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LONG-TERM UROLOGIC MANAGEMENT FOLLOWING SPINAL CORD INJURY

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Presentation on theme: "LONG-TERM UROLOGIC MANAGEMENT FOLLOWING SPINAL CORD INJURY"— 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 UTI’s 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 UTI, Pyelonephitis, Stones, Renal dz. Spasticity, Aut. Dys., Pressure Ulcers Mortality Sepsis, Renal dz Social Incontinence 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 “Clean” technique (Lapides)
sterile gloves new catheters costlier $$ “Clean” technique (Lapides) wash hands reuse catheters (povidine-iodine/boiling) and storage easier compliance, safe and effective (Maynard)

9 Complications with “long-term” Indwelling Catheter
recurrent/chronic UTI’s prostatitis/epididymitis urethral fistulas bladder stones bladder cancer (10% with >10 yrs)

10 Suprapubic vs. Urethral Catheter
invasive similar risks: UTI’s, stones, cancer reserved for those with urethral injury

11 “Ideal” Outcome of long-term Rx: “Balanced Bladder”
Minimize UTI’s Low Pressure voiding Low post-void residuals Continence

12 Bladder Anatomy Pontine micturation center
Bladder (detrusser muscle) - Parasympathetic (S2-4) cholinergic innervation (+stretch sens.) 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 sensation, filling/emptying involuntary contractions (reflexic) & duration bladder pressure “Dysynergia”!!!

16 Urodynamics

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

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

19 Detrusser Sphincter Dysynergia (DSD)
Normal (synergistic) Micturation is initiated by: increase in detrusser pressure relaxation of urethral sphincter voiding pressure<40 cm In reflex bladder, we see: simultaneous contraction of sphincter & detrusser 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 (McGuire, Bennet)>50 (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: Least invasive Non-permanent Lifestyle dependent Of low risk

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

25 Pharmacological Rx Anticholinergics (Ditropan, Imiprimine) relax spastic bladder SE’s - dry mouth, dizziness Tolterodine (Detrol - ? Less SE’s Cholinergics (Bethanechol) don’t work well - not rec’d 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 Rx’s
Intravesicular oxybutinin (ditropan) well tolerated, costly Capsacin (intravesicular) blocks afferents C-fibers inc’s bladder capacity not well tolerated (burning, AD, hematuria) DDAVP (anti-diuretic hormone) intranasal

28 “Invasive” bladder Rx’s
Intrathecal Baclofen (Nanninga) dec. pressure, inc. residual & continence Pudendal nerve block (7% phenol) 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: consideration for sphincterotomy difficulty with IC

30 External Sphincterotomy
indicated with refractory DSD not recommended before 9-12 months Potential complications: reoperation (15-25%) XS bleeding (5%) erectile dysfunction (3-60%) - 12-o’clock location rec’d Laser Sphicterotomy

31 Augmentation Enterocystoplasty
“entero”=GI tract, “cysto” = bladder Goal: convert a “small” non-compliant bladder to a “low pressure” urine reservoir Indications: failure of med. Rx upper tract deter./reflux (Bennett) decr’d - Bl Pr. 55cm Inc’d-Bl capacity (350ml) inc’d QOL

32 Abdominal Urinary Stoma
Ureterostomy Ileal conduit diversion

33 Sphincter Balloon Dilation
Balloon dilation of the prostatic urethra some long-term success decreased voiding pressure 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) failure, residual urine, stones, reflux high removal rate

35 Urethral Stents

36 Bladder Functional Electrical Stimulation (FES)
bladder storage bladder emptying

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

38 “VOCARE” Bladder FES System (Neurocontrol)

39 “VOCARE” Bladder System (Neurocontrol)
Benefits Elimination of urethral catheters Decreased incidence of wetness Improved bladder emptying Decreased incidence of UTI’s Indications “complete” SCI “reflexic” bladder

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

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

42 Urinary Tract Infections (UTI)
1 million UTI’s 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 UTI’s 80% with reflex void & ext. cath. - UTI’s sphict. + CC Reveals dec. bacteriuria (Cardenas)

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

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

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

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

48 Conclusions IC & Fluids Evaluate for Reflexic vs Areflexic bladder
consider antichol. Med, alpha stim’s 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: DWE (difficulty w/ evacuation) (20%) impaction (6.9% ) ileus (4.6%) pancreatitis (2.2%) PUD (1.4%) Autonomic dysreflexia

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

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

55 Neurogenic Bowel post SCI
spinal shock phase - loss of reflex-mediated defecation slowed colonic transport 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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