Long haul UROLOGIC MANAGEMENT FOLLOWING SPINAL CORD INJURY William McKinley MD Director SCI Rehab Services Dept PM&R MCV/VCUSlide 2
Objectives Areflexic versus Reflexic Bladder Importance: "DSD" and Urodynamics Current Rxs "Potential" new Rxs Urologic Rx in females UTI\'s Long Term developmentSlide 3
Mortality Associated with Renal Dysfunction Following SCI World War I - 80% World War II - 40% Korean War - 25% Vietnam War - Minimal Today - NegligibleSlide 4
Renal Failure is No Longer the #1 Cause of Death (Reasons): Antibiotics Catheterization (Guttman) Understanding inconveniences of the "high weight bladder" Education to patient/family Follow-up TestingSlide 5
Complications of Neurogenic Bladder Morbidity UTI, Pyelonephitis, Stones, Renal dz. Spasticity, Aut. Dys., Pressure Ulcers Mortality Sepsis, Renal dz Social Incontinence SexualitySlide 6
Potential Treatments Catheters Fluid Control Medications Surgery "Manual" procedures Depends (diapers) "New" choices "Do Nothing"Slide 7
"Intense" Urological Care Following SCI "brief" utilization of indwelling Catheter & liquids (Lloyd) Intermittent Cath (IC) + Fluid Control Sterile versus "Clean" ICSlide 8
Sterile versus "Clean" IC Sterile method sterile gloves new catheters costlier $$ "Clean" procedure (Lapides) wash hands reuse catheters (povidine-iodine/bubbling) and capacity less demanding consistence, protected and successful (Maynard)Slide 9
Complications with "long haul" Indwelling Catheter intermittent/perpetual UTI\'s prostatitis/epididymitis urethral fistulas bladder stones bladder tumor (10% with >10 yrs)Slide 10
Suprapubic versus Urethral Catheter intrusive comparative dangers: UTI\'s, stones, tumor held for those with urethral harmSlide 11
"Perfect" Outcome of long haul Rx: "Adjusted Bladder" Minimize UTI\'s Low Pressure voiding Low post-void residuals ContinenceSlide 12
Bladder Anatomy Pontine micturation focus Bladder (detrusser muscle) - Parasympathetic (S2-4) cholinergic innervation (+stretch sens.) Sympathetic (T9-12) represses bladder (+Pain) Internal sphincter - Sympathetic (T9-12) alpha adrenergic innervation External sphincter - Somatic (S2-4) innervation (Pudendal n.)Slide 13
SCI Bladder Classifications Uninhibited bladder (Brain) Reflexic (UMN) bladder Areflexic (LMN) bladderSlide 14
Reflexic (R) versus Areflexic (A) bladder: Clinical Distinctions Level of harm (above T10 = R, beneath L1 = A) Spasticity (R) Bulbocavernosis (S2-4) reflex (R) bladder "commence" (R) Urodynamics (UD) at @ 3 monthsSlide 15
Urodynamics Cystometrogram + sphincter EMG "key" discoveries about bladder sensation, filling/discharging automatic constrictions ( reflexic ) & span bladder weight "Dysynergia"!!!Slide 16
Areflexic Bladder No purging capacity w/o catheterizaiton outer pressure ("crede") flood! Long haul hypocompliance is seen (10%) high weight bladder long haul renal weakening Rx-IC (liquids) versus credeSlide 18
Reflexic Bladder Non-willful withdrawals with filling can help with discharging bladder post void residuals (UTI\'s) Detrusser-sphincter dysynergia (DSD) long haul renal brokennessSlide 19
Detrusser Sphincter Dysynergia (DSD) Normal (synergistic) Micturation is started by: increment in detrusser weight unwinding of urethral sphincter voiding pressure<40 cm In reflex bladder, we see: concurrent constriction of sphincter & detrusser no collaboration (Dysynergia = DSD)Slide 20
DSD Incidence = up to half (Blaivas, Yallo) Increased bladder reflex voiding Pressures to prompt to renal difficulties UD parameters not entrenched High weights (McGuire, Bennet)>50 (Wyndale)>70 Duration of compressionSlide 21
Potential Complications of DSD Bladder reflux (pee, weight, microbes) Hydronephrosis Pyelonephritis, urosepsis Renal stones Renal brokennessSlide 22
Bladder RefluxSlide 23
Management of DSD Establish low weight stockpiling and purging Ideal Rx ought to be: Least intrusive Non-changeless Lifestyle ward Of okaySlide 24
"Current" DSD Management Recommended Rx: Anticholinergics + IC, (? Alpha blockers) suprapubic tapping Sphincterotomy (guys) + Ext. cath. Bladder Augmentation Not prescribed: Indwelling cath. Crede Cholinergics (bethanachol)Slide 25
Pharmacological Rx Anticholinergics (Ditropan, Imiprimine) unwind spastic bladder SE\'s - dry mouth, dazedness Tolterodine (Detrol - ? Less SE\'s Cholinergics (Bethanechol) don\'t function admirably - not rec\'d Alpha-blockers (Phenoxybenzamine, Hytrin,) incompletely square "inside" sphincter - some clinical adequacy, hypotensionSlide 26
Pharmacological Rx (cont.) Alpha stimulants (Ephedrine) may build sphincter weight - restricted convenience no medication specifically unwinds the striated muscle of the pelvic floor & "outer" sphincter (Baclofen, Valium, Dantrium)Slide 27
Other Pharmacological Rx\'s Intravesicular oxybutinin (ditropan) all around endured, exorbitant Capsacin (intravesicular) pieces afferents C-filaments inc\'s bladder limit not very much endured (smoldering, AD, hematuria) DDAVP (against diuretic hormone) intranasalSlide 28
"Intrusive" bladder Rx\'s Intrathecal Baclofen (Nanninga) dec. weight, inc. lingering & self control Pudendal nerve piece (7% phenol) diminished bladder weight @20cm (Ko)Slide 29
Botulism A Toxin (botox) neighborhood perineal M. infusion restrains Ach. at NMJ unwinds outside sphincter viable (Petit: "diminished bl. Pr.20cm & leftover by 175ml) rehash at 3 months Indications: thought for sphincterotomy trouble with ICSlide 30
External Sphincterotomy demonstrated with obstinate DSD not prescribed before 9-12 months Potential inconveniences: reoperation (15-25%) XS dying (5%) erectile brokenness (3-60%) - 12-o\'clock area rec\'d Laser SphicterotomySlide 31
Augmentation Enterocystoplasty "entero"=GI tract, "cysto" = bladder Goal: change over a "little" rebellious bladder to a "low weight" pee repository Indications: disappointment of med. Rx upper tract stop./reflux (Bennett) decr\'d - Bl Pr. 55cm Inc\'d-Bl limit (350ml) inc\'d QOLSlide 32
Abdominal Urinary Stoma Ureterostomy Ileal course redirectionSlide 33
Sphincter Balloon Dilation Balloon expansion of the prostatic urethra some long haul achievement diminished voiding weight diminished lingeringSlide 34
"Urethral Stents" endoluminal "wire work" prosthesis to keep up patency of the membranous urethra (Chancellor) Goal: diminish voiding weight & leftover pee, resolve hydronephrosis Long-term comes about disillusioning (Low) disappointment, remaining pee, stones, reflux high evacuation rateSlide 35
Urethral StentsSlide 36
Bladder Functional Electrical Stimulation (FES) FES: bladder stockpiling bladder exhaustingSlide 37
Bladder FES to expand bladder stockpiling reflex hindrance (pudendal, penile n\'s, butt-centric fittings) FES to Restore Bladder Emptying sacral root stim. (Brindley \'70) joined by post. Root rhizotomy great achievement rate compl\'s: loss of erectile fnt detrusser myoplasty gracilis muscle E. stimSlide 38
"VOCARE" Bladder FES System (Neurocontrol)Slide 39
"VOCARE" Bladder System (Neurocontrol) Benefits Elimination of urethral catheters Decreased frequency of wetness Improved bladder discharging Decreased rate of UTI\'s Indications "finished" SCI "reflexic" bladderSlide 40
VOCARE (cont.) Surgery back rhizotomy (forestalls reflex cont\'s) FES to bladder nerves beneficiary stimulator embedded in stomach divider outside controller - transmits flag (Brindley): the first 500 patients 84% still use (mean 4 yrs) insufficient (6%), agonizing (1%)Slide 41
Urologic Rx in Females Recs: Antichol. + IC non-reasonable outer incontinence gadget powerlessness (Tetra\'s) to perform IC Abhorrence of "cushioning" Indwelling cath remains an alternative included compl. of spillage around cath. Utilitarian Electrical Stim. Need: better Rx alternatives in females/SCI (NIDRR)Slide 42
Urinary Tract Infections (UTI) 1 million UTI\'s in USA 1/2 of all doctor\'s facility gained diseases = UTI solid asso. with catheters most regular intense & unending restorative complexity taking after SCISlide 43
Urinary Tract Infections def = bacteriuria (>100K) + tissue reaction (>8WBC/hpf) >90% occurrence w/indwelling cath 66% with long haul IC will have intermittent/ceaseless UTI\'s 80% with reflex void & ext. cath . - UTI\'s sphict. + CC Reveals dec. bacteriuria (Cardenas)Slide 44
Risks for Recurrent UTI\'s Lapides \'74 bladder mucosa changes and diminished host resistance expanded weight overdistension remote bodies (catheters) IC at release yet condom cath at f/uSlide 45
Rx of UTI\'s augment liquids, keep guts, perineum, urethra, catheters CLEAN! Treat all UTI\'s however use anti-infection agents just for "symptomatic" UTI\'s bacterial resistance with abuse of anti-microbials symptomatic UTI = fever, torment, discomfort, hematuria, incont., spasticity, shady pee Dx: bacteriuria + pyuria >8-10 WBC/hpfSlide 46
Rx of UTI\'s (cont.) ? Adequacy prophilactic abx . (Bactrim, Nitrofurantoin) acidifying pee with mandelamine, vit. C, and so on. R/o bladder/renal Stones nidus for contamination R/o hypercalciuria, hyperuricosuria Prompt evacuation Lithotripsy percutaneous nephrolithotomySlide 47
Long-term Renal Monitoring Goal - useful (F) and anatomical (An) appraisal w/o intrusiveness (I) intravenous pyelogram - (An), (I) renal ultrasound - (A) Urodynamics - (A) & (F), (I) Renal sweep - (F) Creatinine Clearance BUN/Creatinine, U/A, cytologySlide 48
Conclusions IC & Fluids Evaluate for Reflexic versus Areflexic bladder consider a
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