Patients who suffer severe bladder damage or bladder disease such as invasive cancer may have the entire bladder removed in a cystectomy procedure. Once the bladder is removed, a surgeon can use a portion of the patient's ileum (the final part of the small intestines) or other part of the intestine to create a pouch or reservoir to hold urine. This procedure can be done using an open surgical approach or a laparoscopic approach. Once this new pouch is attached to the ureters and to the urethra, the "new bladder" can fill and stretch to accommodate the urine. As the neobladder cannot contract, a person will use abdominal muscle contractions along with pelvic floor relaxation to empty. If a person cannot empty the bladder adequately, a catheter may need to be utilized. (A prior blog post reported on potential complications of and resources for learning about neobladder surgery.)

During the recovery from surgery, patients will wear a catheter for a few weeks while the tissues heal. Once the catheter has been removed, patients may be instructed to urinate every 2 hours, both during the day and at night. Because patients will not have the same neurological supply to alert them of bladder filling, it will be necessary to void on a timed schedule. The time between voids can be lengthened to every 3-4 hours. Night time emptying may still occur up to two times/evening. Patient recommendations following the procedure may include that patients drink plenty of fluids, eat a healthy diet, and gradually return to normal activities. Adequate fluid is important in helping to flush mucous that is in the urine. This mucous is caused by the bowel tissue used to create the neobladder, and will reduce over time.

Urinary leakage is more common at night in patients who have had the procedure, and this often improves over a period of time, even a year or two after the surgery. As pelvic rehabilitation providers, we may be offering education about healthy diet and fluid intake, pelvic and abdominal muscle health and coordination, function retraining and instruction in return to activities. In addition to having gone through a major surgical procedure, patients may also have experienced a period of radiation, other treatments, or debility that may limit their activity levels. The Pelvic Rehabilitation Institute is pleased to offer courses by faculty member Michelle Lyons in Oncology and the Pelvic Floor, Part A: Female Reproductive and Gynecologic Cancers, and Part B: Male Reproductive, Bladder, and Colorectal Cancers. If you would like to explore pelvic rehabilitation in relation to oncology issues, there is still time to register for the Part A course taking place in Torrance, California in May! If you would like to host either of these courses at your facility, let us know!

Wendy Sword, Professor in the School of Nursing at McMaster University, and her colleagues have recently published a study in which they looked at the relationship between mode of delivery and risk for post-partum depression. An interesting correlation that the authors found shows that having urinary incontinence in the first 6 weeks after childbirth doubles the risk for having post-partum depression. In McMaster University's post about this research, it is pointed out that up to 20% of new mothers experience post-partum depression, and this can interfere with the mother's self-care, with bonding between the mother and child, and with the care needed by the infant. Early detection and treatment of post-partum depression is critical.

In this research, 1900 new mothers were studied, up to 1/3 of them had c-sections as the mode of delivery. At 6 weeks post-partum, nearly 8% of the mothers had post-partum depression. The depression was not identified as being related to one mode of child delivery over another. The 5 strongest predictors of post-partum depression were identified as: 1) mother's age less than 25, 2) mother requiring hospital readmission, 3) non-initiation of breast-feeding, 4) good, fair, or poor self-reported health by the mother, and 5) urinary incontinence.

Dr. Sword recommends that providers ask patients about continence status early in the post-partum period, as patients may be embarrassed to bring it up, and also because incontinence is often dismissed as a common issue post-partum that will likely improve. When patients are referred to rehabilitation for continence issues, we often find that the symptoms have persisted for years, sometimes decades, unfortunately. During our marketing visits and education of the community, we can also encourage patient providers to send the patients to rehabilitation as early as possible. It is often at the 6 week appointment that the patient can be screened for such concerns, and this is when many of our referrers are comfortable sending a patient in for a check of the pelvic muscles.