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Lower Urinary Tract Symptoms (includes ketamine cystitis) Dr Peggy CHU Tuen Mun Hospital
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Lower Urinary Tract Symptoms (LUTS) Storage symptoms – Urgency, frequency, urge incontinence, nocturia Voiding symptoms – Weak or intermittent stream, straining, hesistancy, terminal dribbling or incomplete emptying Post micturition symptoms – Post micturition dribbling
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Anatomical causes of LUTS Bladder – Overactive bladder, e.g post CVA – UTI Prostate – Benign prostatic enlargement Urethral – Urethral stricture, e.g years post gonorrhoea Urinary sphincter
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LUTS ↑ as ages ↑ Can occur up to 30% man aged > 65 yrs ↓ QOL May point to pathology of urinary tract
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LUTS: Initial Assessment Med Hx to identify possible causes, co- morbidities, drugs P/E: abd, genitalia, Digital rectal exam (DRE) IPSS (to allow assessment of subsequent symptom change) Freq vol chart Urine x dipstick: blood, glucose, protein, leucocytes & nitrites +/- PSA
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LUTS: IPSS + QOL
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LUTS: IPSS Chinese www.hkua.org
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LUTS: QOL Chinese www.hkua.org
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LUTS: Initial Assessment +/- PSA testing in cases of LUTS are suggestive of benign prostatic enlargement Prostate feels abn on DRE
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Freq-vol chart
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frequency Compulsive water drinking
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C/O : frequency urinary incontinence
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LUTS: when is referral necessary If LUTS Cx by Recurrent /persistent symptomatic UTI Urinary retention Renal impairment suspected to be caused by lower urinary tract dysfunction Suspected urological cancer Bordersome LUTS not responding to conservative management or drug
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LUTS: Role of conservative Px LUTS with storage symptoms Fluid intake Lifestyle changes ( avoid coffee, tea etc) Supervised bladder training Temporary containment products ( pads)
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LUTS: post micturition dribbling Loss of a few drops of urine after the main urine stream has finished Happens when rearranging trousers Can result in wet and stained clothing
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LUTS: post micturition dribbling Aetiology urethra not emptied by muscles surrounding it “sump” of urine pools in urethra ↑ when ages ↑ Treatment push the last few drops of urine from the urethra with the fingers before the final shake
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LUTS: post micturition dribbling Technique pass urine in usual manner & wait for a few sec for bladder to empty Place finger tips of hand 3 finger widths behind scrotum and press gently towards base of penis Can be repeated
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LUTS: Drug treatment
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Alpha blocker – Same efficacy, difference in S/E (due to difference in T ½ and uroselectivity) – Precaution in patients also taking beta blocker – Postural hypotension Anticholinergic – Avoid in closed angle glaucoma – Dry mouth, constipation
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Ketamine Cystitis
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Ketamine (C 13 H 16 CINO) (2-(o-Chlorophenyl)-2-(methylamino) cyclohexan-1-one Anaesthetic agent, “ dissociative anesthesia ” Rapid onset, short duration of action N-dealkylated in liver, metabolized and excreted in urine (>90%)
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Hong Kong Statistics Central Registry of Drug Abuse 58 th Report
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Patients TMH Sep 2006 - Jun 2010 113 patients M: F = 90: 43 mean age 25.6 yrs (14 – 42) years of ketamine abuse: 3/12 to 11 years referred by A&E, GP, psychiatrist C/O: LUTS+ve
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Lower Urinary Tract Symptomatology frequency, urgency, dysuria, urge incontinence, painful haematuria urine culture –ve no response to multiple courses of oral antibiotics
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Normal bladder“ketamine bladder”
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normal bladder bladder of ketamine abuser
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Upper Urinary Tract blood creatinine +/- hydronephrosis papillary necrosis ureteric stricture
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Blood Creatinine 10/113 – Creatinine 126 - 1069 – 2 required PCN
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Upper Tract Radiology all have renal USG – 30% bilateral hydronephrosis – 10% unilateral hydronephrosis
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Pathophysiology ?chronic submucosal inflammatory response resulting from chemical cystitis ?microvascular changes ?autoimmune (raised ESR & C3/4) ?bacteriuria
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Treatment Antibiotics Antimuscarinic agent (oxybutynin, detrusitol) ? Cystoplasty ABSTINENCE
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New Problems with ketamine abuse
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Guidelines (before Jun 2008) 25 g within discretion of sentencer 25 – 400 g2 - 4 yrs ’ imprisonment 400 - 800 g4 - 8 yrs 800 g 8 yrs
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Guideline (after Jun 2008) 1 g within discretion of sentencer 1 - 10 g 2 - 4 yrs ’ imprisonment 10 - 50 g4 - 6 yrs 50 - 300 g6 - 9 yrs 300 - 600 g9 - 12 yrs 600 - 1000 g12 - 14 yrs 1000 g 14 yrs
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Thank You
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