Long haul UROLOGIC MANAGEMENT FOLLOWING SPINAL CORD INJURY William McKinley MD Director SCI Rehab Services Dept PM&R MCV/VCU
Slide 2Objectives Areflexic versus Reflexic Bladder Importance: "DSD" and Urodynamics Current Rxs "Potential" new Rxs Urologic Rx in females UTI\'s Long Term development
Slide 3Mortality Associated with Renal Dysfunction Following SCI World War I - 80% World War II - 40% Korean War - 25% Vietnam War - Minimal Today - Negligible
Slide 4Renal 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
Slide 5Complications of Neurogenic Bladder Morbidity UTI, Pyelonephitis, Stones, Renal dz. Spasticity, Aut. Dys., Pressure Ulcers Mortality Sepsis, Renal dz Social Incontinence Sexuality
Slide 6Potential 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" IC
Slide 8Sterile 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 9Complications with "long haul" Indwelling Catheter intermittent/perpetual UTI\'s prostatitis/epididymitis urethral fistulas bladder stones bladder tumor (10% with >10 yrs)
Slide 10Suprapubic versus Urethral Catheter intrusive comparative dangers: UTI\'s, stones, tumor held for those with urethral harm
Slide 11"Perfect" Outcome of long haul Rx: "Adjusted Bladder" Minimize UTI\'s Low Pressure voiding Low post-void residuals Continence
Slide 12Bladder 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 13SCI Bladder Classifications Uninhibited bladder (Brain) Reflexic (UMN) bladder Areflexic (LMN) bladder
Slide 14Reflexic (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
Slide 15Urodynamics Cystometrogram + sphincter EMG "key" discoveries about bladder sensation, filling/discharging automatic constrictions ( reflexic ) & span bladder weight "Dysynergia"!!!
Slide 16Urodynamics
Slide 17Areflexic 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
Slide 18Reflexic Bladder Non-willful withdrawals with filling can help with discharging bladder post void residuals (UTI\'s) Detrusser-sphincter dysynergia (DSD) long haul renal brokenness
Slide 19Detrusser 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 20DSD 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
Slide 21Potential Complications of DSD Bladder reflux (pee, weight, microbes) Hydronephrosis Pyelonephritis, urosepsis Renal stones Renal brokenness
Slide 22Bladder Reflux
Slide 23Management of DSD Establish low weight stockpiling and purging Ideal Rx ought to be: Least intrusive Non-changeless Lifestyle ward Of okay
Slide 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 25Pharmacological 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
Slide 26Pharmacological 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 27Other 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
Slide 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 29Botulism 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
Slide 30External 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
Slide 31Augmentation 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
Slide 32Abdominal Urinary Stoma Ureterostomy Ileal course redirection
Slide 33Sphincter Balloon Dilation Balloon expansion of the prostatic urethra some long haul achievement diminished voiding weight diminished lingering
Slide 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 rate
Slide 35Urethral Stents
Slide 36Bladder Functional Electrical Stimulation (FES) FES: bladder stockpiling bladder exhausting
Slide 37Bladder 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
Slide 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" bladder
Slide 40VOCARE (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 41Urologic 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 42Urinary 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
Slide 43Urinary 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 44Risks 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
Slide 45Rx 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
Slide 46Rx 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
Slide 47Long-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
Slide 48Conclusions IC & Fluids Evaluate for Reflexic versus Areflexic bladder consider a