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Lower Urinary Tract Symptoms (includes ketamine cystitis)

Lower Urinary Tract Symptoms (includes ketamine cystitis). Dr Peggy CHU Tuen Mun Hospital. Lower Urinary Tract Symptoms (LUTS). Storage symptoms Urgency, frequency, urge incontinence, nocturia Voiding symptoms

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Lower Urinary Tract Symptoms (includes ketamine cystitis)

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  1. Lower Urinary Tract Symptoms (includes ketamine cystitis) Dr Peggy CHU Tuen Mun Hospital

  2. 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

  3. 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

  4. LUTS • ↑ as ages ↑ • Can occur up to 30% man aged > 65 yrs • ↓ QOL • May point to pathology of urinary tract

  5. 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

  6. LUTS: IPSS + QOL

  7. LUTS: IPSS Chinese www.hkua.org

  8. LUTS: QOL Chinese www.hkua.org

  9. LUTS: Initial Assessment +/- PSA testing in cases of • LUTS are suggestive of benign prostatic enlargement • Prostate feels abn on DRE

  10. Freq-vol chart

  11. Freq-vol chart

  12. • frequency Compulsive water drinking

  13. C/O : frequency urinary incontinence

  14. 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

  15. LUTS: Role of conservative Px LUTS with storage symptoms • Fluid intake • Lifestyle changes ( avoid coffee, tea etc) • Supervised bladder training • Temporary containment products ( pads)

  16. 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

  17. 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

  18. 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

  19. LUTS: Drug treatment

  20. LUTS: Drug treatment • 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

  21. Ketamine Cystitis

  22. Ketamine (C13H16CINO)(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%)

  23. Hong Kong Statistics Central Registry of Drug Abuse 58th Report

  24. 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

  25. Lower Urinary Tract Symptomatology • frequency, urgency, dysuria, urge incontinence, painful haematuria • urine culture –ve • no response to multiple courses of oral antibiotics

  26. Normal bladder “ketamine bladder”

  27. normal bladder bladder of ketamine abuser

  28. Upper Urinary Tract blood creatinine +/- hydronephrosis papillary necrosis ureteric stricture

  29. Blood Creatinine • 10/113 • Creatinine 126 - 1069 • 2 required PCN

  30. Upper Tract Radiology • all have renal USG • 30% bilateral hydronephrosis • 10% unilateral hydronephrosis

  31. Pathophysiology ? chronic submucosal inflammatory response resulting from chemical cystitis ? microvascular changes ? autoimmune (raised ESR & C3/4) ? bacteriuria

  32. Treatment • Antibiotics • Antimuscarinic agent (oxybutynin, detrusitol) • ? Cystoplasty •   ABSTINENCE

  33. New Problems with ketamine abuse

  34. Guidelines (before Jun 2008)

  35. Guideline (after Jun 2008)

  36. Thank You

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