Indiana Pouch: Surgery, Complications, and Catheterization

What is an Indiana Pouch?

An Indiana pouch is a continent catheterizable urine pouch constructed during a urinary diversion surgery. It is made from the person’s own intestines to substitute some but not all functions of the bladder. 

When a bladder malfunctions due to cancer, bladder exstrophy, chronic inflammation, spina bifida, or other diseases and damages, it is often removed or bypassed, and an Indiana pouch can be constructed to hold and collect urine in its place. 

Like the bladder, the Indiana pouch is located inside the abdominal wall, and it is continent, meaning urine will not leak out involuntarily. However, unlike the bladder, the Indiana pouch cannot be contracted at will to squeeze urine out, and thus needs to be catheterized with intermittent catheters four to six times a day. 

During a urinary diversion surgery to create the Indiana pouch, ⅓ of the person’s large intestine—the ascending colon and cecum—is removed and made into a ball-like pouch. A part of the small intestine that is connected to the big intestines—the ileum—is also removed 

The ileum is then pulled through a surgically created opening on the belly, which is called a urostomy, and sewn onto the outside of the abdominal wall. The pink, fleshy, moist tissue one sees around their urostomy, which is called a stoma, is made of the ileum. 

The ileum forms a channel between the Indiana pouch and the opening on the belly (urostomy), allowing catheters to pass through it and reach the pouch. 

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 normal flow of urine before surgery is this: kidneys filter blood and produce urine, which flows down to the bladder through the ureters, which flows from the bladder to the urethra, exiting through the urethral opening located on one’s external genitals. 

After an Indiana pouch construction surgery, urine flows from the ureters into the Indiana pouch, which does not allow urine to flow freely into the ileum channel, and must be catheterized to drain urine. The Indiana pouch is continent because between the ileum channel and the pouch lies the “gate-keeper” ileocaecal valve, a sphincter muscle valve that originally separates the small intestine from the large intestine now holds urine safely inside the Indiana pouch. 

Indiana pouch surgery

University of Rochester Medical Center recommends that you prepare for surgery by cutting down or quitting smoking and alcohol consumption. They also recommend that you increase your physical activity, practice deep breathing, and take probiotics for two weeks before the surgery.

The surgery is estimated to last around 6-8 hours. Afterward, you would stay in the hospital for 3-4 days, maybe longer.

After the surgery, a physical therapist will help you achieve moderate movements to avoid developing blood clots. It is recommended that you continue to engage in light physical activity when you go home, but do not jog, run, or lift anything heavier than 10 pounds for at least a month.

Before you go home, an ostomy nurse will teach you everything you need to know about caring for your Indiana pouch, which includes how to insert intermittent catheters and how to irrigating your pouch. See this article on some tips to care for your stoma and pouch. 

Indiana pouch complications

Here are some of the complications that may surface post-operation:

1. Development of blood clots, infections, lung or heart problems which may require intensive care.
2. Vitamin deficiencies, B12 in particular.
3. Thick mucus coming out of the pouch. The presence of mucus is normal and can be decreased by irrigating the pouch and drinking more water.  
4. Formation of urinary stones in the pouch caused by incomplete drainage. This can be avoided by practicing correct catheterization techniques. 
5. Catheter-associated infection, trauma, scarring, and irritation.
6. Problems with the stoma, such as infection, irritation, and loss of blood circulation.
7. Incontinence: urine leakage occurs more frequently during the first few months as the pouch is still learning to hold urine. But it can also occur if the ileocecal valve is not totally continent, or if the pouch goes too long without catheterization. 
8. Diarrhea, constipation, or other bowel problems 
9. Loss of erectile function. Some nerves that control erection may be removed if they’re close to the bladder (in the case of bladder cancer) 
10. Shortened vagina from having part of the vagina removed (in the case of bladder cancer) 

Indiana pouch catheterization

To decrease the risk of UTI and injuries when catheterizing an Indiana pouch, here are some things to keep in mind.

1. Never force a catheter in! Sometimes your abdominal muscles clamp down and stop the catheter from advancing. In this case, take a few deep breaths, change into a more relaxing position, and try again. If you took out your intermittent catheter, you must use a new one. If repeated attempts don’t work, seek help from your healthcare provider or go to the emergency room if your pouch is too full. 
2. Always wash your hands before catheterizing.
3. Use non-touch catheters, which decrease the chance of catheter contamination
4. Use pre-lubricated catheters for quick and easy insertion. 
5. To ensure complete drainage, once the catheter is inserted a few inches into the pouch, wait till all liquids drain out before slowly pulling out inch by inch. Every time you pull out in inch, wait till all urine drains before pulling out another inch. If you are using a straight catheter, you can also slightly rotate the catheter for more complete drainage. Do not rotate if you are using a coude catheter (curved tip).

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