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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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Alfuzosin: Uroxatral
Silodosin: Rapaflo
Hormonal Therapy
Desmopressin: DDAVP: Desmopressin works by limiting the amount of
water that is eliminated in the urine, acting as an “antidiuretic.” Utilized
for MS-related nocturia 0.5-1.5 episodes per night, reduces urinary
frequency in the first 6-8 h after delivery, and is associated with an
increase in uninterrupted sleep by a mean of 2 h
FDA, US Food and Drug Administration.
Table 16.8
Behavioral Modifications for Urinary Tract Symptoms in Multiple
Sclerosis
25,32
Fluid titration Moderate fluid intake not to exceed 4-6 oz/h
Reduce bladder
irritant
consumption
Moderate alcohol, fruit juices, caffeine, chocolate,
artificial sweeteners, acidic foods/sauces
Stop oral intake 23 h before bedtime
Reduces nocturia, nocturnal enuresis risk
Change medication
timing
Avoid diuretics in the evening and take medications 2-3 h
before bedtime
Timed voiding Void at regular intervals vs. voiding when urgency creates
demand→reduces urge incontinence risk
Bladder
retraining/Kegel
exercises
Pelvic floor physical therapy controls urge, extends
voiding intervals, promotes efficient voiding
Avoid constipation Regular bowel movement promotes efficient bladder
emptying and reduces risk of urinary tract infection
Table 16.9
Consortium of MS Centers Treatment Recommendations and
Algorithm
32
Urinary bladder symptoms in multiple sclerosis (from the algorithm):
Assess for treatable causes: DIAPPERS
Check postvoid residual (PVR): <150 mL
No Rx
Observation
Symptom complex: urge, frequency, urge incontinence (UI) with no
voiding complaints and PVR<100 mL
Rx: Anticholinergic, beta-3 agonist, pelvic floor muscle therapy
(PFMT) (optional)
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No improvement: Refer to urology
Improvement: Continue Rx; genitourinary (GU) referral
Symptom complex: urge, frequency, UI, voiding complaints, and
PVR > 100 mL
Anticholinergic, beta-3 agonist, PFMT (optional)
No improvement: Refer to urology
Improvement: Continue Rx; GU referral
Symptom complex: PVR > 150 mL, urgency, UI, stop-and-go
“stuttering” urine flow, incomplete emptying with incontinence:
suspect detrusor external sphincter dyssynergia (DSD/DESD)
Anticholinergic + alpha blocker ± skeletal muscle relaxant, trial
with B-3 agonist; optional PFMT
If reduction in urge and frequency with elevated PVR: GU
referral for CIC ± BTXA; S/P tube ± BTXA
If clinically improved, continue Rx; GU referral
Symptom complex: PVR > 150 mL, absent sensory urge or awareness
of need to void, no UI; overflow incontinence suspected, abnormal
uroflow
Trial to void with alpha blocker and timed voids, PFMT. Check
PVR; still elevated—cannot r/o areflexia or underactive
bladder ± DESD
Catheterization indwelling vs. CIC; GU referral
Stress incontinence only
Urology/urogynecology referral
Mixed incontinence
Urology/urogynecology referral
CIC, clean intermittent catheterization.
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FIGURE 16.5 Consortium of MS centers bladder symptom
and treatment algorithm. 32 DESD, detrusor external sphincter
dyssynergia; PFMT, pelvic floor muscle therapy; PVR,
postvoid residual; UI, urge incontinence.
With permission from CMSC.
The reasons to change or augment a given regimen are (1)
evidence of upper tract deterioration, (2) recurrent sepsis or
fever of urinary tract origin, (3) lower urinary tract
deterioration, (4) inadequate storage, (5) inadequate emptying,
(6) inadequate control, (8) unacceptable side effects, and (9)
skin changes secondary to incontinence or collecting device.
20
Take alpha blocker with dinner; not at bedtime (hs), as this
may cause increased nocturia. Risks associated with alpha
blockade are orthostatic hypotension, especially when taken
on an empty stomach or in combination with other
antihypertensive medications, asthenia, and incontinence.
Refractive Neurogenic Bladder Treatments
Injection of BTX-A in the detrusor muscle has an important
direct effect on the motor function of the urinary bladder and
an indirect effect on the sensory regulation of bladder function.
BTX-A inhibits acetylcholine exocytosis. Parasympathetic
postganglionic nerves release acetylcholine in the
neuromuscular synapse. Acetylcholine then binds with the M2
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and M3 muscarinic receptor in the detrusor muscle, leading to
contraction.
17
BTX-A exerts its inhibition of exocytosis at the neural side of
the neuromuscular junction. When the vesicles cannot anchor
to the cell membrane, no acetylcholine is shed into the
synaptic cleft and the contraction is blocked. The heavy chain
of the BTX-A toxin facilitates toxin entry into the nerve cells
via endocytosis.
38
The second effect of intradetrusor injections of BTX-A is via
the afferent, sensory pathway. Afferent output from the
bladder is normally conducted by myelinated Aδ-fibers that
carry the signals to the higher brain regions. When these
pathways are damaged by neurological disease, a spinal reflex
arc consisting of small, unmyelinated C-fibers arises. This
involuntary reflex arc leads to uncontrolled bladder
contractions and neurogenic detrusor overactivity (NDO).
17,39
BTX-A injections reduce sensory receptor levels in the
bladder suburothelium. In its turn, this may reduce the
sensitivity of aberrant C-fibers to mechanical stimulation.
39
It is generally accepted that a dosage of 200 to 300 U of
onabotulinum toxin is comparable with 500 to 750 U of
abobotulinum toxin. 38 These are considered the optimal doses
for intradetrusor injections in NDO.
40-42
Percutaneous Tibial Nerve Stimulation
This type of neuromodulation provides stimulation from the
posterior tibial nerve to the sacral nerve plexus and controls
for urgency, urge incontinence, and fecal incontinence. A
patient sits comfortably with the treatment leg elevated. A fine
needle electrode is inserted into the lower, inner aspect of the
leg, slightly cephalad/rostral to the medial malleolus. As the
goal is to send stimulation through the tibial nerve, it is
important to have the needle electrode near (but not on) the
tibial nerve. A surface electrode (grounding pad) is placed
over the medial aspect of the calcaneus on the same leg. The
needle electrode is then connected to an external pulse
generator which delivers an adjustable electrical pulse that
travels to the sacral plexus via the tibial nerve. Among other
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functions, the sacral nerve plexus regulates bladder and pelvic
floor function. With correct placement of the needle electrode
and level of electrical impulse, there is often an involuntary
toe flex or fan, or an extension of the entire foot. However, for
some patients, the correct placement and stimulation may only
result in a mild sensation in the ankle area or across the sole of
the foot. The treatment protocol requires once-a-week
treatments for 12 weeks, 30 minutes per session. Many
patients begin to see improvements by the 6th treatment.
Patients who respond to treatment may require occasional
treatments (~ once every 3 weeks) to sustain improvements.
32,43
InterStim Neuromodulation
This procedure provides an electrical charge to an area near
the S3 sacral nerve, altering neural activity. The stimulations
cause nerve depolarization, producing an action potential. The
signal propagates along the axon and alters abnormal sensory
inputs from the bladder. Efferent pathways are uninhibited and
do not suppress voluntary voiding.
32,43,44
Full-body magnetic
resonance imaging (MRI) can be done safely in all but
orthopedic and neurological pathologies, and therefore until
such time full-body MRI-safe neurostimulators are developed,
sacral nerve stimulation is not recommended.
43,45-47
Other Treatment Options
32,43,45-52
Other options include long-term Foley catheter in patients with
areflexic NGB and NGB with NDO±DESD (Tables 16.10 and
16.11).
Table 16.10
Urethral vs. Suprapubic Catheterization
50-52,56
Urethral Catheter Suprapubic Catheter
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Urethral Catheter Suprapubic Catheter
Urethritis, or inflammation of the
urethral meatus
Balanitis
Phimosis
Urethral fistula: Vesicovaginal fistula;
perineoscrotal abscess and
urethrocutaneous fistula
Scrotal abscesses seen in men
Epididymitis, orchitis, scrotal abscess,
prostatitis, and prostatic abscess
Hematuria
Bladder stones
Latex allergy
Urethral erosion-hypospadias in men;
Urethral decompensation in women with
incompetent bladder neck (patulous
urethra) requiring urinary diversion
Pain
Urinary tract infection, urosepsis
Bladder spasm requiring anticholinergic
therapy, Botox injections
Bladder cancer
Difficult catheter passage, especially in
men with a large prostate
Creation of urethral false passage
Urethral stricture, bladder neck
contracture
Urethral encrustation
Injury to external sphincter
Difficult to maintain healthy hygiene
Trauma, traumatic extraction
Prohibited sexual activity
Obstruction of catheter
Urinary diversion
Hematuria
Bladder stones
Pain
Bowel perforation
Latex allergy
Cutaneous infection at
cystotomy site
Urinary tract infection,
urosepsis (as a result,
MS exacerbation)
Bladder spasm
requiring
anticholinergic therapy,
Botox injections
Bladder cancer
Easy catheter changes
Urethral encrustation
(associated with
alkaline urine)
Requires anesthesia
(local, IV sedation,
general anesthesia)
Traumatic extraction
less commonly occurs
If a suprapubic catheter
becomes blocked, urine
can drain via the urethra
(an alternative option)
A suprapubic catheter
leaves the genitals free
for sexual activity
Hygienic maintenance
is easier
The procedure is
reversible. When a
catheter is removed
permanently, the hole
heals quickly
Variable-sized catheters
can be used, reducing
the risk of a blocked
catheter without
increased pain
Urinary diversion
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Table 16.11
Recommendations for Care of the Patient With Long-term
Catheterization
49-52,56
Provide for adequate and efficient drainage; prevent kinking
Regular bladder irrigations with the appropriate volume of irrigating
solution utilizing piston syringe irrigations to break up and aspirate
bladder mucus and loose encrustations
Persistent blockage and drainage problems should alert treating health
care providers to assess for bladder stone by x-Rry and/or cystoscopy
Acidification (cranberry pills, vitamin C)
Change catheter monthly and as needed
Teach willing family and/or health care giver catheter management
When symptomatic for infection or exacerbation of MS: perform urine
c+s and treat accordingly
c+s, culture and sensitivity.
Urinary Diversion
53
Most patients undergoing surgical intervention have secondary
progressive/primary progressive disease, have failed
nonsurgical therapies, and have a higher EDSS (Tables 16.12–
16.14).
Table 16.12
Indications for Urinary Diversion
53
Chronic urinary tract infections due to retained urine/failure to empty
Chronic urinary tract infection due to chronic catheter with or without
incontinence due to detrusor overactivity
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Bladder cancer (associated with chronic infection)
Catheter-associated erosions
Renal compromise from low bladder compliance and increased
intravesical pressures
Vesicoureteral reflux with nephropathy
Refractory urinary incontinence causing tissue breakdown with skin
complications
Table 16.13
Absolute and Relative Contraindications to Urinary Diversion
57
Absolute Contraindications:
Renal insufficiency
Hepatic insufficiency
Inability in the case of continent urinary diversion, to
perform clean intermittent stoma catheterization (CISC)
Unwillingness to do CISC in the case of continent
diversion surgery
Relative
Contraindications:
Advanced age
Multiple
comorbidities
Prior pelvic
radiation
Inflammatory or
malignant bowel
disease
Need for adjuvant
chemotherapy
Table 16.14
Surgical Procedures in the Adult Patient With Multiple Sclerosis
53
Ileovesicostomy: A noncontinent diversion in which a loop of small bowel
ileum is anastomosed to the bladder dome. This loop of ileum is brought out
through the abdominal wall as a stomal urostomy. Often called, “ileal chimney”
Ileal cystoplasty: Bladder wall reconstruction using a segment of ileum to
augment bladder capacity
Bladder autoaugmentation: A technique in which detrusor muscle over the
entire dome of the bladder is excised while leaving the bladder epithelium intact.
The bladder epithelium distends with bladder filling, augmenting bladder
capacity. No bowel is used
Ileal conduit diversion: An isolated segment of ileum serving as a substitution
for the urinary bladder, into which ureters can be implanted, the lumen of which
is connected to the skin. The bladder can be removed or left in situ
Continent catheterizable stoma diversion: The creation of an intestinal
reservoir with a catheterizable channel that is brought from the reservoir to the
skin with creation of a stoma. The channel can be catheterized several times a
day to empty the reservoir
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Tables 16.12– 16.14 describe the indications for urinary
diversion, contraindications to urinary diversion, and identifies
the various types of urinary diversion.
53,57
Because bladder dysfunction can often be associated with
bowel and sexual dysfunction, the following chapter will focus
on these two areas that significantly affect patients’ quality of
life.
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