FCS Urol Orals > NGB > Flashcards

NGB Flashcards

(39 cards)

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1
Q

Name afferent sensory fibres in the bladder

A

A delta = myelinated fibres —> response to stretch
C - fibres = unmyelinated response to chemical/noxious stimuli

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2
Q

Neuromodulators of bladder C Fibres

A

Neuropeptides
-Substance P
- Calcitonin gene related peptide
- Vasoactive intestinal peptide

Classical neurotransmitteds
- Glutamate
- ATP
- NO

Inflam grownth mediaters
- Nerve growth factor
- Prostaglandins
- Bradykinin

TRP- Transient receptor potential channel agonists = sensory modulators
- Capsaicin
- Menthol
- Directly activate and desensitize C fibres

Monoamines
Serotonin/Noradrenaline

Other
Opiods
Cannabinoids
Ach

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3
Q

Different aspects you look on UDS at for a NGB

A

A. Filling Cystometry - CCSS • Compliance • Capacity • Sensation • Storage
- NDO
- DLPP

Voiding - not always possible
- BOOI
- BCI
- Complete emptying ?

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4
Q

If you can calculate one value which value would you like

A

DLPP : The Lowest Detrussor pressure at which urine leakage occurs in the absence of a detrussor contraction

The higher the DLPP —> Increase likehod of UUT damage
DLPP> 40cmH0 = HUN

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5
Q

Which DLPP Value is worrying ?

A

DLPP > 40 has risk of UT deterioration

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6
Q

Abrahams Griffits normogram

A

BOOI Pdet @Qmax - 2xQmax

Men BOOI > 40 obstructed
20-40 Equivocal
< 20 non obstructed

Female
BOOI = Pdet @Qmax -2.2 Qmax
BOOI> 18 = Obstruction 90%
< 1 = No obstruction

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7
Q

NGB management Goals.

A
  1. Protect the upper tract
  2. Improve urinary continence
  3. Restore lower UT function
  4. Improve QOL
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8
Q

What types of muscuranic receptors do you get and where is it located

A

Muscarinic receptors are locatedd througout the body primarily target organs of the parasympatheticthetic system.
M2 & M3 = In the bladder detrussor , More M2 than M3 but M3 is the major mediator of contraction

M1 = Brain , stomach
M2 = Heart ( SA and AV nodes)
M3 = Bladder , pupil, bronchi, glandular tissue ( salivary glands)
M4 = CNS
M5 : CNStepa

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9
Q

Which Antichollinergic can you use in elderly

A

Trospium ( Least CNS effects)
Solifenacin M3> M2> M1 thus also less side effects on the brainn

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10
Q

Which Rx can you give intravesical for NGB

A

Oxybutinin
BOTOX

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11
Q

What else can you give intravesical

A

Vinneloids ( What burns your tongue) = How does it work -> overstimulate c - fibres then modulates the bladder

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12
Q

Where do you inject Botox for NGB

A

Make a grid in the bladder , enject the entire bladder - Avoid trigone

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13
Q

Which pts with NGB can you treat with BOTOX

A

Neurogenic detrussor overactivity / Idiopathic OAB

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14
Q

5 causes for NDO

A

• SCI
• MS
• Parkinsons
• Stroke
• Spina Bifida / MMC

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15
Q

Dosage of Botox for NGB

A

200 IU

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16
Q

Dosage of Botox for OAB

17
Q

How long does BOTOX last

18
Q

How does BOTOX work

19
Q

Which Side effects do you need to councel the pt on if they get BOTOX

Study These Flashcards
A

Acute urinary retension —> Need for CISC
UTI

20
Q

What can cause post micturation syncope

Study These Flashcards
A

Paraganglioma in the bladder

21
Q

What will you do for a NGB in an acute pt with SCI

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A

Phase 1 : Early acute management
- After injury - monitor physiological stability including Urine output and timely catheterisation
NB!
- Awareness of Urinary retension post injury = catheterisation needed
- Limiting prolonged TUC to preserve the urethra ( Major cause of USD)
- Continence = to prevent pressure sores
- SPC can be considered or CIC ( even in the intensive setting)

Phase 2 : Rehab preferrably in specialised centre
- Establish if the patient is suitable for CIC ( Pat insight, compliance , dexterity, mental capacity or willing caregiver)

AVOID CISC if :

  • inability to catheterise themselves or a carer who is unwilling to perform catheterisation
    •Abnormal urethral anatomy, such as stricture, false passages or bladder neck obstruction
    •Bladder capacity <200 mL
    •Poor cognition, little motivation, inability or unwillingness to adhere to the catheterisation time schedule
  • high fluid intake regimen
    •Adverse reaction to passing a catheter into the genital area multiple times a day
  • Risk of AD with bladder filling or urethral instrumentation

CIC = Single use or reuse 4-6 weeks

@ 3months of Rehab phase = UDS ( Reflex neurogenic activity has usually returned by 3 months )

A Patient with normal sensory voiding does not need a UDS
- Do Uroflow + KUB +PVR
- AXR

Triggered reflex voiding is not recommended = due to risk of elevated bladder pressures

Phase 3 = Post discharge / Rehab

Assess the upper urinary tract at regular intervals in high-risk patients.
Perform a physical examination and urine laboratory test every year in high-risk patients.
Any significant clinical changes should instigate further, specialised, investigation.
Perform urodynamic investigation as a mandatory baseline diagnostic intervention in high-risk patients at regular

22
Q

What is the effect of Antichollinergics on the brain

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A

Confusion
Delirium
Cognitive impairment

23
Q

BOTOX and pregnancy

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A

BOTOX
- Causes fetal harm
- Decrease fetal weight
- Skeletal ossification abn
- Abortions
- Pre term delivery
- Maternal death
- Excreted in breast milk

24
Q

Urologic meds and Pregnancy

Study These Flashcards
A

BOTOX
- Causes fetal harm
- Decrease fetal weight
- Skeletal ossification abn
- Abortions
- Pre term delivery
- Maternal death
- Excreted in breast milk

NSAID:
Fetal pulmonary HPT
Premature closure of ductal arteriosus

25
Discuss the indications, mechanisms of action, side effects and method of administrating botulinum toxin in urology/for detrusor overactivity
Indications : Refractory OAB NGB BPS Contra indications Active UTI Hypersensitivity Pt unwilling to perform CIC Autonomic dysreflexia= caution Myasthenia Gravis MOA : Botulinum toxin boNT- A consists of a light chain and heavy chain with a disulphide bond. BoNT - A binds to the synaptic vesicle protein 2 and is internalised by the nerve terminal and the 2 chains are cleaved. The light chain passes into the cytosol and cleaves the SNAP-25 that renders the SNARE protein complex ( SNAP 25, Synaptoprevin, Syntaxin ) inactive and blocks acetycholine neurotransmiter release Method of administration: 100 IU 20 sites Not the trigone for OAB Use a needle that allows 3mm penetration 20ml saline with 100IU = 1ml at every site 200IU for NGB Side effects - Urinary retension - UTIs Effect : Decrease frequency, urgency , incontinence
26
UTIs in NGB = General rules
Treat bacteriuria only if symptomatic (bacterial colonisation does not require treatment). • Urine microscopy, culture and sensitivity (MCS) is mandatory prior to initiating antibiotics in symptomatic patients, but it should not delay prompt treatment. • Choose antimicrobials with as little impact on bowel flora as possible. • Adjust antibiotics according to sensitivity of organism. • Treat proven infections for at least 5 days. Re-infections are treated for 7 - 14 days. • Repair structural and functional risk factors. • Prophylaxis only to be used in recurrent infections and in consultation with experienced clinicians/urologist. • Patients with indwelling catheters should not be given routine antibiotic prophyla
27
10 y/o male with a MMC presents with UTIS and incontinence Comment on the MCUG
Static image of an AP view of a MCUG . The field does not include the pelvis and I am unable to asess the pubic symphisis, bladder neck and urethra. The MCUG reveals a filled bladder with trabeculations and Left Grade 5 VUR
28
10 y/o male with MMC + recurrent UTIs and incontinence with left VUR and trabeculated bladder. What would you like to do next.
1. U - dipstick , UMC&S 2. Baseline Creatinine 3. Bladder diary 4. Stool diary 5. Check what medication the patient is on 6.KUB ultrasound to asess the hydronephrosis and parenchyma of both kidneys 7. UDS to asess the compliance , DLPP and for NDO
29
What do you see on this UDS
Hostile Bladder 1. Filling cytometry , no mention of the pt name or filling rate , the study is callibrated with a possitive cough test There are NDO ( + pves no pabd = increades pDET) PDET incleases with filling to > 60cmH20
30
How do you calculate EBC in children ( 10yr)
= 330 Infants = weight x7 > 1 yr=Age +1 x 30 Koffs = (Age +2) x30 Hjalmas = 30+ ( Age x30)
31
How do you calculate bladder compliance
Change in Volume / Change in pdet Example : 160ml , 80cmH20. 160/80 =2ml/cm < 30 = Abn > 40 = Normal/non neurogenic bladder
32
What is normal bladder compliance
Normal compliance > 30 -40ml.cm H20 Abnormal = < 30
33
Why will pressure flow studies not be helpfull?
These children can often not void
34
What is DLPP
DLPP is the lowest detrussor pressure that urinary leakage occurs with no increase in padb pressure
35
How will you manage this child ?
Multifaceted approach : Bowel Mx = Adress constipation Bladder management : Start Antichollinergics if not started already Oxybutinin Can add Mirabegron works sinnergestic + CISC If pt has lots of side effects from Oxybutinin it can be given intravesical 0.7mg/kg BD Overnight catheter can help to decrease pressures at night and helps with CISC during day = less needed Repeat UDS in 3 months If pt still has incontinence and gets UTIS BOTOX —> repeat UDS after 6 weeks Last option = Augmentation
36
Cautions and complications of Bowel Augmentation
Stones Bladder perforation 25% mortality MEtabolic complications DIVERSION Drugs recycling Infections Vit B12 deficiency Electrolyte abn = Hypokalaemic, hyperchloremic metabolic acidosis Renal deterioration ( Increased P on UT, stones, VUR, Pre op Crt) Sensorium altered - Mg deficiency, Abn Ammonia Stones, Intestinal issues Osteopenia/ osteomalasia - Chronic acidosis and Vit D resistance Neoplasms Stomal herniation Stenosis at the anastomosis
37
What will you do about the VUR
Renogram to asess differential function Focus on the bladder first Some institutions will add deflux with BOTOX = Total endoscopic management Or reimplant with Augmentation
38
You are called to the ward for a child with MMC post neurosurgical intervention
1. KUB ultrasound = 5-10% abn 2. PVR —> If more than 5ml —> CISC + antichollinergics 3. At 3 months = KUB, UDS after spinal closure healed and child can lie on there back , MCUG if any UT abd 4. Bowel Management NB! Repeat UdS at 10m-1 yr, 3yrs, 9 yrs and in between if indicated If Antimusc not working can do Doublet therapy If not successfull to overnight catheter drainage
39
Goals of NGB management
1. Preserve renal function 2. Maintain lowe bladder pressures 3. Prevent / avoid HUN 4. Avoid UTIs 5. Aim for Urinary and Faecal continence 6. Sexual function 7. Fertility
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