In This Issue of JWOCN

This issue of the journal focuses on a variety of topics in wound and continence care, including several that are not as well studied as pressure ulcers or overactive bladder dysfunction. Nevertheless, they are no less essential to WOC practice than the more prevalent conditions, especially since our knowledge of their epidemiology, pathophysiology, diagnosis, and management is based on little or no evidence.

Barbara Pieper, Mary Sieggreen, Cheryl Nordstrom, Barbara Freeland, Pauline Kulwicki, Madelyn Frattaroli, and colleagues report on a study that identified patients' knowledge and concerns about wound care prior to discharge from an acute care facility. Read this article, and complete the associated CE activity, to gain insight about what patients know and do not know about wound care after hospital discharge and the fears and concerns this lack of knowledge generates. I urge you to pay special attention to their observations about the persistent myth about moist vs dry wound healing and the need to leave the wound open to air.

Mary Roberts reviews current knowledge about skin tears in frail elders. Skin tears are an excellent example of a wound type that is less prevalent and typically less devastating than pressure ulcers, but no less relevant when they occur. Read her integrative review to gain knowledge about current concepts on the etiologies and classification of these wounds, as well as recommendations for their management. WOC nurses with a significant geriatric population will be particularly interested in the discussion of prevention of skin tears, an increasingly important issue in the long-term care setting as the mean age of residents continues to climb.

Joan Junkin and Joan Selekof report on the prevalence of urinary and fecal incontinence and associated skin damage in 2 health systems. They initially reported results at the WOCN National Conference and published an abstract in the Conference proceedings. You will want to read this final report to learn about the prevalence of incontinence-associated dermatitis and pressure ulcers seen in patients with urinary and/or fecal incontinence in a community-based and a university-affiliated healthcare system. Continence nurses and any WOC nurse interested in the use of indwelling catheterization in the acute care facility will be particularly interested to note the number of patients who were classified as continent owing to the use of a short-term indwelling catheter. This research report represents another example of the small but growing body of research about moisture-associated skin damage. Refer to the last 2 issues of the journal to gain further insights into the scope of this problem and current knowledge about its diagnosis and management.

Katherine Moore, Vu Truong, Eric Estey, and Don Voaklander sought to identify risk factors associated with an increased risk of urinary incontinence following radical prostatectomy. Read their article for insights into factors other than the often-studied PSA values and tumor grading (Gleason) score that influence the risk of urinary incontinence after surgery. In addition to these insights, I was intrigued by their observation that baseline incontinence and cofactors of increasing age and history of transurethral resection of the prostate significantly influenced the risk of postoperative urinary incontinence. We traditionally think of men approaching radical prostatectomy as entirely continent, followed by an acute onset of urine loss after postoperative catheter removal. The results of this study remind us that many men enter surgery with preexisting (albeit usually mild) incontinence that is easily forgotten, unless it is evaluated prior to surgery and men are made aware of its potential to affect the postoperative course.

Sandra Cochran reviews clinical practice guidelines for indwelling catheters in both acute and long-term care facilities. Her article elegantly demonstrates the persistent and wide gaps in our knowledge about the management of patients with indwelling catheters. In addition to gaining insights into evidence-based (and tradition-based) myths and realities about indwelling catheter management, I urge you to consider this review as a good background for an application for the Center for Clinical Investigation's grant focusing on catheter management. Funding for the grant is provided by Hollister, but it is entirely administered by the Center.

Kathryn Getliffe, Mandy Fader, Colleen Allen, Kim Pinar, and Katherine Moore report on a systematic review of the literature comparing insertion technique (clean vs sterile) and catheter type (coated vs uncoated) on urinary tract infection frequency and secondary outcomes, including urethral trauma and hematuria. You will wish to read this review to determine the paucity of evidence comparing insertion technique and catheter type on UTI and the difficulty researchers encounter when attempting to enroll and retain subjects when completing a clinical trial in this area. Continence nurses will also appreciate the unique difficulties encountered clinically when seeking to objectively diagnose a UTI in patients with spina bifida, spinal cord injuries, or similar disorders that impede the patient's perceptions of the symptoms we rely on to differentiate a clinically relevant infection from asymptomatic bacteriuria. I would also urge every reader to pay particular attention to the techniques used to generate this systematic review. They are based on criteria promulgated by the Cochran Collaboration, applied with considerable skill by authors and researchers who are members of this esteemed group.

The Challenges in Practice feature focuses on extravasation injuries. Kathy Froiland reviews the current knowledge about extravasation injuries, and she deftly differentiates concepts of vesicants vs irritants. She also reviews the classification of extravasation injuries and provides information about their prevention and management. Igor Maslovsky provides a brief care report of a patient with an extravasation injury associated with parenteral administration of vincristine and doxorubicin. This case report focuses on dilemmas of management associated with a complex extravasation injury caused by 2 vesicants typically managed by conflicting interventions. Taken together, these articles provide an excellent overview of our incomplete knowledge of this clinically relevant but comparatively uncommon wound.

Evidence From Other Publications

WOUND CARE

Sum and Ridley1 report on 5 cases of extravasation injuries associated with radiographic contrast materials and review the literature related to their prevention and management. They report a 0.4% to 1.0% incidence of extravasation injuries and note the increasing prevalence of these injuries associated with the significant increase in the number of contrast-enhanced radiologic studies. Their article is important for every WOC nurse whose practice is associated with a radiology department or service. In addition to a comprehensive and insightful review of contrast material-related extravasation injuries, this research is pertinent to WOC practice because it identifies an area of practice not traditionally thought of when considering populations at significant risk for extravasation injuries.

OSTOMY CARE

This issue of the journal contains no platform articles focusing on ostomy care, so I have chosen to review 2 recent articles related to ostomy care. One article focuses on pouchitis and the other on colostomy as a viable treatment option for patients with fecal incontinence refractory to more conservative interventions.

In a 2-part Evidence-Based Report Card published in 2002,2,3 Colwell and Gray reviewed research-based clinical evidence concerning the management of pouchitis and research about its possible etiologies. Multiple possible etiologies were identified, including infection by one of several potentially pathogenic substances commonly found in intact gastrointestinal tracts. In a recent issue of Digestive Diseases and Sciences, Shen and coworkers4 report on the case of a 63-year-old male with pouchitis occurring 12 years following creation of an ileal-anal pouch anal anastomosis (IPAA). Symptoms of pouchitis included increased defecation frequency up to 14 times daily, abdominal discomfort, and fecal incontinence described as "seepage." Endoscopic evaluation revealed a Pouchitis Disease Activity Index of 5. He was initially treated with 4 weeks of metronidazole 250 mg given 3 times daily, with incomplete symptom relief. A more extensive evaluation of possible etiologies for his pouchitis was undertaken, including serum CMV DNA testing (which was negative) and Clostridium difficile toxin A and B toxin tests of his stool, which were positive. Based on these results, metronidazole was discontinued and a 2-drug regimen of ciprofloxacin (administered as 500 mg twice daily) and tinidazole (administered as 500 mg 3 times daily) was initiated. The patient was also advised to avoid nonsteroidal antiinflammatory drugs, which have been correlated with C. difficile-associated diarrhea. A followup visit in 4 weeks revealed complete resolution of pouchitis-related symptoms. This article is pertinent to WOC practice because it reveals another potential etiology for pouchitis and reinforces the role of ciprofloxacin for treatment, especially when a reasonable trial of metronidazole fails to produce symptom relief.

Is surgical diversion a viable alternative for patients with fecal incontinence who cannot be managed by more conservative means? In my last Context for WOC Practice, I reported on a study comparing neurogenic bowel managed by colostomy to bowel management using conservative means.5 In a recent issue of the World Journal of Surgery, Colquhoun and coworkers6 compared quality of life in a postal survey of 39 patients who underwent colostomy to manage fecal incontinence vs 71 patients with fecal incontinence and intact digestive tracts. Unlike the participants in the study of patients with spinal cord injuries reported by Luther and colleagues,5 these subjects tended to be able-bodied women with a history of diverticular disease. They found that respondents with a colostomy reported higher scores (indicating a higher quality of life) on the well-validated SF-36 instrument on subscales coping-embarrassment, lifestyle, and depression than women with fecal incontinence. These results suggest that although colostomy represents a significant surgical procedure that profoundly alters fecal elimination, it remains a viable alternative in highly selected patients whose fecal incontinence does not respond to more conservative interventions.

CONTINENCE CARE

Overactive bladder, characterized by urgency, daytime voiding frequency, and nocturia, with or without urge incontinence, is usually managed by behavioral interventions, pharmacotherapy, or preferably a combination of these strategies. What, then, do we do for patients who fail to respond adequately to either of these interventions? Casanova, McGuire, and Fenner reviewed the literature and report on existing evidence related to the injection of Botulinum Toxin A into the bladder wall under endoscopic guidance. They found evidence that 50-75% of patients with neurogenic and idiopathic detrusor overactivity, respectively, remain dry at 12 weeks following the injection.7 While our pharmacologic armamentarium for overactive bladder has grown in the last 5 years, we still lack a safe and effective "second-line" treatment alternative for those who do not respond to the first-line treatments, behavioral therapies, and antimuscarinic drugs. Botulinum Toxin A is currently undergoing clinical trials to determine its role in the management of overactive bladder dysfunction. The results of this trial will be of keen interest to every WOC nurse who manages patients with overactive bladder and urge incontinence and to the thousands of patients who suffer from the symptom syndrome but fail to respond to first-line therapies.

References