BLADDER IRRIGATION

INTRODUCTION

Bladder Irrigation is a procedure to wash out the inside of the bladder. Flushing the augmented
or neobladder is sometimes needed to remove the excess mucus that is created by the intestine
that is now in the bladder. This helps the urine to drain freely through the catheter and keep the
catheter from being plugged with mucus, helps to prevent infections and stones.

DEFINITION
Irrigation is a procedure used to wash out the bladder. The bladder will be irrigated ( flushed)
with saline(salt water) to keep the urine draining freely through the catheter and to keep the
catheter from getting plugged.
PURPOSES
 To cleans the bladder from decomposed urine, bacteria, excess of mucus, pus and blood
clots.
 To maintain the patency of the urinary catheter.
 To relieve congestion and pain in case of inflammatory conditions by the application of
heat.
 To promote healing.
 To prevent the clot formation in case of bladder surgeries.
 To prevent and treat infections.
 To arrest bleeding
TYPES OF BLADDER IRRIGATION
 Manual bladder irrigation
 Continuous bladder irrigation
MANUAL BLADDER IRRIGATION
 Manual bladder irrigation is used for clearing clot retention
 Catheter blockage is a very common complication in long term catheter users.
 Up to 50% of long term catheters are changed prematurely due to catheter blockages
Signs of a blocked catheter
 No urine flow from the catheter

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  Patient complaining of suprapubic pain, becoming more pronounced as the bladder fills
 If unrelieved vaso-vagal symptoms may develop ie sweating ,tachycardia and
hypotension
 Bypassing around the catheter
Equipments
 Dressing pack x1
 Catheter tip 50ml syringe x1
 Chlorhexidine swabs 70% alcohol
 Blue under sheet
 Unsterile jug
 500ml bottle Normal Saline
 PPE- sterile gloves, goggles and apron
Procedure
 Explain to patient
 Maintain asepsis (this is done as an aseptic procedure to prevent a UTI as the closed
urinary drainage system is being broken)
 Place blue sheet under the catheter and drainage bag connection
 Prepare sterile setup with 500ml N/S in kidney dish
 Place unsterile jug on bottom of trolley
 PPE and sterile gloves
 Using 50ml volumes of normal saline, irrigate the catheter by flushing in and drawing
back to evacuate any clot or debris. If resistance is encountered reasonable pressure can
be used, (except following renal transplant or bladder surgery).
 Empty each returned syringe directly into the unsterile jug on the bottom of the trolley
 Continue to irrigate with 50ml volumes until you achieve a clear or clot free return
 Reconnect catheter to drainage bag without contaminating either Calculate the difference
between volume infused and volume returned and record on the fluid balance

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CONTINUOUS BLADDER IRRIGATION
Purpose
To prevent blood clot formation, allow free flow of urine and maintain patency, by continuously
irrigating the bladder with Normal Saline
Articles
 3way catheter
 0.9% sodium Chloride irrigation bags as per facility policy
 Continuous bladder irrigation set and closed urinary drainage bag with antireflux valve.
 Alcohol wipes
 Non sterile gloves
 Personal protective equipment (PPE)
 Under pad
 IV pole
Procedure
 Explain procedure to the patient and ensure patient privacy
 Position the patient for easy access to the catheter whilst maintaining patient comfort
 Ensure that the patient has a three-way urinary catheter.
 Hang irrigation flasks on IV pole and prime irrigation
 set maintaining asepsis of irrigation set
 Don goggles and impervious gown , place underpad underneath catheter connection
 Attend hand wash and don non-sterile gloves
 Swab IDC irrigation and catheter ports with alcohol swabs and allow to dry

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 Open the irrigation lumen of the catheter. Connect the irrigation set to the irrigation
lumen of the catheter, maintaining clean procedure
 Ensure urine is draining freely before commencing continuous irrigation.
 Unclamp the irrigation flask that was used to prime the irrigation set and set the rate of
administration by adjusting the roller clamp.

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Documentation
Record in the progress notes
a) Date and time of procedure
b) Indication for the manual irrigation including the patients’ clinical symptoms
c) Result of irrigation i.e. volume of return, describe output/clots/debris and also colour of urine
d) On the fluid balance chart record volume infused, volume returned and the difference being
urine volume
General instructions
 Should not be done without written order.
 As far as possible, bladder irrigation are avoided.
 The safest and most effective means of irrigating the urinary system is by “internal
irrigation”
 The fluid should be instilled gently and allowed to drain back by gravity.
 If the fluid flows easily into the bladder but fails to return, there is a clot over the eye of
the catheter

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  In such situation no more fluid is introduced into the bladder but try to dislodge the clot
by milking the tubing.
 All the articles that are used for the irrigation must be sterile.
NURSES RESPONSIBILITY
Before
 Check for order
 Inform the patient
 Arrange articles
 Comfortable position
 Privacy
 Hand washing
 Expose only the area
During
 Maintain aseptic technique
 Follow all the steps
 Use only recommended solutions
 Arrange the flow rate for CBI
 Make sure that the fluid is coming back
After
 Clean the area
 Replace the articles
 Regular catheter care should be given to CBI pt.
 Watch for any contraindications
 Record and report the procedure
COMPLICATIONS
Infection
 Urinary tract offer a favourable environment for the multiplication of bacteria because it
is dark, moist & warm .
 Injury to the mucosa of the bladder leads to growth of the bacteria in bladder. Changing
the pH value of urine by medication .force of the flow cause injury.

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Tissue trauma
 During the insertion of the catheter & procedures applied to the bladder , tissue trauma
may take place .even the slight movement of the catheter can cause tissue trauma &
breakdown.
Urethral irritation
 Symptoms include burning sensation & pain at urethral meatus will be experienced
especially by the male patient due to indwelling catheter.
Bladder spasm
 Bladder spasm may occur due to the balloon of an indwelling catheter resting directly on
the bladder neck.
 Forcing fluid more than what is tolerable by the patient will lead to muscle spasm &
pain.

OSTOMY CARE
UROSTOMYA 
 Urostomy (urinary ostomy) is an opening on the belly created by a urinary
diversion surgery that acts as the new exit point for urine.
 A urinary diversion surgery is needed when the bladder malfunctions due to
disease or damage.
 The surgery redirects the flow of urine to bypass the bladder and exit through
the urostomy.
 Before the surgery, urine would flow from the kidneys through the  ureters to
the bladder; from there it would flow through the urethra and exit the body at
the urethral opening. 
 After the surgery, urine flows from the ureters to the urostomy, passing
through a pouch surgically made from the person’s intestines.
 The diseased bladder is removed or by-passed.Urostomy is not to be confused
with a colostomy or ileostomy, both of which diverts the fecal flow, not the
urine flow.

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  All of them are subcategories of ostomy, which refers to the opening on the
belly where either stool or urine leaves the body.

STOMA
 All kinds of ostomy will have
a stom a. While ostomy refers to the
opening on the belly, stoma
refers to the bit of intestine that is
pulled through the ostomy and sewn onto the outside of the belly.

 You can see it as the pink fleshy tissue that surrounds your ostomy.

  For colostomy, a part of the colon is made into the stoma, but for ileostomy
and urostomy, a part of the ileum is made into the stoma. 
URINARY DIVERSION TYPES
 There are three main ways to divert the flow of urine away from the bladder:
creating a continent catheterizable pouch, an ileal conduit, or a neobladder.
 The biggest difference between them is whether or not they are continent, and
whether or not they have a stoma.
The Indiana pouch: a type of Continent Catheterizable Urine Pouch

 A continent catheterizable urine pouch refers to a pouch made out of part of

the person’s intestines, which holds urine inside the body much like a
bladder, but differing from a bladder, it cannot sense when it’s full to
contract and push the urine out.

 An intermittent catheter must be passed through the stoma and into the pouch
to drain it several times a day. 

 A very common type of continent catheterizable pouch is called the  Indiana

pouch, which is made of roughly ⅓ of the person’s big intestines—the

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 ascending colon and the cecum, and a small section of the small intestines—
the ileum.
 During an Indiana pouch surgery, the ascending colon and cecum are made
into the pouch, while the ileum is pulled through the urostomy and sewn onto
the outside of the belly, forming the stoma.  

 The ureters, the two tubes that carry urine from the kidneys to the bladder are
cut off from the bladder and re-sewn onto the Indiana pouch.

 The Indiana pouch is continent, meaning urine will not leak out involuntarily.
The ileocaecal valve holds the urine in.

 However, one cannot voluntarily pass urine by contracting the Indiana pouch,
and thus needs intermittent catheters. 

The Neobladder 

 When the bladder is removed (cystectomy), a  neobladder (new bladder) can

be surgically created to take its place.
 The neobladder is also created from parts of the intestines, but what’s
different about the neobladder is it does not require a stoma to drain. No
urostomy is created during a neobladder construction surgery . 
 The neobladder takes the same place that your old bladder did. The ureters
and urethra are sewn onto the neobladder, so the urine flows from the kidneys
to the neobladder, then into the urethra and out of the body.
 There is no need for a stoma. With training, you can urinate like usual.  

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  However, urinary retention and leakage are often complications of the
neobladder, especially at first. Therefore it’s likely that your doctor would
instruct you to use intermittent catheters for a while.

UROSTOMY CARE AND STOMA CARE

 Urostomy care is very important. Different types of urostomy requires

different types of care.
 Caring for your urostomy first requires caring for your stoma.  
 The stoma is made from a part of your small intestine, ileum, which has no
nerve-ending but is still very delicate. If it’s scrapped or cut you would see
white or yellow lines on it. The stoma is vulnerable to irritations and
infections, here are some tips to take good care of it (tips mentioning pouch
are for ileal conduits): 
 Right after the surgery, don’t do anything strenuous. Don’t lift anything more
than 10 pounds for four weeks. 
 Always wash your hands before touching the stoma or areas around the
stoma.
 Washing around the stoma with water is enough, but you can use mild
unscented soap if you want. If you wear a pouch, rinse well because soap can
affect the adhesiveness of the skin barrier.  
 Before you decide on a pouch, patch test the area around your stoma for
different types of adhesive to see if you have any allergic reactions.  
 Find the right-fitting pouch system for yourself; ask for help from the ostomy
nurse if you have trouble doing so. 
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  Closely monitor your stoma’s color, size, discharge, and the skin around it.
Know what is normal and what is not. You should’ve been thoroughly
educated by your ostomy nurse (also see below to remind yourself).

Caring for an Indiana Pouch  

For several weeks or even months after the surgery, you may
experience problems with 
 Leaking: this is normal as your pouch is still learning to hold urine
 Leaking at night: if your pouch is not leaking during the day but leaking at
night, try to cut back on consumption of liquids right before sleep, or
catheterize right before sleep.
 Frequent catheterization : you may find yourself catheterizing frequently in
the first few weeks. This is normal as the pouch is still adjusting to hold more
liquid. 
 Difficult catheterization: the stoma and the channel leading up to your
pouch can be irritated by frequent catheterization, leading to the swelling and
obstruction of the catheter’s passage. This problem should resolve on its own
after your body is more used to catheterization.  
 Difficult catheterization (continued): sometimes the catheter cannot pass
because your abdomen muscles are tense due to nervousness or a tense body
position. Experiment with different positions and try to relax as much as
possible. 
 Blood in urine: a small amount of blood from time to time is normal and is
likely due to irritation from the catheter. However, if the amount becomes
concerning (dark urine), please notify your physician.  
 Incomplete drainage: the urine is chronically incompletely drained, it can
form crystals and eventually stones. The retained urine can also increase your
chance of getting an infection.  
 Thick mucus discharge: you may notice a lot of mucus coming out of the
stoma, sometimes even blocking the catheter from draining. This is normal,
but to avoid it, you can drink plenty of water and  irrigate your pouch to

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 prevent mucus built-up. It is generally recommended that you irrigate your
pouch one a day. Check with your doctor for what’s right for you.  
 Infections: infections can occur when urine is not drained frequently or
completely. They can also occur when the catheter is contaminated by the
user’s hands. Watch out for foul-smelling, cloudy, or dark urine as this is a
common symptom. 
 Notify your doctor or ostomy nurse if anything concerns you. Don’t be shy
about talking to them. Although online sources can offer advice, only they
know your particular situation well.  

As an overview, here are the things you should be doing to take care of your Indiana
pouch:

 Drink plenty of water to avoid infections and mucus built-up

 Never force a catheter in. If a catheter is not going in, take a few deep
breaths, relax, and change position if necessary. Forcing a catheter can
damage the pouch channel.
 Lubricate the catheter before insertion or use a  pre-lubricated catheter to
avoid irritating the pouch channel.  
 Wash your hands before handling the stoma or a catheter. Use a  no-touch
catheter to decrease the risk of contamination.  
 Irrigate the pouch according to the doctor’s instructions.
 Try to achieve complete drainage. To do this, first ensure that mucus will not
block the catheter. Once you’ve inserted the catheter a few inches into the
pouch, pull out inch by inch, and each time you pull out an inch, wait till all
fluids have drained to pull out another inch. Rotate the catheter slightly as
you pull out. Do not rotate if you are using a coudé catheter.
 Watch out for signs of infections: cloudy, dark, foul-smelling urine, lower
back pain, fever, vomiting, and chills.  

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  If you are struggling with catheter insertion and frequent infections, check
out this catheter that is non-touch and pre-lubricated with anti-bacterial
silicone oil.
 Pre-lubrication makes insertion hassle-free, and not touching the catheter
tube can decrease the chance of catheter contamination  
Ileal Conduit Care
An ileal conduit requires a different way of caring than the Indiana pouch because
urine is emptied into an ostomy pouch rather than drained by a catheter.  
 Most problems associated with ileal conduit come with an ill-fitting pouch
system which can result in irritated stoma and skin.  
 Here are some tips to avoid skin and stoma irritations:
Use a correct-fitting pouch system for your stoma:
 This might be especially difficult at first when you are still learning, and the
newly-made stoma is in the progress of shrinking down after the surgery.
Some people’s stomas fluctuate in size long after their surgery.
 Notify your doctor or ostomy nurse when your stoma changes over half an
inch in size over a single day, as that might indicate a problem.
 Here is a more detailed guide on how to measure your stoma.
 A pouch opening that is too large can cause urine to leak and irritate the
skin, an opening that is too small can cut or injure the stoma causing it to
swell.
 Change the pouching system once a week or more to avoid leaks and skin
irritation.
 If there is itching and burning around your stoma, it is a sign for you to
change the pouching system and clean your skin.
 Be gentle when removing the pouch system.
 Do not rip the skin carrier off but peel it away gently.
 Don’t remove the pouching system more than once a day unless there is an
issue. 

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  Cleaning the stoma and skin with water is enough. If you wish to use soap,
rinse well as soap might affect the adhesiveness of the skin barrier. Pat the
skin dry before putting on the skin barrier and pouch.
 Look out for allergic reactions or sensitivities. Even if you’ve used the same
products for years, sensitivities and allergies can develop spontaneously. If
this happens, you can use a pouch of different material, or use a pouch cover.

Neobladder Care
 A neobladder is made of your intestines and functions differently than a
normal bladder.
 You would need a foley catheter during your stay in the hospital and for a
while after you go home. Afterward, you will switch to urinating on your
own, sometimes with the aid of intermittent catheters.
 You may experience urinary retention and urinary leakage during the time
your neobladder is adjusting. Eventually, you can urinate like usual.  
 To care for your neobladder, drink plenty of fluids to avoid mucus built-up
and UTIs and irrigate the catheter per doctor’s instructions.
 Wear pads and absorbent clothing as your neobladder may leak.   
 Because a neobladder does not contract like a normal bladder, you need to
push down on it to help squeeze the urine out and simultaneously relax your
abdominal and sphincter muscle to allow urine to exit.   

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 At first, you would have trouble emptying the neobladder completely, so your
doctor may ask you to drain residual urine with a catheter and to keep track
of the volume of residual urine.
 Your physician may instruct you to stop using a catheter when you have
demonstrated a consistent low level of residual volume.  
 If you drain more than 150 cc’s of residual urine, you should contact your
physician as this might be a problem

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