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 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 M 3 –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 M 3 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