Download Lower Urinary Tract Symptoms (includes ketamine cystitis)

Lower Urinary Tract Symptoms
(includes ketamine cystitis)
Dr Peggy CHU
Tuen Mun Hospital
Lower Urinary Tract Symptoms (LUTS)
• Storage symptoms
– Urgency, frequency, urge incontinence, nocturia
• Voiding symptoms
– Weak or intermittent stream, straining, hesistancy,
terminal dribbling or incomplete emptying
• Post micturition symptoms
– Post micturition dribbling
Anatomical causes of LUTS
• Bladder
– Overactive bladder, e.g post CVA
– UTI
• Prostate
– Benign prostatic enlargement
• Urethral
– Urethral stricture, e.g years post gonorrhoea
• Urinary sphincter
LUTS
• ↑ as ages ↑
• Can occur up to 30% man aged > 65 yrs
• ↓ QOL
• May point to pathology of urinary tract
LUTS: Initial Assessment
• Med Hx to identify possible causes, comorbidities, drugs
• P/E: abd, genitalia, Digital rectal exam (DRE)
• IPSS (to allow assessment of subsequent
symptom change)
• Freq vol chart
• Urine x dipstick: blood, glucose, protein,
leucocytes & nitrites
• +/- PSA
LUTS: IPSS + QOL
LUTS: IPSS Chinese
www.hkua.org
LUTS: QOL Chinese
www.hkua.org
LUTS: Initial Assessment
+/- PSA testing in cases of
• LUTS are suggestive of benign prostatic
enlargement
• Prostate feels abn on DRE
Freq-vol chart
Freq-vol chart
• frequency
Compulsive
water drinking
C/O : frequency
urinary
incontinence
LUTS: when is referral necessary
If LUTS Cx by
• Recurrent /persistent symptomatic UTI
• Urinary retention
• Renal impairment suspected to be caused by
lower urinary tract dysfunction
• Suspected urological cancer
• Bordersome LUTS not responding to
conservative management or drug
LUTS: Role of conservative Px
LUTS with storage symptoms
• Fluid intake
• Lifestyle changes ( avoid coffee, tea etc)
• Supervised bladder training
• Temporary containment products ( pads)
LUTS: post micturition dribbling
• Loss of a few drops of urine after the main
urine stream has finished
• Happens when rearranging trousers
• Can result in wet and stained clothing
LUTS: post micturition dribbling
Aetiology
urethra not emptied by muscles surrounding it
“sump” of urine pools in urethra
↑ when ages ↑
Treatment
push the last few drops of urine from the
urethra with the fingers before the final shake
LUTS: post micturition dribbling
Technique
• pass urine in usual manner & wait for a few sec
for bladder to empty
• Place finger tips of hand 3 finger widths behind
scrotum and press gently towards base of penis
• Can be repeated
LUTS: Drug treatment
LUTS: Drug treatment
• Alpha blocker
– Same efficacy, difference in S/E (due to difference
in T ½ and uroselectivity)
– Precaution in patients also taking beta blocker
– Postural hypotension
• Anticholinergic
– Avoid in closed angle glaucoma
– Dry mouth, constipation
Ketamine Cystitis
Ketamine (C13H16CINO)
(2-(o-Chlorophenyl)-2-(methylamino) cyclohexan-1-one
• Anaesthetic agent, “dissociative anesthesia”
• Rapid onset, short duration of action
• N-dealkylated in liver, metabolized and excreted in urine
(>90%)
Hong Kong Statistics
Central Registry of Drug Abuse 58th Report
Patients
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TMH
Sep 2006 - Jun 2010
113 patients
M: F = 90: 43
mean age 25.6 yrs (14 – 42)
years of ketamine abuse: 3/12 to 11 years
referred by A&E, GP, psychiatrist
C/O: LUTS+ve
Lower Urinary Tract Symptomatology
• frequency, urgency, dysuria, urge incontinence, painful
haematuria
• urine culture –ve
• no response to multiple courses of oral antibiotics
Normal bladder
“ketamine bladder”
normal bladder
bladder of ketamine abuser
Upper Urinary Tract
• blood creatinine
• +/- hydronephrosis
• papillary necrosis
• ureteric stricture
Blood Creatinine
• 10/113
– Creatinine 126 - 1069
– 2 required PCN
Upper Tract Radiology
• all have renal USG
– 30%
– 10%
bilateral hydronephrosis
unilateral hydronephrosis
Pathophysiology
? chronic submucosal inflammatory response
resulting from chemical cystitis
? microvascular changes
? autoimmune (raised ESR & C3/4)
? bacteriuria
Treatment
 Antibiotics
 Antimuscarinic agent (oxybutynin, detrusitol)
 ? Cystoplasty
   ABSTINENCE
New Problems with ketamine abuse
Guidelines (before Jun 2008)
 25 g
25 – 400 g
400 - 800 g
 800 g
within discretion of sentencer
2 - 4 yrs’ imprisonment
4 - 8 yrs
 8 yrs
Guideline (after Jun 2008)
1g
1 - 10 g
10 - 50 g
50 - 300 g
300 - 600 g
600 - 1000 g
 1000 g
within discretion of sentencer
2 - 4 yrs’ imprisonment
4 - 6 yrs
6 - 9 yrs
9 - 12 yrs
12 - 14 yrs
 14 yrs
Thank You