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
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 • • • • • • • • 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