence care
Pelvic floor muscle training, bladder training, timed voiding, fluid and caffeine management, constipation prevention, containment products, and external catheters for men.
Metabolic and long-term risks
Ileal conduit and other bowel segments cause hyperchloremic metabolic acidosis, vitamin B12 deficiency, and stones. Continent reservoirs risk rupture with overdistension, infection, stones, and nocturnal leakage.
Worked example
On postoperative day 1 the stoma is dark purple and firm. Reasoning: this is ischemia, not normal edema; a normal stoma is pink-red and moist. Notify the surgeon immediately, avoid forcing a pouching system onto compromised tissue, and document color, size, and the time of notification.
Traps that cost marks
- Sizing the pouch to the swollen postoperative stoma and never re-measuring.
- Expecting an ileal conduit to be dry between pouch changes.
- Missing nausea, vomiting, or confusion in a neobladder patient, which may signal acidosis or obstruction.
- Failing to ask about body image and sexual concerns.