urologic, colorectal, and abdominal surgeries

indication for urinary diversion surgeries

bladder disease or urinary tract dysfunction requiring rerouting or excision caused by

• cancer

• obstruction of distal ureter

• birth anomalies / diseases

• trauma

urostomy

rerouting of urine away from bladder / urethra by moving termination of distal ureters to outside the body through a stoma

most common type of urostomy

ileal conduit

ileal conduit process

bladder removed

small ileal pouch created

distal ureter connects ileal pouch to external bag via stoma

remaining intestine is anastomosed

what is a risk of getting a urostomy

risk of needing stenting

what are the 3 types of urinary diversion surgeries

urostomy

neobladder

transurethral resection of bladder tumor (TURBT)

neobladder

most involved type

painful

urine rerouted internally

what urinary diversion surgery can benefit from pelvic floor PT

neobladder

because urine rerouted internally and leaks a lot initially

transurethral resection of bladder tumor (TURBT)

scope inserted through urethra

tumor cut

patients tend to have a catheter after procedure

what increases the risk of stoma related complications post procedure

higher BMIs

weight changes

what are complications post urostomy and ileal conduit

integumentary (from adhesives)

stoma related

prolapse from increased intra-abdominal pressure

stenosis

GI issues

hernia

what is important for PT to do before mobilizing a patient with a urostomy bag

make sure the bag is not full

determine which side it is on

urostomy post op instructions

no lifting >10 pounds

no driving until cleared by physician

no strenuous activity or work for 6 weeks

no sexual intimacy initially then avoid constant pressure on stoma

transfer via log roll

pelvic splanchnic and hypogastric nerves

innervate prostate, bladder, detrusor muscle

pudendal nerve

motor innervation to external anal and uretral sphincters

sensory innervation to genitalia

pelvic health concerns post urostomy

erectile dysfunction

pain with intercourse

signs of menopause

sexual dysfunction (60-80% of population)

MSK (hip, LBP, etc) issues that are originating from GI issues

upper GI tract components

mouth

pharynx

esophagus

stomach

lower GI tract components

small intestine

large intestine

accessory organs of gastrointestinal system

liver

gallbladder

pancreas

what are 2 inflammatory bowel diseases

crohns disease

ulcerative collitis

what layers and parts of GI tract are affected by crohns disease

ALL layers

involves any / all parts of GI tract (usually end of small intestine and beginning of large intestine)

crohns disease

chronic inflammatory disease of all layers

skip lesions throughout GI tract

significant weight loss

fistulas

80% eventually need surgery

what layers are affected by ulcerative collitis

mucosal and submucosal lining of the large intestine

ulcerative collitis

chronic inflammatory disease of mucosal and submucosal lining of the large intestine (colon and rectum)

severe diarrhea because large intestine not absorbing water well

cancer association

20% eventually need surgery

monoclonal antibody therapy

may help patients with active crohns disease

effective for moderate to severe ulcerative collitis

what are 4 bowel diversion surgeries

ileostomy

colostomy

J pouch

hartmann’s

indications for ileostomy

large intestine unable to process waste

congenital motility / obstruction

IBD

ovarian or colorectal cancer

small bowel obstruction

post trauma

ileostomy procedure

diseased section of ileum removed

loop or end of ileum sewn to abdominal wall to create stoma (typically on R side)

waste collected in external bag

colon, rectum, and anus are bypassed (or removed if needed)

can a loop ileostomy be reversed or is it permanent

it can be reversed after 6-12 weeks

PT considerations for ileostomy

ostomy bag must be emptied several times each day

may need to “burp the bag” if collecting too much gas

gait belt placement

always check bag before supine to sit, hip or abdominal ther ex, and OOB

function of ileum

absorption of B12

B12 needed for myelin sheath, RBCs, metabolism, energy, mood

tools used as a gauge for symptom status

functional bowel disorder severity index

irritable bowel syndrome severity scoring system (GOLD STANDARD)

functional bowel disorder severity index questions

how bad is the pain

have you been diagnosed with a functional disorder like IBS

how many times have you gone to a doctor because of symptoms

irritable bowel syndrome severity scoring system questions

severity of pain

current pain level

abdominal distention

bowel habits

interference with life

organic causes of obstructive dysfunction / disease

ulcers

gallstones

reflux

mechanical causes of obstructive dysfunction / disease

adhesions from fibrous scars post surgery (MOST COMMON)

chronic inflammation also causes adhesions

functional causes of obstructive dysfunction / disease

effects peristalsis (upper or lower GI)

post surgical complications

neonatal / congenital diseases

ileus

multiple interrupted air pockets

small bowel obstruction

dilated large bowel

obstructed where small intestine meets large intestine

generally considered worse than ileus

PT implications for ileus, snall bowel, and large bowel obstruction

get person OOB and walking with physician clearance

consider clamp times (start with 1 hr and progress in 2 hr increments)

stop PT and report if patient gets nauseated with clamp

therapeutic exercise

emergency signs and symptoms associated with ileus, small bowel, and large bowel obstructions

excessive emesis

absent flatus

absent bowel activity

visceral manipulation

may help improve peristalsis after multiple surgeries that cause adhesions to lay down

indications for colon resection

cancer

diverticulitis

adhesions

LBO

IBS

disease

colon resection procedure

part of diseased large intestine removed

remaining healthy ends of colon reattached (anastomosis)

colostomy created if cannot be anastomosed

colostomy

external opening in colon with pouch collecting fecal waste

purpose and function of colostomy

sited above groin on left side of abdomen

can be temporary if colon needs to heal after surgery

if possible reversal — colostomy at least 6 weeks but recommended 2-6 months

PT implications for colostomy

early mobility for gastric motility

abdominal support system weight lifting

splinted coughing

log roll transfers

incentive spirometry

stoma inspection and wound care

empty bag before PT

ileal-anal pouch (j pouch) indications

chronic IBD

congenital diseases

colon or rectal cancer

genetic familial adenomatous polyposis

acute colitis

ileal anal (j pouch) procedure

usually 2-3 stage process

excision of entire colon and rectum (proctocolectomy)

internal reservoir pouch made from ileum then connected to anus

ileostomy created to delay ileal anal pouch use so it can heal

stoma closed at 3-6 months

person can now eliminate waste through anus

complications related to ileal anal (j pouch)

stricture

inflammation

leakage

infection

dehydration

diarrhea

electrolytes

hartmann’s procedure (recto-procto-sigmoidectomy) indications

rectal or colon cancer / tumors

extreme diverticulitis

perforated or obstructed bowel

hartmann’s procedure (recto-procto-sigmoidectomy) procedure

resecting last section of colon (sigmoid) and rectum

causes end colostomy

rectum sealed off (rectal stump)

concerns with hartmann’s procedure (recto-procto-sigmoidectomy)

mortality rate 9-10%

potential nerve damage (prostate, anal sphincter, bladder, etc)

whipple procedure (pancreaticoduodenectomy)

used to remove cancerous tumors located in head and neck of pancreas

resection of distal portion of stomach, head of pancreas, duodenum, and surrounding lymph nodes

remaining pancreas and digestive organs reconnected

common complications of whipple procedure (pancreaticoduodenectomy)

delayed gastric emptying (7-10 days)

abdominal infections

digestive difficulties

long length of stay and recovery

rectal trumpet

similar to a foley cath but for the rectum

moving with a lot of friction can cause internal damage

urinary catheters

indwelling

external

intermittent, self catheters

continuous bladder irrigation

can easily pull and be uncomfortable

bag fills quickly, make sure it is empty before PT