NON-Neurogenic Chronic Urinary Retention AUA White Paper

Transcription

1 NON-Neurogenic Chronic Urinary Retention AUA White Paper Great Lakes SUNA Inside Urology March 16, 2018 Michelle J. Lajiness FNP-BC Nurse Practitioner DMC Urology

2 Incidence Really unknown Lack consensus on definition Unknown Difficult to differentiate non neurogenic from neurogenic

3 AUA White Paper Based on expert opinion Lacks evidenced base trials Lacks consensus No standardized criteria

4 Goals of White Paper Characterize patients with CUR into clinically definable index patient populations in adult men and women(>18 years old) Propose diagnostic and treatment alogorithms for these index populations Identify future areas of research for CUR

5 CUR Definition There is no one definition Use of the term varies in the literature Research tends to use atonic detrusor Urodynamic study No contraction during study Recently linked with primary muscle activity and underactive bladder

6 ICS definition A contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or failure to achieve complete bladder emptying within a normal time span

7 AUA Definition (clinical) Non Neurogenic CUR is empirically defined herein as an elevated PVR >300 ml that has persisted for at least six months documented on two or more separate occasions.

8 Controversy PVR as definition PVR consensus >100- >500 ml Cut off value based on total volume voided vs. volume left Sign not uniform diagnosis

9 Conditions Commonly associated with CUR Outlet obstruction Poor bladder contractility

10 Outlet obstruction Long-term use of medications Antihistamines Alpha adrenergic agonists antipsychotics Urethral or bladder neck constricture High grade pelvic floor prolapse Urethral diverticula in women

11 Outlet Obstruction Prior anti-incontinence procedure Prior vaginal vault prolapse procedure Primary bladder neck obstruction in men and women Dysfunctional voiding

12 Poor bladder contractility Long standing outlet obstruction Long term use of medication Anticholinergic/Antispasmotic Tricyclic anti depressants Beta adrenergic agonist Calcium channel blockers Non steroidal anti inflammatory Opioids Benzodiazepines antipsychotics

13 Poor Bladder Contractility Diabetes Constipation Frailty idiopathic

14 Categories of CUR High risk Subset of individuals with CUR who are at potentially elevated risk for organ system harm or failure from CUR Symptomatic CUR Subset of individuals who are bothered by symptoms

15 High risk CUR Radiology findings Hydronephrosis Hydroureter Lab findings Stage III chronic kidney disease GFR ml/min Recurrent symptomatic, culture proven UTI Culture proven systemic urosepsis Signs and symptoms Urinary Incontinence associated with skin breakdown UI associated with decub

16 Symptomatic CUR Having subjectively moderate to severe urinary symptoms impacting QOL on a validated urinary questionnaire History of requiring catheterization for treatment of a symptomatic episode of inability to void within the last 6 months Excluding acute onset or urinary retention caused by oncologic, traumatic, or any neurologic event.

17 Treatment Algorithm

18 Treatment Summary Taken from Stoffel et al (2016) Non-Neurogenic Chronic Urinary Retention: Consensus Definition, Management Strategies, and future Opportunities

19 Treatment If patient is asymptomatic and there is no hydro--- DO NOT CATH PATIENT

20 Index Patient The first medically-identified Pt in a family or other group, with a particular condition which triggers a line of investigation

21 Medication Outlet obstruction caused by prostate Alpha blockers 5-alpha- reductase inhibitors Primary bladder obstruction male and female Alpha blockers Improve bladder contractility Cholinergic agonist Bethanechol

22 Catheterization CIC performed frequently enough to effectively target reduction of risk and symptoms should be tailored for the individual treatment plan If long term catheterization is needed consider SP tube

23 Surgical Treatments Dictated by etiology In men obstruction secondary to prostate several surgeries available Chronic BOO in women secondary to prior mid urethral sling placement simple sling incision Prolapse- several options

24 Surgical Treatment CUR due to decreased bladder contractility consider sacral neuromodulation

25 Outcome measures Symptom improvement, as measured by quality questionnaires Risk reduction, as defined by resolution of hydronephrosis, renal failure, recurrent UTI, urosepsis, and secondary complications from overflow incontinence Successful trial of voiding without catheterization Stability of symptoms and risk over time

26 WHAT S NEXT Define it Determine causes Research on interventions Multi-institutional cohort studies Identify molecular markers Investigation for pharmacological and neurological interventions.

27 UAB Symposium

28 Index Patient Examples 50 year old male c/o urinary frequency, hesitancy, slow stream and nocturia

29 Index Patient 1 work-up AUA SI >15 50 g prostate on DRE UA normal PVR- 350 cc

30 Risk Category Low/Risk Symptomatic

31 Index Patient 1 Treatments Timed voiding Fluid management PVR 6 months later 450 cc Renal Ultrasound and renal panel negative

32 Treatment Index Patient 1 Offer CIC and/or Alpha blockers and/or 5-alpha- reductase inhibitors Formal evaluation for outlet obstruction with a UDS Goal improve QOL monitor with validated questionnaires

33 Index Patient 2 77 year old male HX of CHF Four culture positve UTI s over the past 3 months Long history of bothersome, irritative LUTS

34 Index Patient 2 work-up 60 g prostate 2 separate PVR s over 6 months >500ml UA positive for leukocyte esterase, nitrites, and crystals Renal US shows mild to moderate hydronephrosis and a 3 cm bladder stone

35 Risk Category High/Risk Symptomatic

36 Index Patient 2 Treatment Immediate catheterization to address UTI and hydro Consider evaluation for a bladder outlet procedure and/or lithotripsy Long term CIC or SP Tube

37 Index Patient 3 75 yo female No symptoms No prior urologic history Presents to EC after a fall for hip pain CT shows distended bladder no hydro PE shows mild vaginal vault prolapse PVRS consistently >400 ml

38 Risk Category Low Risk/Asymptomatic

39 Index Patient 4 80 yo male Distant history or TURP and chronically elevated PVR No bothersome symptoms RUS shows bilat hydroureteronephrosis and a PVR 1,800 ml

40 Risk Category High Risk/Asymptomatic

41 Index Patient 4 treatment PVR consistent with longstanding bladder decompensation Short term indwelling foley CIC if able after

42 Conclusion Need clinical research studies Only treat those high risk categories Treatment should be based on Assessment of symptoms Reduction of risk Ability to void without catheterization Stability of symptoms/risk over time