neurogenic bladder speaker name: jenna katorski rn cnp · neurogenic bladder disclosure information...
TRANSCRIPT
JENNA KATORSKI RN CNP
GILLETTE LIFETIME SPECIALTY HEALTHCARESAINT PAUL, MINNESOTA
Neurogenic Bladder
Disclosure InformationAACPDM 67th Annual Meeting October 16-19, 2013
Speaker Name: Jenna Katorski RN CNP
Disclosure of Relevant Financial Relationships
I have no financial relationships to disclose.
Disclosure of Off-Label and/or investigative uses:
I will not discuss off label use and/or investigational use in my presentation
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
Symptoms of Neurogenic Bladder
� Inability to control urination
or urinary incontinence
� Recurrent urinary tract infections
� Dribbling, straining or inability to urinate or urinary retention
� Hydronephrosis on imaging
Neurogenic Bladder Complications
� Renal damage/failure secondary to high bladder pressures
� Renal stones or bladder stones
� Vesicoureteral reflux (VUR)
� Increased risk for UTIs and pyleonephritis, especially if VUR present
Assessment Tools
� Patient History
� Void/cath/leak diary
� Bladder scan (post void residual)
� Renal ultrasound
� Cystometrogram (urodynamics)
� Advanced imaging
CYSTOMETROGRAM (CMG)
URODYNAMIC STUDIES (UDS)
Urodynamics
What Are Urodynamics?
� 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
� 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
Normal Bladder Function on CMG
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
� PVR should be < 10% of bladder capacity
What Can You Learn From UDS?
� Sensation
� Detrusor compliance
� Detrusor over activity (uninhibited contractions)
� Leak point pressure
� Capacity
� Sphincter muscle activity
Neurogenic Bladder Classifications
Bladder, Outlet or Both
� Bladder dysfunction� Overactive
� Uninhibited detrusor contractions
� urgency/frequency/leakage
� 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
PadsPads BriefsBriefs
Non-invasive incontinence products
Male External CatheterMale External Catheter Female External CatheterFemale External Catheter
External Catheters Indwelling Catheters
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
� Positioning
� Urethral Events
� Scrotal Events
� Bladder Events
� Pain
� Urinary Tract Infections
Catheters
Open vs Closed Catheters for IC
� Open
� Sterile catheter is packed separately
� Closed System
� Catheter drainage bag is connected in one entire sterile system
Catheter Tips
� Straight � Coude
� 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
� 5FR-10FR
� Adult
� 8FR-18FR
� Lengths
� 14”-16”
� 6” = Female
� Foley balloon size
� 5-30ml
Medical Management Options
Timed Toileting
� Schedule time to toilet to routinely empty bladder
Functional Toileting Evaluation
� Environmental
� Communication
� Spasticity and tone management
� Equipment
� Bracing
Medications
� Anticholinergic Medications:
� Reduce uninhibited bladder contractions; improves bladder storage and pressures.
� Routes: oral or topical (patch & gel)
Considerations When Prescribing
� Side Effects
� Safety vs tolerability
� Worsening conditions
� Frequency/Route
� Memory/executive function concerns
� Dexterity
Common Antimuscarinics: Receptor
� Darifenacin (Enablex): M3
� Fesoterodine (Toviaz): M2 & M3
� Oxybutynin (Ditropan) M2 & M3� Ditropan IR� Ditropan XL � Oxytrol patch � Gelnique 10% transdermal gel
� Solifenacin (Vesicare): M2 & M3
� Tolterodine (Detrol): M2 & M3� 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 GI Effects -Constipation
Headache Other
Darifenacin(Enablex):
19-35% <1% 15-21% 7%
Fesoterodine(Toviaz):
19-35% 4-6%
Oxybutynin(Ditropan)
Oral: 29-71%Topical 2-12%Transdermal 4-10%
Oral 1-5% Oral 1-<5% Oral 7-15%Topical 1%Transdermal 3%
Oral: 6-10%Topical 2%
Topical and transdermal site reaction 4-17%
Solifenacin(Vesicare):
11-28% <1% 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% Increase HR with escalating dose, no prolongation
Mirabegron (Myrbetriq)
3% 9-11% 2-3% 4%
GILLETTE LIFETIME SPECIALTY HEALTHCARE
ADULT UROLOGY
Screening & Surveillance
Purpose
� 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
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 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 yrSuprapubic 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)
Risk of transitional cell carcinoma, stone formation, metabolic acidosis, vitamin B12 deficiency
Ileal Conduit Risk of transitional cell carcinoma, stone formation, metabolic acidosis, vitamin B12 deficency.
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.
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
Indiana Pouch (Continent Cutaneous Pouch)
Annual: RBUS, KUB X-ray, Cr, BUN, Electrolytes, & Vitamin B12Annual after 10 yrs: RBUS, KUB X-ray, Cr, BUN, Electrolytes, Vitamin B12 &
Urine Cytology
Ileal Conduit Annual: RBUS, KUB X-ray & Vitamin B12Annual 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
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.
PLEASE WELCOME
DR. CHARLES DURKEE
ASSOCIATE PROFESSOR, PEDIATRIC UROLOGY CHILDREN'S HOSPITAL OF WISCONSIN
MEDICAL COLLEGE OF WISCONSIN
Thank you!