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