CUA NLUTD 2019 GL Flashcards
List a few complications of neurogenic bladder?
urinary incontinence, UTI, urolithiasis, sepsis, ureteric obstruction, VUR, Renal failure
What is the general categorizaiton of NLUTD for suprapontine, infrapotine-suprasacral, and sacral/infra-sacral lesions?
Should voiding diaries be encouraged for all patients with NLUTD?
yes. GL says so
what do you do if your NLUTD has PVR>300
follow them and make sure it is stable. Obv need to also make sure they have a low pressure reservoir and good compliance etc
Who should have UDS, renal-bladder imaging(US) and renal function checked?
Patients with
1- spina bifida
2-advanced stage MS
3-SCI
Are VUDS preferred for patients for NLUTD?
yes, patients with NLUTD should have UDS and preferrably VUDS
What is a cut off for a safe DLPP?
40 but this is based on historical values and pediatric literature. and the lower it is the better, the issue is that the lower the DLPP the more likely patient is gonna have incontiennce
What kind of findings one may see on KUB US in NLUTD?
HN, bladder wall thickening, elevated PVR, bladder or renal stones, bladder diverticula, renal atrophy
What is the best way to measure renal function in NLUTD?
Is renal dysfunction common in MS due to bladder dysfunction?
serial Cr, nuclear medicine scan, 24 hour urine collection,
NO, it can occur but uncommon
What UDS findings in NLUTD are concerning for urological morbidity?
Compliance <20, DLPP>40, DSD, NDO, VUR
IS there a role for use of screening cystoscopy programs for NLUTD? are they at higher risk of bladder cancer? how does cytology fare?
No, dont do cysto without cause
They are at higher risk of bladder ca and more likely to have advanced disease
A recent metanalysis showed cytology outperformed cysto in select populations(word for word from GL..)
What are the high risk faeatures and what are the 5 domains that you gotta pay attention to when assessing NLUTD?
Know this table
GL Statement: All patients with neurogenic bladder should have …. and ….as part of their initital evaluation
UA and PVR
GL statement: How long after SCI should a patients have their baseline urological assessment?
Within 6 months
which NLUTD patients would be moderate risk? who would be high risk?
Moderate risk: anyone with SCI, SB or advanced MS
High risk: any of the above groups with high risk features covered earlier. ( there are 5 domains and each have high risk features in)
Overview of management of NLUTD
What are two theories of upper urinary tract deterioation from neurogenic bladder?
1- high pressure obstructs the orficies and obstruction fucks shit up
2- high pressure overwhelms the UVJ mechanisms and that causes reflux and fucks up the upper tract
What would leakage between CIC episodes be suggestive of?
high storage pressures probably
Who with NLUTD would need an indwelling catheter?
CIC is preferred but
non compliant patietns, those with poor dexterity, or those with mental deficiencies
what are long-term complications of urethral cathetrizaiton in men and women?
men: false passage, strictures, diverticuli, iatrogenic hypospadias
females: dilatation, erosion, potentially destruction
If someone has an indwelling catheter at risk of urethral damage? what should be done for them?
Conversion to a SP catheter before irriversible damage is done to urethra, should be done for patients who are at risk of urethral complications
If a Neurogenic patient has recurrent falls. what should a urologist do?
NDO with urge incontinece has been associated with falls. managed it
What is the most common cause of UTI in NLUTD?
Enterobacteriae family
especially: E.Coli
what 3 things need to be present for you to be able to diagnose UTI in NLUTD?
leukocyturia, bacteriuria, clinical symptoms
What are generally accepted values for cut-off for bacteruria:
any from SP
10^2 from clean catheterized
10^4 from clean voided
What is the defention for leukocytouria?
>100 leuks/ml or positive Leukocyte estrase
Should asymptomatic bacteruria be treated in NLUTD? any exceptions?
NO
Yes, pregnant patients, procedures associated with mucosal bleeding.
Urine cultures should always be obtained prior to antimicrobial therapy due to the increased risk of nosocomial and multidrug-resistant microorganisms
Correct
A…….day course of antimicrobials is recommended for patients with prompt clinical response and …….days for those with significant infection or a delayed response
seven-
10–14
which type of cathetrization is highest risk of UTI in NLUTD
Urethral
5x higher than SP and CIC
SP has a higehr risk of bladder calculi than CIC
condom cath can get pseudomonas and klebsiella bacteruria and UTI rates are comparable to CIC
how often should indwelling catheters be changes?
Is routine use of Abx or silver coated catheters recommended ?
No
Is there any evidence for use of gentamycin bladder irrgation for people on CIC?
yes, if they have recurrent UTIs gentamycin irrigation can reduce the rate of UTI 75%
Is antimicrobial PPX recommended in patietns with NLUTD with UTIs?
No it is NOT
Does intravesical Botox decrease the frequency of autonomic dysreflexia?
Yes, recent studies suggest that
which NLUTD bladder drainage patients have the highest qol and what has the lowest
Best: those who can micturate normally
lowest: indwelling catehter or CIC by attendant
Who is the ideal patient for CIC?
ideal person for CIC has a
low Pdet at capacity; a minimum volume of 350–400 cc; an unobstructed urethra; and is compliant, understanding, continent, and cooperative with adequate hand function
Antimuscarinics should,
therefore, be offered to people with urodynamic findings of
NDO or those with SCI and symptoms of overactive bladder
(OAB)
Name a Few
oxybutynin IR and ER, tolterodine IR and ER, propiverine IR,
darifenacin, and solifenacin
should the patient still get anti-muscaranics if they are using cath?
Yes, giving anti-muscaranics has been associated with decreased upper tract deterioation.
What is the recommended starting dose for Botox by health canada for intravesical adminstration?
OnabotulinumtoxinA: 200 units.
AbobotulinumtoxinA 750 units.
Is intravesical instilation of oxybutinin an option in NLUTD?
yes, for patients who dont respond to oral or remain incontient with oxybutinin
0.1% oxybutinin hydrochloride leads to improve bladder capacity
Does S2-S4-S5 with dorsal rhizotomy and SNS work?
yeah, better storage pressures and less AD
PTNS
appears to be well-tolerated and effective in small studies,
with minimal reported adverse events, mainly mild to
moderate pain at the puncture site
Correct
When is Bladder augmentation indicated?
1-reduced compliance or
2-NDO
refractory to all other non-surgical treatments,
3-or reduced
bladder capacity necessitating an indwelling catheter or
4- CIC to be done too frequently
what are CI to Bladder augment?
bladder cancer
bladder stones
Bowel disease or previous bowel resections
inability/unwillingness to do CIC
what should be done in cases on thick fibrous low capacity bladders?
supratrigonal cystectomy for preperation for augment instead of clam cystoplasty
What are options for someone who doesnt have a catheterizable urethra or cant cath it?
cutaneous diversion
Mitrafinoff or monti are Listed
What are you last resort surgical options?
incontinent diversion:
Illiovesicostomy and ileal conduit
What are indications to performing end stage illeal conduit in NLUTD and should bladder be removed at the time of surgery?
indications are
1- severe stress incontinece(devastated with no good recon options)
2- end stage bladder with high grade reflux
3-chronic UTIs with impaired compliance
4- malignancy
5- fistulization
What are CI to sphincterotomy?
detrouser underactivity, female pateint, desire to preserve fertility
Should the urologist be involved in follow up assessment of NLUTD?
yes yearly for sure for mod-high risk patients. ohter ones can be seen by GP or physiatrist yearly.
Should patients with NLUTD have annual US KUB?
mod-high risk ones yes
Is the use of survaillance cysto recommended for bladder augments?
not routinely. for cause it is
How often should UDS follow up be performed?
Q2-5 years for mod risk
annually for high risk
Do VUDS if available.
