Transcript LONG-TERM UROLOGIC MANAGEMENT FOLLOWING SPINAL …

LONG-TERM UROLOGIC
MANAGEMENT FOLLOWING
SPINAL CORD INJURY
William McKinley MD
Director SCI Rehab Services
Dept PM&R
MCV/VCU
Objectives
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Areflexic vs Reflexic Bladder
Importance: “DSD” and Urodynamics
Current Rxs
“Potential” new Rxs
Urologic Rx in females
UTI’s
Long Term follow-up
Mortality Associated with Renal
Dysfunction Following SCI
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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 complications of the “high
pressure bladder”
 Education to patient/family
 Follow-up Testing
Complications of Neurogenic
Bladder
 Morbidity
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UTI, Pyelonephitis, Stones, Renal dz.
Spasticity, Aut. Dys., Pressure Ulcers
 Mortality
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Sepsis, Renal dz
 Social
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Incontinence
Sexuality
Potential Treatments
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Catheters
Fluid Control
Medications
Surgery
“Manual” techniques
Depends (diapers)
“New” alternatives
“Do Nothing”
“Acute” Urological Care
Following SCI
 “temporary” use of indwelling Catheter &
fluids (Lloyd)
 Intermittent Cath (IC) + Fluid Control
 Sterile vs. “Clean” IC
Sterile vs. “Clean” IC
 Sterile technique
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sterile gloves
new catheters
costlier $$
 “Clean” technique (Lapides)
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wash hands
reuse catheters (povidine-iodine/boiling) and
storage
easier compliance, safe and effective (Maynard)
Complications with “long-term”
Indwelling Catheter
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recurrent/chronic UTI’s
prostatitis/epididymitis
urethral fistulas
bladder stones
bladder cancer (10% with >10 yrs)
Suprapubic vs. Urethral Catheter
 invasive
 similar risks: UTI’s, stones, cancer
 reserved for those with urethral injury
“Ideal” Outcome of long-term
Rx: “Balanced Bladder”
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Minimize UTI’s
Low Pressure voiding
Low post-void residuals
Continence
Bladder Anatomy
 Pontine micturation center
 Bladder (detrusser muscle) Parasympathetic (S2-4) cholinergic
innervation (+stretch sens.)
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Sympathetic (T9-12) inhibits 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) 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) at @ 3 months
Urodynamics
 Cystometrogram + sphincter EMG
 “key” findings about bladder
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sensation, filling/emptying
involuntary contractions (reflexic) & duration
bladder pressure
“Dysynergia”!!!
Urodynamics
Areflexic Bladder
 No emptying ability w/o
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catheterizaiton
external compression (“crede”)
overflow!
 Long-term hypocompliance is seen (10%)
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high pressure bladder
long-term renal deterioration
 Rx-IC (fluids) vs. crede
Reflexic Bladder
 Non-voluntary contractions with filling
 can assist with emptying bladder
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post void residuals (UTI’s)
 Detrusser-sphincter dysynergia (DSD)
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long-term renal dysfunction
Detrusser Sphincter Dysynergia
(DSD)
 Normal (synergistic) Micturation is initiated
by:
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increase in detrusser pressure
relaxation of urethral sphincter
voiding pressure<40 cm
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simultaneous contraction of sphincter &
detrusser
no synergy (Dysynergia = DSD)
DSD
 Incidence = up to 50% (Blaivas, Yallo)
 Increased bladder reflex voiding Pressures
to lead to renal complications
 UD parameters not well established
 High pressures
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(McGuire, Bennet)>50
(Wyndale)>70
 Duration of contraction
Potential Complications of DSD
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Bladder reflux (urine, pressure, bacteria)
Hydronephrosis
Pyelonephritis, urosepsis
Renal stones
Renal dysfunction
Bladder Reflux
Management of DSD
 Establish low pressure storage and
emptying
 Ideal Rx should be:
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Least invasive
Non-permanent
Lifestyle dependent
Of low risk
“Current” DSD Management
 Recommended Rx:
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Anticholinergics + IC, (? Alpha blockers)
suprapubic tapping
Sphincterotomy (males) + Ext. cath.
Bladder Augmentation
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Indwelling cath.
Crede
Cholinergics (bethanachol)
Pharmacological Rx
 Anticholinergics (Ditropan, Imiprimine)
relax spastic bladder
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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
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)
Other Pharmacological Rx’s
 Intravesicular oxybutinin (ditropan)
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well tolerated, costly
 Capsacin (intravesicular)
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blocks afferents C-fibers
inc’s bladder capacity
not well tolerated (burning, AD, hematuria)
 DDAVP (anti-diuretic hormone)
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intranasal
“Invasive” bladder Rx’s
 Intrathecal Baclofen (Nanninga)
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dec. pressure, inc. residual & continence
 Pudendal nerve block (7% phenol)
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decreased bladder pressure @20cm (Ko)
Botulism A Toxin (botox)
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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:
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consideration for sphincterotomy
External Sphincterotomy
 indicated with refractory DSD
 not recommended before 9-12 months
 Potential complications:
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reoperation (15-25%)
XS bleeding (5%)
erectile dysfunction (3-60%) - 12-o’clock
location rec’d
 Laser Sphicterotomy
Augmentation Enterocystoplasty
 “entero”=GI tract, “cysto” = bladder
 Goal: convert a “small” non-compliant
bladder to a “low pressure” urine reservoir
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failure of med. Rx
upper tract deter./reflux
(Bennett) decr’d - Bl Pr. 55cm
• Inc’d-Bl capacity (350ml)
• inc’d QOL
Abdominal Urinary Stoma
 Ureterostomy
 Ileal conduit diversion
Sphincter Balloon Dilation
 Balloon dilation of the prostatic urethra
 some long-term success
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decreased voiding pressure
decreased residual
“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)
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failure, residual urine, stones, reflux
high removal rate
Urethral Stents
Bladder Functional Electrical
Stimulation (FES)
 FES:
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bladder storage
bladder emptying
Bladder FES
 FES to increase bladder storage
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reflex inhibition (pudendal, penile n’s, anal
plugs)
 FES to Restore Bladder Emptying
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sacral root stim. (Brindley ‘70)
• accompanied by post. Root rhizotomy
• good success rate
• compl’s: loss of erectile fnt
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detrusser myoplasty
• gracilis muscle E. stim
“VOCARE” Bladder FES
System (Neurocontrol)
“VOCARE” Bladder System
(Neurocontrol)
 Benefits
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Elimination of urethral catheters
Decreased incidence of wetness
Improved bladder emptying
Decreased incidence of UTI’s
 Indications
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“complete” SCI
“reflexic” bladder
VOCARE (cont.)
 Surgery
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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
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84% still utilize (mean 4 yrs)
inadequate (6%), painful (1%)
Urologic Rx in Females
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Recs: Antichol. + IC
non-suitable external incontinence device
inability (Tetra’s) to perform IC
Abhorrence of “padding”
Indwelling cath remains an option
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added compl. of leakage around cath.
 Functional Electrical Stim.
 Priority: better Rx options in females/SCI
Urinary Tract Infections (UTI)
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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
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)
Risks for Recurrent UTI’s
 Lapides ‘74
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bladder mucosa changes and decreased host
resistance
• increased pressure
• overdistension
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foreign bodies (catheters)
 IC at discharge but condom cath at f/u
Rx of UTI’s
 maximize fluids, keep abdomen, perineum,
urethra, catheters CLEAN!
 Treat all UTI’s but utilize antibiotics only
for “symptomatic” UTI’s
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bacterial resistance with overuse of antibiotics
symptomatic UTI = fever, pain, malaise,
hematuria, incont., spasticity, cloudy urine
Dx: bacteriuria + pyuria >8-10 WBC/hpf
Rx of UTI’s (cont.)
 ? Effectiveness
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prophilactic abx. (Bactrim, Nitrofurantoin)
acidifying urine with mandelamine, vit. C, etc.
 R/o bladder/renal Stones
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nidus for infection
R/o hypercalciuria, hyperuricosuria
Prompt removal
• Lithotripsy
• percutaneous nephrolithotomy
Long-term Renal Monitoring
 Goal - functional (F) and anatomical (A)
assessment w/o invasiveness (I)
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intravenous pyelogram - (A), (I)
renal ultrasound - (A)
Urodynamics - (A) & (F), (I)
Renal scan - (F)
Creatinine Clearance
BUN/Creatinine, U/A, cytology
Conclusions
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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
Promising studies
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Intravesicular drugs
nerve blocks
stents
bladder FES
“Urologic care of patients with
SCI is one of the more important
factors to define their prognosis
and quality of life”
Q&A
Neurogenic Bowel in SCI
 A potentially life-altering impairment
 Complications:
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DWE (difficulty w/ evacuation) (20%)
impaction (6.9% )
ileus (4.6%)
pancreatitis (2.2%)
PUD (1.4%)
Autonomic dysreflexia
Colon NeuroPhysiology
 GI innervation
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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
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Aurbachs plexus
Meissners plexus
Colon NeuroPhysiology
 Maintain fecal continence
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Tonic Internal Anal Sphincter (IAS) - (smooth
m.)
Reflex contraction of External Anal Sphincter
(EAS) - (striated M.)
90 degree anorectal angle (puborectalis sling)
 Defecation
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“urge” - rectal & Puborect. Stretch
relaxation of Puborect and EAS
Neurogenic Bowel post SCI
 spinal shock phase - loss of reflex-mediated
defecation
 slowed colonic transport
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80 hrs (SCI) vs. 39 hrs (Normal)
 Reflexic vs Areflexic bowel
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)
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.
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
Bowel Program Components:
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diet (fiber) & fluids
meds (stool softeners, bulking agents)
rectal stimulant (suppository, digital)
timing
positioning
assistive techniques (valsalva, abd massage)
Q&A