Use of a Convex Pouching System in the Postoperative Period: A National Consensus.

Convex pouching systems have been available for ostomy patients for decades; however, controversy remains over the use of convexity in the postoperative period. A group of 10 nurses and physicians with expertise caring for patients with an ostomy completed a scoping review identifying research-based evidence and gaps in our knowledge of the safety and effectiveness related to the use of a convex pouching system following ostomy surgery. Results of this scoping review demonstrated the need for a structured consensus to define best practices when selecting a pouching system that provides a secure and reliable seal around the stoma, avoids undermining and leakage of effluent from the pouching system, and contributes to optimal health-related quality of life for patients following ostomy surgery. The expert panel reached consensus on 8 statements for the use of convex products immediately after surgery and throughout the first 6 months after stoma creation, as well as describing goals in choosing the best pouching system for the patient with an ostomy.

Modified Whitaker test: a novel diagnostic for nephroptosis.

A 77-year-old woman presented with right flank pain radiating to the ipsilateral groin and associated nausea, consistent with renal colic. In the emergency department, a non-contrast CT scan revealed severe right-sided hydronephrosis but failed to demonstrate a calculus or ureteropelvic obstruction. The patient improved with fluids and followed up with a community urologist. Initial work-up with cystoscopy and ureteroscopy, voiding cystourethrogram and diuretic renography failed to deduce a diagnosis. At our hospital, we used a modified dynamic (supine and upright) Whitaker test in a novel fashion to diagnose nephroptosis, a rare hypermobility condition of the kidney.

Peristomal Medical Adhesive-Related Skin Injury: Results of an International Consensus Meeting.

Stomal and peristomal skin complications (PSCs) are prevalent in persons living with an ostomy; more than 80% of individuals with an ostomy will experience a stomal or peristomal complication within 2 years of ostomy surgery. Peristomal skin problems are especially prevalent, and a growing body of evidence indicates that they are associated with clinically relevant impairments in physical function, multiple components of health-related quality of life, and higher costs. Several mechanisms are strongly linked to PSCs including medical adhesive-related skin injuries (MARSIs). Peristomal MARSIs are defined as erythema, epidermal stripping or skin tears, erosion, bulla, or vesicle observed after removal of an adhesive ostomy pouching system. A working group of 3 clinicians with knowledge of peristomal skin health completed a scoping review that revealed a significant paucity of evidence regarding the epidemiology and management of peristomal MARSIs. As a result, an international panel of experts in ostomy care and peristomal MARSIs was convened that used a formal process to generate consensus-based statements providing guidance concerning the assessment, prevention, and treatment of peristomal MARSIs. This article summarizes the results of the scoping review and the 21 consensus-based statements used to guide assessment, prevention, and treatment of peristomal MARSIs, along with recommendations for research priorities.

Ostomy care and management: a systematic review.

The frequency of ostomy surgery in Canada is not known, but it is estimated that approximately 13,000 ostomy surgeries are performed annually in Canada. This systematic review incorporates evidence for the assessment and management of colostomies, ileostomies, and urostomies, as well as the peristomal skin. The review was completed as part of a best practice guideline document generated by a task force appointed by the Registered Nurses' Association of Ontario.

Bladder perforation in augmentation cystoplasty during urodynamic investigation: a case report and review of the literature.

BACKGROUND: Spontaneous bladder rupture is a known complication of augmentation cystoplasty. We report the second case of bladder rupture during filling cystometry many years after bladder augmentation and the first case occurring in a patient with an autoaugmentation cystoplasty. In addition, the management and outcome for a bladder perforation in an autoaugmentation cystoplasty will be discussed. CASE: A 20-year-old male with a history of an L4 myelomeningocele underwent an autoaugmentation cystoplasty for neurogenic bladder dysfunction and decreased bladder wall compliance five years previously. He self catheterized four times daily. During filling cystometry, detrusor pressure increased to 60 cm H(2)O with 300 mL filling. Detrusor pressure then rapidly decreased to 20 cm H(2)O without evidence of external leakage. The infusion was immediately stopped and X-ray showed intraperitoneal leakage of contrast material. Serial abdominal examination demonstrated worsening abdominal distension. Exploratory laparotomy revealed a 2 cm perforation within the autoaugment portion of the bladder. CONCLUSION: An autoaugmentation cystoplasty improves bladder compliance and capacity with the use of native urothelial tissue. Although perforation after autoaugmentation has not been previously reported, caution must be used during urodynamic evaluation in patients with decreased bladder wall compliance and augmentation cystoplasty.

Traces: making sense of urodynamics testing--Part 9: Evaluation of sensations detrusor response to bladder filling.

Part 9 of the Traces series continues the discussion of how urodynamic clinicians generate usable data from a filling cystometrogram. This article focuses on the question: "What is the detrusor's response to bladder filling?" Answering this question requires the clinician to identify and differentiate detrusor contractions from abdominal events, artifacts, or low bladder wall compliance; documentation of the volume of the contraction; and assessment of its clinical relevance as an overactive or subclinical detrusor contraction.

Traces: making sense of urodynamics testing--part 7: Evaluation of bladder filling/storage: Evaluation of urethral sphincter incompetence and stress urinary incontinence.

The "Traces" series discusses how the urodynamic clinician generates usable data from a filling cystometrogram. Part 7 focuses on the question, "Is the urethral sphincter mechanism competent?" From a practical viewpoint, this question can be divided into two queries: 1) does this patient have observable urodynamic stress urinary incontinence (SUI), and 2) does this patient have intrinsic urethral sphincter incompetence, also referred to as intrinsic sphincter deficiency or a low pressure urethra? Signs of SUI include clinician observation of urine loss with coughing or during Valsalva's maneuver. Urodynamic SUI is the observation of urine loss with increased abdominal and intravesical pressures in the absence of a detrusor contraction. The most commonly used techniques for assessment of urethral sphincter function and SUI are the urethral pressure profile and the abdominal leak point pressure. Both are useful for answering these queries, but both tests are vulnerable to physiologic and technical artifacts that must be minimized to produce technically accurate and clinically meaningful results.

Traces: making sense of urodynamics testing--Part 6: Evaluation of bladder filling/ storage: bladder wall compliance and the detrusor leak point pressure.

This article defines the concept of bladder wall compliance, discusses various means of measuring or assessing compliance, and reviews its clinical relevance. Based on existing evidence, low bladder wall compliance is attributable to increased detrusor muscle tone during bladder filling or changes in the viscoelastic properties of the bladder wall that impede the bladder wall's ability to stretch. While one can identify the individual components that compromise compliance, the filling CMG is only able to detect whole bladder wall compliance (for example, the combined effects of increased detrusor muscle tone and compromised viscoelastic properties of the bladder wall). From a clinical perspective, whole bladder wall compliance is divided into two categories: normal and low. Low bladder wall compliance is clinically relevant because of its potential to produce upper urinary tract distress, and there is increased risk for febrile urinary tract infections, ureterohydronephrosis, vesicoureteral reflux, renal scarring, compromised urinary tract function, and urinary incontinence because of its direct influence on the bladder outlet. It may produce pain and pressure in the patient with preserved sensations of bladder filling. Low bladder wall compliance is associated with a variety of clinically relevant disorders, including neurogenic bladder dysfunction, pelvic irradiation, interstitial cystitis, and radical prostatectomy.

Traces: making sense of urodynamics testing--Part 5: evaluation of bladder filling/storage functions.

Lower urinary tract function is characterized by two stages: bladder filling/ storage and micturition. Natural bladder filling tends to be slow, intermittent, and variable, while urodynamics testing employs a continuous, supraphysiologic fill rate. A clear understanding of the typical proportion between bladder storage and micturition is essential when urodynamics findings are interpreted within a clinical setting. When completing a filling cystometrogram, the urodynamics clinician must answer five essential questions to generate clinical meaningful results: bladder capacity, bladder wall compliance, competence of the urethral sphincter mechanism, sensations of bladder filling, and detrusor response to bladder filling/storage. While the emphasis of each question differs depending on the patient's lower urinary tract symptoms and specific questions posed by the referring physician, the combined answers to these questions form a comprehensive evaluation of lower urinary tract filling and storage functions. This article will address how the urodynamic clinician answers the first question, "What is the capacity of this bladder?"

Optimizing treatment outcomes with phosphodiesterase type 5 inhibitors for erectile dysfunction: opening windows to enhanced sexual function and overall health.

PURPOSE: Phosphodiesterase type 5 (PDE5) inhibitors have proved to be efficacious, safe, and well tolerated, in clinical trials and practice, for men with erectile dysfunction (ED). However, many patients are not satisfied with treatment and discontinue it prematurely. This review discusses evidence-based strategies that nurse practitioners (NPs) can use to improve diagnosis of ED, optimize patient outcomes, and identify opportunities to detect other potentially serious comorbid conditions. DATA SOURCES: This article was based on a previously published review, which involved a PubMed-MEDLINE search of the clinical literature from January 1, 1998 (year of sildenafil's approval in many markets), through August 30, 2008 (date of search). CONCLUSIONS: Strategies to optimize responses to PDE5 therapy are summarized by the mnemonic "EPOCH": Evaluating and educating to ensure realistic expectations of therapy; Prescribing a treatment individualized to the couple's needs and preferences; Optimizing drug dose/regimen and revisiting key educational messages at follow-up visits; Controlling comorbidities via lifestyle counseling, medications, and/or referrals; and Helping patients and their partners to seek other forms of therapy if they have decided not to use a PDE5 inhibitor. IMPLICATIONS FOR PRACTICE: The "EPOCH" mnemonic may remind NPs of steps to optimize treatment outcomes with PDE5 inhibitors.

Traces: making sense of urodynamics testing--part 3: electromyography of the pelvic floor muscles.

Electromyography (EMG) of the pelvic floor muscles is a valuable but challenging component of urodynamics testing. Optimal assessment relies on thoughtful selection of needle, wire, or surface patch electrodes; consistent display of EMG tracings simultaneously with pressure and flow tracings; and minimization of technical and environmental artifacts. This article reviews technical aspects of EMG, including the selection of the best electrodes for a given clinical scenario, minimization of environmental and technical artifacts, and clinical measurement during the filling cystometrogram and voiding pressure flow study.

AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome.

PURPOSE: To provide a clinical framework for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. MATERIALS AND METHODS: A systematic review of the literature using the MEDLINE® database (search dates 1/1/83-7/22/09) was conducted to identify peer reviewed publications relevant to the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. Insufficient evidence-based data were retrieved regarding diagnosis and, therefore, this portion of the Guideline is based on Clinical Principles and Expert Opinion statements. The review yielded an evidence base of 86 treatment articles after application of inclusion/exclusion criteria. These publications were used to create the majority of the treatment portion of the Guideline. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). Additional treatment information is provided as Clinical Principles and Expert Opinion when insufficient evidence existed. See text and algorithm for definitions, and detailed diagnostic management, and treatment frameworks. RESULTS: The evidence-based guideline statements are provided for diagnosis and overall management of interstitial cystitis/bladder pain syndrome as well as for various treatments. The panel identified first through sixth line treatments as well as developed guideline statements on treatments that should not be offered. CONCLUSIONS: Interstitial cystitis/bladder pain syndrome is best identified and managed through use of a logical algorithm such as is presented in this Guideline. In the algorithm the panel identifies an overall management strategy for the interstitial cystitis/bladder pain syndrome patient. Diagnosis and treatment methodologies can be expected to change as the evidence base grows in the future.

Traces: making sense of urodynamics testing--Part 8: Evaluating sensations of bladder filling.

The "Traces" series discusses how the urodynamic clinician generates usable data from a filling cystometrogram (CMG). Part 8 focuses on the question, "What are the sensations of bladder filling?" Recent research suggests that sensations of bladder filling wax and wane from consciousness in healthy persons free of bothersome lower urinary tract symptoms. Because of its invasive and atypical nature when compared to daily life, multichannel urodynamics testing cannot reproduce the numerous and complex variables that influence bladder sensation in the healthy individual, making the evaluation of sensations of bladder filling a particularly challenging component of the filling CMG. Routine assessment of bladder sensations focuses on identification of three landmarks--first sensation of bladder filling, first desire to void, and a strong desire to void. A fourth sensation, bladder fullness or a compelling desire to void, is recommended. In addition to assessing these sensations, the urodynamic clinician must assess sensations indicating associated disease or disorders affecting lower urinary tract function, including urgency, pain, and atypical sensations. This assessment should be completed in the context of the results of one or more validated instruments used to measure bladder sensations.