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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2745_Библиотеки_им_академика_М_И_Перельмана
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Type of Medication Examples Potential Effects on Continence
Sedatives/hypnotics Long-acting
benzodiazepines
(e.g., diazepam,
flurazepam)
Sedation, delirium, immobility
Beta receptor
agonists
Terbutaline,
isoproterenol,
Myrbetriq
Urinary retention
Anticholinergics Dicyclomine,
oxybutynin,
antihistamines
Urinary retention, overflow
incontinence, delirium, fecal
impaction
Antipsychotics Thioridazine,
haloperidol
Anticholinergic actions, sedation,
rigidity, immobility
Antidepressants Amitriptyline,
desipramine
Anticholinergic actions, sedation
Corticosteroids Prednisone Increased urinary tract infections
Narcotic analgesics Opiates Urinary retention, fecal impaction,
sedation, delirium
α-Adrenergic
antagonists
Prazosin,
terazosin,
tamsulosin, etc.
Urethral relaxation may precipitate
stress incontinence in women
α-Adrenergic
agonists
Nasal
decongestants
Urinary retention in men
Calcium-channel
blockers
All, i.e.,
nifedipine,
nicardipine,
felodipine
Urinary retention: nocturnal diuresis
owing to fluid retention
Potent diuretics Furosemide,
bumetanide
Polyuria, frequency, urgency
Angiotensinconverting enzyme
inhibitors
Captopril,
enalapril, lisinopril
Drug-induced cough can precipitate
stress incontinence in women and in
some men with previous
prostatectomy
Chemotherapy Cyclophosphamide
(Cytoxan)
Vincristine
Bladder cancer risk
Urinary retention
Modified from Resnick NM. Geriatric incontinence. Urol Clin North Am.
1996;23(1):55-74.
Bladder Sensation Can Be Defined During
History Taking by Five Categories
29
Normal
The individual is aware of bladder filling and increasing
sensation up to a strong desire to void.
Increased
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The individual feels an early and persistent desire to void.
Reduced
The individual is aware of bladder filling but does not feel a
definite desire to void.
Absent
The individual reports no sensation of bladder filling or desire
to void.
Nonspecific
The individual reports no specific bladder sensation but may
perceive bladder filling as abdominal fullness, vegetative
symptoms, or spasticity.
Physical Examination
6,25,28,29
MS involvement in the cervical spinal cord is associated with
lower extremity spasticity evidenced by hyperactive reflexes
and bladder detrusor overactivity (DO) with or without
detrusor external sphincter dyssynergia (DESD). 6 General
examination with urologic- and neurourologic-focused
examination includes the following.
28
Abdominal/pelvic examination/genital examination—
prostate examination in men, vaginal vault examination
in women
A sensorimotor assessment of L1 to S4 cord segments
Rectal tone—S2 to S4 sacral reflex assessment
Bulbocavernosus reflex—S2 to S4 sacral reflex
assessment
Plantar response—pyramidal tract integrity
Cremasteric reflex—L1 root integrity
Deep tendon reflexes—reflect the integrity of the upper
motor neuron and lower motor neuron function
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Diagnostic Evaluation
The common causes of transient urinary incontinence can be
easily remembered by the term “DIAPPERS” (Table 16.3).
Table 16.3
Treatable Transient Causes of Incontinence
31-33,48,54,55
Delirium (confusional state)
Infection-urinary (only symptomatic)
Atrophic urethritis, vaginitis
Pharmaceuticals
Psychological, especially severe depression (rare)
Excess urine output (e.g., congestive heart failure, hyperglycemia)
Restricted mobility
Stool impaction
Patients should undergo microscopic urinalysis, which is more
accurate than dipstick testing in that it can detect upper tract
pathology by detecting for protein, hematuria, glucose,
ketones, bilirubin, and acid/base status; baseline basic
metabolic profile to assess electrolyte status, serum glucose
level as a diabetes screen, serum creatinine, and estimated
glomerular filtration rate as a measure of kidney function;
hemoglobin A1C to assess for diabetes; And prostate-specific
antigen to assess for prostate cancer in men.
32
Radiographic Assessment
Upper tract radiographic studies demonstrating upper tract
pathology (elevation in creatinine, caliectasis, stone, renal
scarring, hydroureteronephrosis) in patients with MS are
limited in number and have been reported to be as low as
0.34% to 16.7%. Patients at risk for upper tract disease
progression have been reported (1) to be older patients or as
having (2) detrusor sphincter dyssynergia in the male, (3) poor
bladder compliance, (4) Expanded Disability Status Scale
(EDSS) >5, and (5) indwelling catheter. These at-risk patients
should be followed with serum creatinine levels routinely.
With respect to the lower urinary tract assessment, a voiding
cystourethrogram alone or as part of urodynamic evaluation
can be performed to assess concomitant stress urinary
incontinence.
1,28
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Postvoid Residual
Checking with handheld ultrasound or straight catheter aids in
differentiating between OAB (characterized by minimal to no
residual) and a failure to empty either due to one or both an
underactive bladder and/or, in men, outlet obstruction from
enlarged prostate. A normal PVR is <150 mL.
32
Voiding Diary
A voiding diary is a record of the timed volumetric oral intake
over a 24-hour to 3-day interval with timed documentation of
episodes with degree of severity of urgency with urge
incontinence and severity of incontinence with physical
activities.
33
Screening Questionnaires
Urogenital Distress Inventory (UDI-6), 34 geriatric self-
efficacy scale for urinary incontinence (GSE-UI),
35
incontinence impact questionnaire—short form IIQ-7, 36 and
the pelvic floor impact questionnaire (PFIQ) 37 are just a few
of urinary and pelvic floor questionnaires used to assess
urinary, bowel, and pelvic floor dysfunction. No MS-specific
urinary questionnaires are available.
Urodynamics
A cystometrogram (Figure 16.2) measures the ability of the
bladder to accommodate urine. It measures changes in bladder
pressure with filling, stability, and defines capacity. The
normal cystometrogram has two phases:
Filling storage phase
a. Phase I: Initial compliance: represents the initial
response to filling
b. Phase II: Tonus limb
c. Phase III: Terminal compliance: viscoelastic
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Voiding phase (Figure 16.3):
a. Flow rate (Q): Volume of fluid expelled via the
urethra per unit time (mL/s)
b. Voided volume (V
void
): Total volume expelled via
the urethra (mL)
c. Maximum flow rate (Q
max
): Maximum measured
value of the flow rate after correction for artifacts
d. Voiding time: Total duration of micturition (s)
e. Flow time: Time over which measurable flow
actually occurs
f. Average flow rate (Q
ave
): Voided volume divided by
the flow time
g. Time to maximum flow: Elapsed time from onset of
flow to maximum flow
FIGURE 16.2 Classic cystometrogram.
Reprinted from Wein AJ, English WS, Whitmore KE. Office
urodynamics. Urol Clin North Am. 1988;15(4):609-623. Copyright
© 1988 Elsevier. With permission.
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FIGURE 16.3 Normal uroflow.
Reprinted from Wein AJ, English WS, Whitmore KE. Office
urodynamics. Urol Clin North Am. 1988;15(4):609-623. Copyright
© 1988 Elsevier. With permission.
It is the author’s practice to perform urodynamics on all
patients with MS who present with urologic symptoms.
However, others withhold urodynamics until patients present
with an elevated PVR of >150 mL and have failed two courses
of empiric medical management, with obstructive symptoms
and any evidence of upper urinary tract pathology. 1 Female
patients with MS may have concomitant stress urinary
incontinence and require urodynamic evaluation.
1
Common Findings on Urodynamic
Testing and Associated Symptoms
29,33
See Table 16.4.
Table 16.4
Common Findings on Urodynamic Testing and Associated Symptoms
29,33
Urodynamic
Finding
Definition Associated
Symptoms
Detrusor
overactivity
without
obstruction
Involuntary detrusor contractions during
bladder filling with or without leakage
Urgency,
frequency, urge
incontinence, and
nocturia
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Urodynamic
Finding
Definition Associated
Symptoms
Detrusor
sphincter
dyssynergia
Detrusor contraction concurrent with an
involuntary contraction of the urethral or
periurethral striated muscle
Urinary
hesitancy,
straining,
stuttering
urination, or
obstruction
Detrusor
overactivity
with outlet
obstruction
Detrusor overactivity plus detrusor
sphincter dyssynergia may obstruct urine
flow
Urinary urgency
with hesitancy,
straining, or
obstruction
Detrusor
overactivity
with
impaired
contractility
Detrusor overactivity with reduced strength
and/or duration of bladder contraction,
resulting in prolonged bladder emptying or
incomplete emptying
Slow bladder
emptying and/or
urinary retention
Detrusor
areflexia
Inability of the bladder to contract with
routine filling at normal physiological
volumes to elicit bladder emptying
Urinary retention
Urodynamic Risk Factors
The following are dangerous and require intervention to
prevent upper and lower urinary tract decompensation:
Impaired compliance
Detrusor-external sphincter dyssynergia (DESD)
Detrusor-intrinsic sphincter dyssynergia (DISD)
High-pressure detrusor overactivity (DO) present
throughout bladder filling
Elevated detrusor leak point pressure (DLPP) >40 cm
H2O
Poor emptying with high storage pressures
Case Study
The patient underwent complex urodynamics, which
demonstrated a small-capacity bladder (298 mL), detrusor
overactivity (at 267 mL) leading to uninhibited spontaneous
void, abnormal uroflow with low maximum flow (6.4 mL/s)
and low average flow (4.1 mL/s), prolonged voiding time,
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incomplete emptying with a PVR of 165 mL, and evidence
of pelvic floor muscle dysfunction during voiding phase
(DESD) and subsequent pelvic floor spasm post void.
FIGURE 16.4 Clinical vignette urodynamics.
Reproduced from Aliotta PJ. Personal communications. 2018 .
See eBook for color figure.
The patient was treated with pelvic floor therapy,
anticholinergic (±beta 3 receptor agonist to further reduce
urgency and frequency and help restore bladder capacity
without adverse side effects associated with increased doses
of anticholinergics), and an alpha blocker. Intermittent clean
catheterization was also discussed pending outcome from
the above-mentioned interventions.
Cystoscopy
Cystoscopy is used in the evaluation of recurrent urinary tract
infection, cystolithiasis, bladder outlet obstruction, and
incontinence.
Treatment/Therapies
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Treatment is tailored based on the effect of concurrent
medications (Table 16.2), patient factors profile (Table 16.5),
symptom complex (Table 16.3), urodynamic profile (Figure
16.4), lower urinary tract assessment, medical therapies
(Tables 16.6 and 16.7), and additional therapies (Table 16.8) as
per symptom/therapy algorithm (Table 16.9 and Figure 16.5).
Table 16.5
Patient Factors to Consider in Choosing Therapy
25,32
Prognosis of underlying disease, especially if progressive or malignant
General health
Limiting factors: hand dexterity, body habitus, ability to transfer,
ambulatory status
Activities of daily living
Mental status
Motivation
Desire to be catheter free (willingness to do intermittent catheterization)
Desire to avoid surgery
Sexual activity status
Reliability
Educability
Psychosocial environment, family support and cooperation
Economic resources
Table 16.6
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Medications Used to Treat Bladder Dysfunction in Multiple Sclerosis:
Bladder Storage
Antimuscarinics/Anticholinergics
Fesoterodine: Toviaz
Oxybutynin: Ditropan/Ditropan XL/Oxytrol Patch/Gelnique
Solifenacin: Vesicare
Trospium chloride: Sanctura/Sanctura XR
Darifenacin: Enablex
Tolterodine: Detrol/Detrol LA
Hyoscamine: Levsin SL/Levsinex
Beta-3 Agonist
Miragebron: Myrbetriq
From Orasanu B, Mahajan ST. Bladder and Bowel Dysfunction in Multiple
Sclerosis. Multiple Sclerosis and Related Disorders: Clinical Guide to Diagnosis,
Medical Management, and Rehabilitation. New York: Demos Medical Publishing
2013.
Table 16.7
Medications Used to Treat Bladder Dysfunction in Multiple Sclerosis:
Impaired Bladder
Alpha Adrenergic Blockers
Prazosin: Minipres
Doxazosin: Cardura/Cardura XL
Terazosin: Hytrin
Uroselective Alpha Blockers
Specific to smooth muscle receptors at the bladder neck, approved by the
FDA for use in men, but used in females with evidence for bladder neck
dysfunction
Tamsulosin: Flomax
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