Lower Urinary Tract Symptoms (includes ketamine cystitis)

Dr Peggy CHUTuen Mun Hospital

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

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

LUTS

• ↑ as ages ↑• Can occur up to 30% man aged > 65 yrs

• ↓ QOL• May point to pathology of urinary tract

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

LUTS: IPSS + QOL

LUTS: IPSS Chinese

www.hkua.org

LUTS: QOL Chinese

www.hkua.org

LUTS: Initial Assessment

+/- PSA testing in cases of• LUTS are suggestive of benign prostatic

enlargement• Prostate feels abn on DRE

Freq-vol chart

Freq-vol chart

• frequency

Compulsive water drinking

C/O : frequency urinary incontinence

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

LUTS: Role of conservative Px

LUTS with storage symptoms• Fluid intake• Lifestyle changes ( avoid coffee, tea etc)• Supervised bladder training• Temporary containment products ( pads)

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

LUTS: post micturition dribbling

Aetiologyurethra not emptied by muscles surrounding it“sump” of urine pools in urethra↑ when ages ↑

Treatmentpush the last few drops of urine from the urethra with the fingers before the final shake

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

LUTS: Drug treatment

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

Ketamine Cystitis

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%)

Hong Kong Statistics

Central Registry of Drug Abuse 58th Report

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

Lower Urinary Tract Symptomatology

• frequency, urgency, dysuria, urge incontinence, painful haematuria

• urine culture –ve• no response to multiple courses of oral antibiotics

Normal bladder “ketamine bladder”

normal bladder bladder of ketamine abuser

Upper Urinary Tract

• blood creatinine• +/- hydronephrosis

• papillary necrosis• ureteric stricture

Blood Creatinine

• 10/113– Creatinine 126 - 1069– 2 required PCN

Upper Tract Radiology

• all have renal USG– 30% bilateral hydronephrosis– 10% unilateral hydronephrosis

Pathophysiology

? chronic submucosal inflammatory response resulting from chemical cystitis

? microvascular changes? autoimmune (raised ESR & C3/4)? bacteriuria

Treatment

AntibioticsAntimuscarinic agent (oxybutynin, detrusitol) ? Cystoplasty ABSTINENCE

New Problems with ketamine abuse

Guidelines (before Jun 2008)

25 g within discretion of sentencer

25 – 400 g 2 - 4 yrs’ imprisonment

400 - 800 g 4 - 8 yrs

800 g 8 yrs

Guideline (after Jun 2008)

1 g within discretion of sentencer

1 - 10 g 2 - 4 yrs’ imprisonment

10 - 50 g 4 - 6 yrs

50 - 300 g 6 - 9 yrs

300 - 600 g 9 - 12 yrs

600 - 1000 g 12 - 14 yrs

1000 g 14 yrs

Thank You