Tiddles: an overview of bladder symptoms

Dr Jason Ward

Outline

• Catheter problems

• Irritable bladder/bladder spasm

• Haematuria

• Fistulae

• Pain

Norman

• 75 year old man with glioblastoma

• Urinary catheter for 10/7 for incontinence

• Bed bound

• Recurrent bypassing despite catheter change

• 16Ch long term catheter

Indwelling urinary catheters• Need long term catheter if > 14/7

– silicone or hydrogel coated latex

• Catheter size– depends on urine not patient size– 1 Ch (FG)= 0.33m, 12Ch=4mm, 16Ch=6mm– 16-18Ch if debris – 10mls water in balloon

• Drainage bag – below level of bladder and keep system closed

By-passing catheter

• Causes– twisted drainage tube

– constipation

– blockage with debris

– bladder spasm

• Treatment– exclude UTI

– reduce water in balloon

– smaller catheter

– anti-cholinergic drugs

– bladder washouts

Encrustation/infection 1

• 90% long term catheters bacteriuria in 4/52

• 50% recurrent encrustation– urease producing bacteria i.e Proteus spp– materials in lumen & biofilm on catheter

surface– struvite (magnesium ammonium phosphate) +

calcium phosphate

Encrustation 2

• Avoid long term antibiotics

• No firm evidence for cranberry juice/vitamin C

• Planned catheter changes every 6/52

• Bladder washouts – used in 36-44% long term catheter patients – no studies unequivocally confirm they decrease

UTI, but may help encrustation

Bladder washouts• Avoid chlorhexidine

• 0.9% Normal saline– used to flush debris, small clots

• Solution G (3.23% citric acid + Mg)– if pH 7.4-7.7 reduces encrustation

• Solution R (6% citric acid + Mg)– if pH > 8.0 dissolves encrustation

• Mandelic acid 1%– reduces Pseudomonas spps

Clot retention

• 3 way urethral catheter 22/24F

• Saline or water continuous irrigation

• If unable to pass catheter – NOT suprapubic– Need endoscopic evaluation

Miscellaneous

• Chronic retention– no need to decompress bladder slowly

• Catheter clamping– avoid, no evidence that it is beneficial

• Catheter valves– useful for ‘rehab’ patients

Irritable bladder/spasm

• Frequency, urgency, urge incontinence

• Spasm – deep, suprapubic/tip penis, seconds to minutes

Oxybutynin

• Tertiary amine – high affinity for ACh(M) - particularly M3 – direct anti-spasmodic effect on bladder

• Superior to placebo for detrussor instability

• Side effects - dose related, anti-ACh– 57-93% on 5mg tds, 23% – modified release less SE but as effective

Newer antimuscarinic drugs

• Tolterodine (Detrusitol)– selective M3 in bladder > salivary glands – 2mg bd– as effective as oxybutynin but better tolerated– similar SEs but fewer

• Trospium Chloride (Regurin)– non-selective ACh(M), does not cross BBB– No RCTs looking at symptoms

• Propiverine (Detrunorm) – Anti-ACh(M) + Ca channel actions– Decrease detrussor muscle contractions– 15mg bd-tds– Few trials in detrsussor instability – ?less frequent SEs

• Flavoxate– no anti-ACh action – reduces bladder contractions in vitro and vivo– no RCTs to show benefit over placebo

Other anti-spasmodics

• Imipramine, amitriptyline

• Intra-vesicle capsacin

• Benzodiazepines

• NSAIDs

• Hyoscine

• Sympathomimetics

Stan

• 83 year old man

• Carcinoma bladder treated with RXT

• Normal coagulation

• Persistent haematuria – symptomatic anaemia

Haematuria

• Bladder installations – saline– alum– silver nitrate – phenol, formalin (need anaesthetic) – tranexamic acid

• Vascular embolization– hypogastric artery

Bladder radiotherapy

• 17-21Gy 2/3# vs 30-36Gy 5-10#

• Improvement in symptoms – haematuria 52-85%– pain 68%– urgency 55%

• Side effects– Diarrhoea 42-68% with 21Gy

Tranexamic acid

• ? Risk of clotting – 3/6 patients pre-prostatectomy developed clots– 0/100 patients developed clots when used 24hrs

post prostatectomy – 0/5 patients with cancer related haematuria– can cause existing clots to become tenaceous – CI upper tract bleeding(ureteral obstruction)

• Ethamsylate ?safer

Fistulae

• Vesicoenteric

• Vesicovaginal• Urethrocutaneous• Rectourthral

• Pneumaturia, faecal matter in urine, odour, UTIs

• Urine PV• Mass, urine drainage• Urine PR, pneumaturia

Management

• Surgical repair

• Urinary diversion

• Ileostomy

• Urinary catheters

Bladder pain

• Reversible factors

• WHO Ladder

• Adjuvants– ?NSAIDs– anti-cholinergics

• Intra-vesicle lignocaine

• Spinal opioids