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Thursday 5 April 2018



Indwelling catheterisation
  • non latex catheters – silicon catheter for longer use
  • suprapubic catheterisation – less traumatic
  • leg bag is worn during day and night time collection device used in bed
  • bladder capacity and compliance tend to decrease over time
  • watch for autonomic dysreflexia
  • regular use of anticholinergics
    • improve bladder compliance
    • lower bladder leak point pressure
    • less chance for hydronephrosis
    • prevent involuntary bladder contraction and urine leakage
  • high fluid intake (>2L/day)
    • facilitate mechanical washout
    • decrease solute concentration and less chance of stone formation
  • mainly used in atonic bladder and spinal shock
Intermittent self catheterisation
  • by Lapides
  • proper hand washing before the procedure – catheter cleaned with soap and water – air dried – placed in clean paper bag
  • recurrent UTI – latex catheter used – can be sterilized by heating in microwave oven
  • catheterized every 4-6hrs – amount of urine should be <500ml – may need to awaken at night to catheterize
  • mainly used in automatic bladder
  • Contraindications
    • inability or unwilling to self catheterize (care giver not willing)
    • abnormal urethral anatomy like strictures, false passages
    • bladder capacity <200ml
    • poor cognition, little motivation, not willing to strictly adhere to schedule
    • high fluid intake regimen
    • autonomic dysreflexia
  • Complications
    • UTI
    • bladder over distension
    • urinary incontinence
    • urethral trauma and hematuria
    • urethral false passages
    • urethral strictures
    • autonomic dysreflexia
    • bladder stones
  • in case of urine leakage and high pressure bladder : medications for overactive bladder
Crede and Valsalva
  • used in LMN injuries with low outflow resistance or post sphincterotomy
  • Crede
    • applying suprapubic pressure to express urine from bladder
    • augments the bladder contraction when bladder is flaccid
    • effectiveness limited by sphincter pressure
  • Valsalva
    • increase intraabdominal pressure – do not ensure complete emptying
  • avoid both these methods as primary techniques for bladder emptying : cause inguinal hernia, rectal prolapse
  • mainly in atonic bladder
  • contraindications
    • detrussor sphincter dyssynergia
    • bladder outlet obstruction
    • vesicourethral reflux
    • hydronephrosis
Reflex voiding
  • sacral micturation reflex should be intact
  • external collection device (condom catheter) to be used
  • incomplete emptying
  • mainly used in automatic bladder
  • can cause autonomic dysreflexia or DESD
Management of Detrussor External Sphincter Dyssynergia (DESD)
  • non surgical methods for dyssynergia
    • alpha blockers
      • lowers urethral resistance and improve voiding
      • contraindicated in symptomatic hypotension
      • to be taken in night to avoid orthostatic hypotension
      • phosphodiesterase can be used if patient already on alpha blockers – with caution
    • botulinum toxin injection into urinary sphincter mechanism
      • in DESD and detrussor over activity in intermittent catheterisation
  • surgical
    • transurethral sphincterotomy with laser
      • procedure of choice
      • can also be done with diathermy knife
    • transurethral stent
Electrical stimulation and posterior sacral rhizotomy
  • electrodes placed on sacral nerves or nerve roots (S2-4)
  • stimulated by stimulator controlled by battery powered remote – operated by user
  • combined with rhizotomy
    • reduce reflex incontinence
    • increase bladder capacity and compliance
    • protect upper nerve tracts
    • reduce autonomic dysreflexia
    • reduce reflex defecation
    • abolish reflex erection and reflex ejaculation
    • abolish sacral sensation
Augmentation cystoplasty
  • ileum, colon or stomach – used to create intraabdominal low pressure reservoir
Urinary diversion
  • secondary form of bladder management
  • ureters transected – connected to segment of intestine (terminal ileum) – then brought to skin through lower abdominal wall
  • external collection device placed over to stomach to collect urine
  • continent urinary diversion
    • no collection device – continence achieved
    • emptied by self catheterisation
Mitrofanoff procedure
  • appendix used to create a channel between abdominal wall and bladder
  • in patients with inadequate access
Cholinergic agents
  • Bethanechol hydrochloride
Anticholinergic agents

  • mainly in atonic bladder
  • oxybutynin, imipramine, flavoxate, darifenacin
  • increases bladder capacity

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