WHAT IS A VOIDING TRIAL?

Around 4 weeks postop (on average), patients are instructed to start urinating through the longer urethra. Doing so requires clamping or plugging the suprapubic (SP) tube (the catheter that is exiting the lower abdomen with its tip in the bladder). When the bladder is full, you will feel the urge to urinate like before surgery. Unclamp/unplug the catheter and urine will drain out of the SP tube. This is done for several days. About 1-3 days prior to your 3 or 4 week postop appointment, you will be instructed to urinate through the penis. If this goes well for several days, the SP tube will be removed.


HOW DO YOU I URINATE THROUGH THE PENIS AND URETHRA?

Urinating through the penis: when you have the strong urge to urinate, instead of unplugging the SP tube, relax your pelvic floor muscles (remember that urinating, aka voiding, is not an active process; you should not strain to urinate; you should be relaxed). The first time you try urinating, it is frequently easiest in the shower. Urine should flow through the penis. Once done and you feel empty, unclamp the SP tube about once per day to verify that you are emptying your bladder mostly through the penis. Typically, about 70% of the voided volume will come from the penis and 30% from the SP tube; this ratio usually improves over time. There will often be an uncomfortable or sometimes painful bladder spasm (intense urge to urinate with or without pain at the original urethra) as your bladder empties and comes into contact with the SP tube within the bladder. This is normal and expected and will resolve once the SP tube is removed.

Remember, the first few times you urinate, there will be blood and particulates in your urine that should clear with drinking plenty of water and urinating frequently. This blood/particulate/urine mix accumulates in your urethra after surgery, and it's good to urinate the mixture out.  


I HAVE PAIN WITH URINATION; IS THIS NORMAL?

The first few times, and sometimes even the first few days, it will burn or hurt to urinate. This is possibly from urine passing through the new urethra and is expected. It is not expected if there is consistently cloudy and odorous urine, as burning/pain with urination with these symptoms indicate a UTI.

If it burns and the urine is clear, hydrate with water to dilute the urine. Over the counter AZO can be taken briefly for 3 days; it becomes a local anesthetic after it is metabolized, making urinating easier for some patients (note: it turns the urine orange).

If it burns and the urine is consistently cloudy, notify your doctor and start the antibiotic provided (typically trimethoprim-sulfamethoxazole aka Bactrim, unless there is a medication allergy) and take if for about 7 days. 

Pain at the end of urination? This is common and occurs as the bladder empties and comes into contact with the tip of the SP tube. It will feel like a bladder spasm (a very uncomfortable urge to urinate). The best way to manage this is to get rid of the SP tube at the followup visit. While awaiting for your followup, if the spasms are too uncomfortable, contact your surgeon for further instructions. 


HOW DO I KNOW I HAVE A FISTULA?

Fistula: if you notice urine coming from a separate opening, stop voiding through the phallus, return to draining urine through the SP tube, and notify your surgeon. It's helpful to have an idea of how much comes out of the fistula. Is it only a few drops of urine, a small stream, or a strong stream? Is it 10% from the fistula, and 90% from the penis tip, or is it 90% from the fistula and 10% from the penis tip?

If the stream that is coming out the tip of the phallus is strong, and the amount dripping from somewhere else is minimal, it is likely a small fistula and small fistulas like this heal about 80% of the time with or without a catheter. In this scenario, there are two main options:

1. The "textbook" answer is to keep the catheter and stop urinating until the fistula finally seals. That said, there is a risk benefit balance here: the longer you keep the catheter, the more bothersome it becomes and the higher the risk of UTIs and other catheter related problems.
2. The other option is to remove the catheter altogether and the fistula will likely heal regardless.

How do we decide?
The tie breaker for whether or not to keep peeing and remove the catheter in the setting of a small fistula is your tolerance of the catheter. If you can't stand it, we or your local provider can remove the catheter and you urinate with the fistula, and the fistula may still heal in about 80% of cases. If you can tolerate the catheter and can't stand the idea of leaking through a fistula, we keep the catheter an extra week or so and try urinating again next week to see if it has healed or improved.


AFTER THE SP CATHETER IS REMOVED, WHAT HAPPENS TO THE HOLE IN THE LOWER ABDOMEN?

This hole will close in about 1-2 days. It may leak urine for less than a day when you urinate. This is expected and quickly resolves.

The hole should be kept clean; ointment is optional and helpful if it alleviates discomfort. Dressings are frequently unnecessary. If more comfortable, a 2x2 or folded 4x4 gauze with tape can be used to cover the hole for about 1 day. ​

MEDICATIONS

If you are taking ditropan (oxybutynin) for bladder spasms, stop taking it 1 day prior to your voiding trial. Most patients will have a script for bactrim (trimethoprim/sulfamethoxazole) or another antibiotic if allergic. If the voiding trial is a success, take one antibiotic tablet before your followup, then the SP tube will be removed at your followup, and take another antibiotic tablet that same evening.

If you notice consistently cloudy or odorous urine, this is likely a UTI. Take the full week's worth of antibiotic in this situation. Notify the office if you don't notice improvement of the urine quality after several days of antibiotics.

CONSTIPATION?

Make sure you are having at least one large bowel movement per day as constipation often negatively alters bladder function. In otherwords, patients who are severely constipated will often find it difficult to urinate reliably.
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