Long haul UROLOGIC Administration Taking after SPINAL Line Harm.


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LONG-TERM UROLOGIC MANAGEMENT FOLLOWING SPINAL CORD INJURY. William McKinley MD Director SCI Rehab Services Dept PM&R MCV/VCU. Objectives. Areflexic vs Reflexic Bladder Importance: “DSD” and Urodynamics Current Rxs “Potential” new Rxs Urologic Rx in females UTI’s Long Term follow-up.
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Long haul UROLOGIC MANAGEMENT FOLLOWING SPINAL CORD INJURY William McKinley MD Director SCI Rehab Services Dept PM&R MCV/VCU

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

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

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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

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

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

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

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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)

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

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

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

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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.)

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

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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

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

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Urodynamics

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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

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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

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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)

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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

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

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Bladder Reflux

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

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

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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

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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)

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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

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

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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

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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

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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

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Abdominal Urinary Stoma Ureterostomy Ileal course redirection

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

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"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

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Urethral Stents

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

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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

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"VOCARE" Bladder FES System (Neurocontrol)

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"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

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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%)

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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)

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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

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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)

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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

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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

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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

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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

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

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