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LONG-TERM UROLOGIC MANAGEMENT FOLLOWING SPINAL CORD INJURY William McKinley MD Director SCI Rehab Services Dept PM&R MCV/VCU.

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Presentation on theme: "LONG-TERM UROLOGIC MANAGEMENT FOLLOWING SPINAL CORD INJURY William McKinley MD Director SCI Rehab Services Dept PM&R MCV/VCU."— Presentation transcript:

1 LONG-TERM UROLOGIC MANAGEMENT FOLLOWING SPINAL CORD INJURY William McKinley MD Director SCI Rehab Services Dept PM&R MCV/VCU

2 Objectives §Areflexic vs Reflexic Bladder §Importance: DSD and Urodynamics §Current Rxs §Potential new Rxs §Urologic Rx in females §UTIs §Long Term follow-up

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

4 Renal Failure is No Longer the #1 Cause of Death (Reasons): §Antibiotics §Catheterization (Guttman) §Understanding complications of the high pressure bladder §Education to patient/family §Follow-up Testing

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

6 Potential Treatments §Catheters §Fluid Control §Medications §Surgery §Manual techniques §Depends (diapers) §New alternatives §Do Nothing

7 Acute Urological Care Following SCI §temporary use of indwelling Catheter & fluids (Lloyd) §Intermittent Cath (IC) + Fluid Control §Sterile vs. Clean IC

8 Sterile vs. Clean IC §Sterile technique l sterile gloves l new catheters l costlier $$ §Clean technique (Lapides) l wash hands l reuse catheters (povidine-iodine/boiling) and storage l easier compliance, safe and effective (Maynard)

9 Complications with long-term Indwelling Catheter §recurrent/chronic UTIs §prostatitis/epididymitis §urethral fistulas §bladder stones §bladder cancer (10% with >10 yrs)

10 Suprapubic vs. Urethral Catheter §invasive §similar risks: UTIs, stones, cancer §reserved for those with urethral injury

11 Ideal Outcome of long-term Rx: Balanced Bladder §Minimize UTIs §Low Pressure voiding §Low post-void residuals §Continence

12 Bladder Anatomy §Pontine micturation center §Bladder (detrusser muscle) - Parasympathetic (S2-4) cholinergic innervation (+stretch sens.) l Sympathetic (T9-12) inhibits bladder (+Pain) §Internal sphincter - Sympathetic (T9-12) alpha adrenergic innervation §External sphincter - Somatic (S2-4) innervation (Pudendal n.)

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

14 Reflexic (R) vs. Areflexic (A) bladder: Clinical Distinctions §Level of injury (above T10 = R, below L1 = A) §Spasticity (R) §Bulbocavernosis (S2-4) reflex (R) §bladder kick-off (R) §Urodynamics (UD) 3 months

15 Urodynamics §Cystometrogram + sphincter EMG §key findings about bladder l sensation, filling/emptying l involuntary contractions (reflexic) & duration l bladder pressure l Dysynergia!!!

16 Urodynamics

17 Areflexic Bladder §No emptying ability w/o l catheterizaiton l external compression (crede) l overflow! §Long-term hypocompliance is seen (10%) l high pressure bladder l long-term renal deterioration §Rx-IC (fluids) vs. crede

18 Reflexic Bladder §Non-voluntary contractions with filling §can assist with emptying bladder l post void residuals (UTIs) §Detrusser-sphincter dysynergia (DSD) l long-term renal dysfunction

19 Detrusser Sphincter Dysynergia (DSD) §Normal (synergistic) Micturation is initiated by: l increase in detrusser pressure l relaxation of urethral sphincter l voiding pressure<40 cm §In reflex bladder, we see: l simultaneous contraction of sphincter & detrusser l no synergy (Dysynergia = DSD)

20 DSD §Incidence = up to 50% (Blaivas, Yallo) §Increased bladder reflex voiding Pressures to lead to renal complications §UD parameters not well established §High pressures l (McGuire, Bennet)>50 l (Wyndale)>70 §Duration of contraction

21 Potential Complications of DSD §Bladder reflux (urine, pressure, bacteria) §Hydronephrosis §Pyelonephritis, urosepsis §Renal stones §Renal dysfunction

22 Bladder Reflux

23 Management of DSD §Establish low pressure storage and emptying §Ideal Rx should be: l Least invasive l Non-permanent l Lifestyle dependent l Of low risk

24 Current DSD Management §Recommended Rx: l Anticholinergics + IC, (? Alpha blockers) l suprapubic tapping l Sphincterotomy (males) + Ext. cath. l Bladder Augmentation §Not recommended: l Indwelling cath. l Crede l Cholinergics (bethanachol)

25 Pharmacological Rx §Anticholinergics (Ditropan, Imiprimine) relax spastic bladder l SEs - dry mouth, dizziness l Tolterodine (Detrol - ? Less SEs §Cholinergics (Bethanechol) dont work well - not recd §Alpha-blockers (Phenoxybenzamine, Hytrin,) partially block internal sphincter - some clinical effectiveness, hypotension

26 Pharmacological Rx (cont.) §Alpha stimulants (Ephedrine) may increase sphincter pressure - limited usefulness §no drug selectively relaxes the striated muscle of the pelvic floor & external sphincter (Baclofen, Valium, Dantrium)

27 Other Pharmacological Rxs §Intravesicular oxybutinin (ditropan) l well tolerated, costly §Capsacin (intravesicular) l blocks afferents C-fibers l incs bladder capacity l not well tolerated (burning, AD, hematuria) §DDAVP (anti-diuretic hormone) l intranasal

28 Invasive bladder Rxs §Intrathecal Baclofen (Nanninga) l dec. pressure, inc. residual & continence §Pudendal nerve block (7% phenol) l decreased bladder (Ko)

29 Botulism A Toxin (botox) §local perineal M. injection §inhibits Ach. at NMJ §relaxes external sphincter §effective (Petit: decreased bl. Pr.20cm & residual by 175ml) §repeat at 3 months §Indications: l consideration for sphincterotomy l difficulty with IC

30 External Sphincterotomy §indicated with refractory DSD §not recommended before 9-12 months §Potential complications: l reoperation (15-25%) l XS bleeding (5%) l erectile dysfunction (3-60%) - 12-oclock location recd §Laser Sphicterotomy

31 Augmentation Enterocystoplasty §entero=GI tract, cysto = bladder §Goal: convert a small non-compliant bladder to a low pressure urine reservoir §Indications: l failure of med. Rx l upper tract deter./reflux l (Bennett) decrd - Bl Pr. 55cm Incd-Bl capacity (350ml) incd QOL

32 Abdominal Urinary Stoma §Ureterostomy §Ileal conduit diversion

33 Sphincter Balloon Dilation §Balloon dilation of the prostatic urethra §some long-term success l decreased voiding pressure l decreased residual

34 Urethral Stents §endoluminal wire mesh prosthesis to maintain patency of the membranous urethra (Chancellor) §Goal: decrease voiding pressure & residual urine, resolve hydronephrosis §Long-term results disappointing (Low) l failure, residual urine, stones, reflux l high removal rate

35 Urethral Stents

36 Bladder Functional Electrical Stimulation (FES) §FES: l bladder storage l bladder emptying

37 Bladder FES §FES to increase bladder storage l reflex inhibition (pudendal, penile ns, anal plugs) §FES to Restore Bladder Emptying l sacral root stim. (Brindley 70) accompanied by post. Root rhizotomy good success rate compls: loss of erectile fnt l detrusser myoplasty gracilis muscle E. stim

38 VOCARE Bladder FES System (Neurocontrol)

39 VOCARE Bladder System (Neurocontrol) §Benefits l Elimination of urethral catheters l Decreased incidence of wetness l Improved bladder emptying l Decreased incidence of UTIs §Indications l complete SCI l reflexic bladder

40 VOCARE (cont.) §Surgery l posterior rhizotomy (prevents reflex conts) l FES to bladder nerves l receiver-stimulator implanted in abdominal wall l external controller - transmits signal §(Brindley): the 1st 500 patients l 84% still utilize (mean 4 yrs) l inadequate (6%), painful (1%)

41 Urologic Rx in Females §Recs: Antichol. + IC §non-suitable external incontinence device §inability (Tetras) to perform IC §Abhorrence of padding §Indwelling cath remains an option l added compl. of leakage around cath. §Functional Electrical Stim. §Priority: better Rx options in females/SCI (NIDRR)

42 Urinary Tract Infections (UTI) §1 million UTIs in USA §1/2 of all hospital-acquired infections = UTI §strong asso. with catheters §most frequent acute & chronic medical complication following SCI

43 Urinary Tract Infections §def = bacteriuria (>100K) + tissue response (>8WBC/hpf) §>90% incidence w/indwelling cath §66% with long-term IC will have recurrent/chronic UTIs §80% with reflex void & ext. cath. - UTIs §sphict. + CC Reveals dec. bacteriuria (Cardenas)

44 Risks for Recurrent UTIs §Lapides 74 l bladder mucosa changes and decreased host resistance increased pressure overdistension l foreign bodies (catheters) §IC at discharge but condom cath at f/u

45 Rx of UTIs §maximize fluids, keep abdomen, perineum, urethra, catheters CLEAN! §Treat all UTIs but utilize antibiotics only for symptomatic UTIs l bacterial resistance with overuse of antibiotics l symptomatic UTI = fever, pain, malaise, hematuria, incont., spasticity, cloudy urine l Dx: bacteriuria + pyuria >8-10 WBC/hpf

46 Rx of UTIs (cont.) §? Effectiveness l prophilactic abx. (Bactrim, Nitrofurantoin) l acidifying urine with mandelamine, vit. C, etc. §R/o bladder/renal Stones l nidus for infection l R/o hypercalciuria, hyperuricosuria l Prompt removal Lithotripsy percutaneous nephrolithotomy

47 Long-term Renal Monitoring §Goal - functional (F) and anatomical (A) assessment w/o invasiveness (I) l intravenous pyelogram - (A), (I) l renal ultrasound - (A) l Urodynamics - (A) & (F), (I) l Renal scan - (F) l Creatinine Clearance l BUN/Creatinine, U/A, cytology

48 Conclusions §IC & Fluids §Evaluate for Reflexic vs Areflexic bladder §consider antichol. Med, alpha stims §later: sphincterotomy, augmentation §recurrent UTI warrants investigation §long-term renal/bladder monitoring

49 Promising studies §Intravesicular drugs §nerve blocks §stents §bladder FES

50 Urologic care of patients with SCI is one of the more important factors to define their prognosis and quality of life

51 Q & A

52 Neurogenic Bowel in SCI §A potentially life-altering impairment §Complications: l DWE (difficulty w/ evacuation) (20%) l impaction (6.9% ) l ileus (4.6%) l pancreatitis (2.2%) l PUD (1.4%) l Autonomic dysreflexia

53 Colon NeuroPhysiology §GI innervation l Vagal Parasympathetic - to transverse colon l Sacral Parasymp. (pelvic N.) -distal to descendig colon and rectum l Sympathetic (Hypogastric N.) l Somatic (Pudendal N.) - EAS §Colonic wall (intramuscular) movement l Aurbachs plexus l Meissners plexus

54 Colon NeuroPhysiology §Maintain fecal continence l Tonic Internal Anal Sphincter (IAS) - (smooth m.) l Reflex contraction of External Anal Sphincter (EAS) - (striated M.) l 90 degree anorectal angle (puborectalis sling) §Defecation l urge - rectal & Puborect. Stretch l relaxation of Puborect and EAS l increased abdominal pressure

55 Neurogenic Bowel post SCI §spinal shock phase - loss of reflex-mediated defecation §slowed colonic transport l 80 hrs (SCI) vs. 39 hrs (Normal) §Reflexic vs Areflexic bowel

56 Assessment of Neurogenic Bowel §patient hx (GI function, diet, symptoms, activity, meds) §P. Exam (anal tone, BC reflex, occult blood) §Physical Function (balance, UE fnt, spasticity, xfer ability, home assess., ability to learn & direct)

57 Management of Neurogenic Bowel §The bowel program should provide predictable & effective elimination. §Bowel programs should be revised as needed throughout the continuum. §Maintain bowel care regimen for 3-5 days prior to considering possible modifications.

58 Bowel Medications §dietary fiber & bulking (bran) - fluid retention w/i colon to inc bulk and softness §stool softeners (docusate) -decrease firmness §stimulant laxatives (bisacodyl) - inc. mucosal stim. & decrease transit time §osmotic laxatives (sorbitol, lactulose, mag citrate) - retain H2O to dec. transit time

59 Bowel Program Components: §diet (fiber) & fluids §meds (stool softeners, bulking agents) §rectal stimulant (suppository, digital) §timing §positioning §assistive techniques (valsalva, abd massage)

60 Q&A


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