Long haul UROLOGIC Administration Taking after SPINAL Line Harm.

Long haul UROLOGIC MANAGEMENT FOLLOWING SPINAL CORD INJURY William McKinley MD Director SCI Rehab Services Dept PM&R MCV/VCU

Objectives Areflexic versus Reflexic Bladder Importance: "DSD" and Urodynamics Current Rxs "Potential" new Rxs Urologic Rx in females UTI\'s Long Term development

Mortality Associated with Renal Dysfunction Following SCI World War I - 80% World War II - 40% Korean War - 25% Vietnam War - Minimal Today - Negligible

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 Testing

Complications of Neurogenic Bladder Morbidity UTI, Pyelonephitis, Stones, Renal dz. Spasticity, Aut. Dys., Pressure Ulcers Mortality Sepsis, Renal dz Social Incontinence Sexuality

Potential Treatments Catheters Fluid Control Medications Surgery "Manual" procedures Depends (diapers) "New" choices "Do Nothing"

"Intense" Urological Care Following SCI "brief" utilization of indwelling Catheter & liquids (Lloyd) Intermittent Cath (IC) + Fluid Control Sterile versus "Clean" IC

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)

Complications with "long haul" Indwelling Catheter intermittent/perpetual UTI\'s prostatitis/epididymitis urethral fistulas bladder stones bladder tumor (10% with >10 yrs)

Suprapubic versus Urethral Catheter intrusive comparative dangers: UTI\'s, stones, tumor held for those with urethral harm

"Perfect" Outcome of long haul Rx: "Adjusted Bladder" Minimize UTI\'s Low Pressure voiding Low post-void residuals Continence

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.)

SCI Bladder Classifications Uninhibited bladder (Brain) Reflexic (UMN) bladder Areflexic (LMN) bladder

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 months

Urodynamics Cystometrogram + sphincter EMG "key" discoveries about bladder sensation, filling/discharging automatic constrictions ( reflexic ) & span bladder weight "Dysynergia"!!!

Urodynamics

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 crede

Reflexic Bladder Non-willful withdrawals with filling can help with discharging bladder post void residuals (UTI\'s) Detrusser-sphincter dysynergia (DSD) long haul renal brokenness

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)

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 compression

Potential Complications of DSD Bladder reflux (pee, weight, microbes) Hydronephrosis Pyelonephritis, urosepsis Renal stones Renal brokenness

Bladder Reflux

Management of DSD Establish low weight stockpiling and purging Ideal Rx ought to be: Least intrusive Non-changeless Lifestyle ward Of okay

"Current" DSD Management Recommended Rx: Anticholinergics + IC, (? Alpha blockers) suprapubic tapping Sphincterotomy (guys) + Ext. cath. Bladder Augmentation Not prescribed: Indwelling cath. Crede Cholinergics (bethanachol)

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, hypotension

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)

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) intranasal

"Intrusive" bladder Rx\'s Intrathecal Baclofen (Nanninga) dec. weight, inc. lingering & self control Pudendal nerve piece (7% phenol) diminished bladder weight @20cm (Ko)

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 IC

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 Sphicterotomy

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 QOL

Abdominal Urinary Stoma Ureterostomy Ileal course redirection

Sphincter Balloon Dilation Balloon expansion of the prostatic urethra some long haul achievement diminished voiding weight diminished lingering

"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 rate

Urethral Stents

Bladder Functional Electrical Stimulation (FES) FES: bladder stockpiling bladder exhausting

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. stim

"VOCARE" Bladder FES System (Neurocontrol)

"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" bladder

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%)

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)

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 SCI

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)

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/u

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/hpf

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 nephrolithotomy

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, cytology

Conclusions IC & Fluids Evaluate for Reflexic versus Areflexic bladder consider a