Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Disclosure Information AACPDM 67th Annual Meeting October 16-19, 2013 Neurogenic Bladder Speaker Name: Jenna Katorski RN CNP Disclosure of Relevant Financial Relationships I have no financial relationships to disclose. JENNA KATORSKI RN CNP Disclosure of Off-Label and/or investigative uses: I will not discuss off label use and/or investigational use in my presentation GILLETTE LIFETIME SPECIALTY HEALTHCARE SAINT PAUL, MINNESOTA Objectives Identify symptoms of neurogenic bladder Describe how urodynamics are helpful in evaluation of neurogenic bladder Describe medical management options for neurogenic bladder Describe recommended follow up for patients with previous urologic surgeries/procedures Neurogenic Bladder Neurogenic Bladder Loss of normal bladder function caused by damage to part of the nervous system Resulting in the bladder and or the sphincter being: Underactive Overactive Neurogenic Bladder Complications Renal damage/failure secondary to high bladder pressures Vesicoureteral reflux (VUR) Renal stones or bladder stones Increased risk for UTIs and pyleonephritis, especially if VUR present Symptoms of Neurogenic Bladder Inability to control urination or urinary incontinence Dribbling, straining or inability to urinate or urinary retention Hydronephrosis on imaging Recurrent urinary tract infections Assessment Tools Patient History Void/cath/leak diary Bladder scan (post void residual) Renal ultrasound Cystometrogram (urodynamics) Advanced imaging What Are Urodynamics? Urodynamics CYSTOMETROGRAM (CMG) URODYNAMIC STUDIES (UDS) Tests to examine voiding disorders Focuses on the bladder’s ability to store and empty urine Tests may include Uroflow, CMG, EMG and Voiding pressure study Detrusor Pressure (Pdet) Pdetrusor=Pves-Pabd Pressure of bladder muscle Reading should be positive number and less than 10 at start of test When filling if Pdet >40cm/H2O, upper tracts are at risk. During Procedure Normal Bladder Function on CMG Patient asked to report First sensation First desire to void Strong desire to void Capacity Patient asked to perform Valsalva Cough Other activities reported to cause leakage Void at end of study Abnormal CMG EMG Sphincter muscles should relax when a patient voids. There can be a dis-coordination between the sphincter and the bladder in myleodysplasia and CP. Destrusor Sphincter Dyssynergia or DSD. Post-Void Residual (PVR) Performed after a uroflow or urination either by bladder scan or catheterization If catheterized, urine is drained and measured Estimated Bladder Capacity formula (age in years x 30) + 30 (up to age 12 at which EBC is 390ml). Adult bladder 400-500ml What Can You Learn From UDS? Sensation Detrusor compliance Detrusor over activity (uninhibited contractions) Leak point pressure Capacity Sphincter muscle activity PVR should be < 10% of bladder capacity Neurogenic Bladder Classifications Bladder, Outlet or Both Bladder dysfunction Overactive Uninhibited detrusor contractions urgency/frequency/leak age Non-compliant (low compliance) Results in leakage and/or upper tract risk Underactive Retention Overflow incontinence Outlet dysfunction Low resistance Incontinence High resistance Retention Mixed Management of Neurogenic Bladder What are the Goals? Prevent renal failure (less common in CP compared to patient’s with SB or SCI with neurogenic bladders. Maintain low/normal pressure during both filling and emptying Minimize UTIs Continence Means of emptying Functional volumes and schedule Adequate long term follow up Consider When Discussing Management Options Patient’s goals Mobility Hand function Spasticity and tone management Communication Availability/scope of care of PCAs/staff Environment/Schedule (home, school, day program, work, respite, camp, etc) Executive function/memory Non-invasive incontinence products Pads Briefs External Catheters Male External Catheter Indwelling Catheters Female External Catheter Intermittent Catheterization (IC) Intermittent Catheterization Techniques Clean technique & re-use catheter Clean technique with single use catheter Sterile technique with single use catheter Complications of Catheterization Catheters Positioning Urethral Events Scrotal Events Bladder Events Pain Urinary Tract Infections Open vs Closed Catheters for IC Open Sterile catheter is packed separately Closed System Catheter Tips Straight Coude Catheter drainage bag is connected in one entire sterile system Olive Catheter Options Coating: Uncoated latex free Silicone (Latex free) Uncoated Red rubber Latex Hydrophilic Antibiotic Catheter Sizes Sized in French (FR) FR=diameter (mm) * 3 Small FR number=small diameter Pediatric Lengths 14”-16” 6” = Female Foley balloon size 5-30ml 5FR-10FR Adult 8FR-18FR Timed Toileting Medical Management Options Schedule time to toilet to routinely empty bladder Functional Toileting Evaluation Environmental Communication Spasticity and tone management Equipment Bracing Considerations When Prescribing Side Effects Safety vs tolerability Worsening conditions Frequency/Route Memory/executive function concerns Dexterity Medications Anticholinergic Medications: Reduce uninhibited bladder contractions; improves bladder storage and pressures. Routes: oral or topical (patch & gel) Common Antimuscarinics: Receptor Darifenacin (Enablex): M3 Solifenacin (Vesicare): M2 & M3 Fesoterodine (Toviaz): M2 & M3 Tolterodine (Detrol): M2 & M3 Oxybutynin (Ditropan) M2 & M3 Ditropan IR Ditropan XL Oxytrol patch Gelnique 10% transdermal gel Detrol IR Detrol LA Trospium (Sanctura): M2 & M3 Sanctura IR Sanctura XR Mirabegron (Myrbetriq) Beta 3 Agonist Older Antimuscarinics Propantheline Hyoscyamine Common Side Effects Dry Mouth Flushing Hypertension <1% GI Effects Constipation Headache 15-21% 7% Other Darifenacin (Enablex): 19-35% Fesoterodine (Toviaz): 19-35% Oxybutynin (Ditropan) Oral: 29-71% Topical 2-12% Transdermal 410% Solifenacin (Vesicare): 11-28% 5-13% Case reports with QT interval prolongation Tolterodine (Detrol): 23-35% 6-7% Individual cases of tachycardia, peripheral edema and palpations reported, no case of torsade de pointes linked to drug. Trospium (Sanctura): 9-22% 9-10% 4-7% Mirabegron (Myrbetriq) 3% 2-3% 4% 4-6% Oral 1-5% Oral 1-<5% <1% 9-11% Oral 7-15% Topical 1% Transdermal 3% Oral: 6-10% Topical 2% Topical and transdermal site reaction 4-17% Increase HR with escalating dose, no prolongation Purpose Screening & Surveillance GILLETTE LIFETIME SPECIALTY HEALTHCARE ADULT UROLOGY Evaluation and management of NGB in adults is complex due to their past urologic history and surgeries. Identify patients at risk of upper tract damage and connect with appropriate urology resources. Background GLSHC provides services for adults with childhood onset disabilities. Majority of patients have transitioned from Gillette Children’s Specialty Healthcare. Urologic services at GLSHC include: Urologist Medical Urology (PM&R physician & NP) RN Imaging Urodynamics Diagnosis/Previous Surgery Why surveillance? Neurogenic Bladder: With/without retention, and/or on cath program, and/or on medications for bladder spasms, and/or recurrent UTIs Risk of hydronephrosis and upper tract damage. Indewelling catheter > 10 yr Suprapubic catheter > 10 yr Used for >10years increases risk of squamous cell carcinoma. Bladder Augmentation Risk of transitional cell carcinoma, bladder stone formation, metabolic acidosis. Bladder Augmentation-Ileal Used Risk of transitional cell carcinoma, bladder stone formation, metabolic acidosis and Vitamin B12 deficiency. Indiana Pouch (Continent Cutaneous Pouch) Ileal Conduit Nephrectomy, Solitary or Horseshoe Require close monitoring of remaining renal function for hydronephrosis, stone formation. New Hydronephrosis Need to evaluate for cause of hydronephrosis to reduce poor outcome of renal failure. Incontinent between catheterization or voids Need to evaluate for cause of leakage: UTI vs high pressure bladder vs incompetent sphincter. Methods Review of literature and recommendations from urologic surgeons who specialize in NGB. Resulted in a guideline outlining recommended urology services based on past medical/surgical history. Research is lacking to support some screening/surveillance for patient increased risk of bladder cancer Diagnosis/Previous Surgery Screening/Evaluation Neurogenic Bladder: With/without retention, and/or on cath program, and/or on medications for bladder spasms , and/or recurrent UTIs. Annual: Renal/Bladder US (RBUS) Bladder Augmentation Indewelling catheter > 10 yr Suprapubic catheter > 10 yr Annual: RBUS, Cr, BUN, Electrolytes Annual after 10 yrs : RBUS, Cr, BUN, Electrolytes, Cystoscopy & Urine Cytology Bladder Augmentation-Ileal Used Annual: RBUS, Cr, BUN, Electrolytes & Vitamin B12 Annual after 10 yrs : RBUS, Cr, BUN, Electrolytes, Vitamin B12, Cystoscopy & Urine Cytology Risk of transitional cell carcinoma, stone formation, metabolic acidosis, vitamin B12 deficiency Indiana Pouch (Continent Cutaneous Pouch) Risk of transitional cell carcinoma, stone formation, metabolic acidosis, vitamin B12 deficency. Annual: RBUS, KUB X-ray, Cr, BUN, Electrolytes, & Vitamin B12 Annual after 10 yrs: RBUS, KUB X-ray, Cr, BUN, Electrolytes, Vitamin B12 & Urine Cytology Ileal Conduit Annual: RBUS, KUB X-ray & Vitamin B12 Annual after 10 yrs: RBUS, KUB X-ray, Vitamin B12 & Urine cytology Nephrectomy, Solitary or Horseshoe Annual: RBUS & Cr New Hydronephrosis RBUS, CMG & Cr Incontinent between catheterization or voids UA/UC, RBUS & CMG (if UA/UC negative) Results Distribution and implementation of the guideline: Increased awareness Provided structure to annual follow up Helped nursing staff prepare patients for upcoming visits Coordinate services: imaging, labs, and records Identified patients who need to re-establish adult urologic care (2011-2012) increased from 106 to 154 out of a total of 178 adults with SB receiving other services at GLSH. Guided a patient education resource comparison and gap analysis creation of eight new urology patient education pieces Thank you! PLEASE WELCOME DR. CHARLES DURKEE ASSOCIATE PROFESSOR, PEDIATRIC UROLOGY CHILDREN'S HOSPITAL OF WISCONSIN MEDICAL COLLEGE OF WISCONSIN Discussion/Conclusion Recommendations will change based on new research developments and individual patient presentation/symptoms/needs. The tool helped providers to identify patients who require close urologic follow up Adult patients benefit from learning the potential risks they face based on their past surgeries and medical histories. May increase their understanding of the importance of ongoing urologic follow up and increase adherence to the guidelines in medical management and self-care.