Q: A 56-year-old nursing-home patient has been a paraplegic for many years following a motorcycle accident. She has a diversion colostomy and an atonic bladder. Despite use of the Foley catheter with the largest balloon, urine leakage resulting in constant dampness has caused chronic, refractory deep decubitus ulcers on her buttocks and perineal areas. An ileoconduit is considered unsafe by urologic surgeons. What can we do to stop the leakage and keep the skin dry? Would connecting the Foley to low, intermittent suction while the patient is in her room be helpful?
Federico Loinaz, MD, Ogdensburg, N.Y.

A: Your patient’s continued urinary leakage may suggest a problem related to breakdown or necrosis of the urethra relative to the long-term use of Foley catheters. Medical and conventional surgical intervention in this case may not be of much help. An unconventional intervention, such as the use of suction, might not be effective. In all likelihood, the urine would not be entirely “vacuumed” from the bladder and, therefore, would continue to leak to some degree. There is literature to support surgical closure of the bladder outlet, particularly in neurologically impaired women. The authors describe combined abdominal and vaginal bladder neck closure along with a catheterizable abdominal stoma or drainage via suprapubic tube. This technique has been very successful in a small number of women with MS (J Urol. 1994;152[6Pt 1]:2081-2084 and Br J Urol. 1994;74:319-321).
—Christopher Ruser, MD (98-10)

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