Professional Documents
Culture Documents
MS Trust
Anna North and Nicola Russell, Letchworth Garden City
Primary Care
Michael Kirby, Centre for Research in Primary Care, Hatfield
Aims
Pathophysiology of bladder dysfunction in MS Queen Square management practice prior to Consensus UK Consensus 2008 on Bladder Management in MS
PAG PMC
How full is my bladder? Is this the right time and place to void?
PMC
Multiple Sclerosis
Result
measure PVR
no
better ?
yes continent
Fowler 1996
Effectofraisedpostmicturitionresidualvolumeand antimuscarinicsonbladderdysfunction
Raised PRV
Continence Advisor to assess for teaching clean intermittent (self) catheterisation.
Mainstay treatment Detrusor Overactivity (DO) causing urgency incontinence Anticholinergics (= antimuscarinics)
Propiverine Oxybutynin Tolterodine Trospium chloride Solifenacin Darifenacin Fesoterodine
DDAVP
Desmospray Desmotabs
once/24 hours restrict fluids extreme care in >60 years old not indicated with ankle swelling
Course of MS
EDDS4
EDDS6
Botulinum-A toxin for treating detrusor hyperreflexia in spinal cord injured patients: a new alternative to anticholinergic drugs? Preliminary results.
B.Schurch, M.Stohrer, G.Kramer, DM Schmid, G.Gaul and D.Hauri J.Urology, 164: 692-697, 2000
BNTX/A treatment in MS
Results 43 patients with intractable NDO due to MS treated 39 women : 4 men Mean age 45.8 years (range 33 61)
65.1% (28/43) performing clean intermittent catheterisation (CISC) pre-treatment 2 patients with indwelling catheters treated Subjective discomfort score 3.4 (range 0.5 9)
15
Incontinence
Frequency
10
*
0 PRE 4/52 16/52
* P <0.0001
Urgency
1st Injection
10.0
2nd Injection
7.5
Urgency
Urgency
7.5
5.0
5.0
2.5
2.5
*
0.0
16/52
PRE
4/52
16/52
* P <0.0001
* P 0.0003 P 0.0056
Quality of Life
1st Injection 2nd Injection
40
30
QoL score
QoL score
30
20
20
*
10
10
20
40
60
80
UDI 6 Scores
NDO/MS
Pr eB oN T/ Po A 1 st B oN T/ A Pr 1 eB oN T/ Po A 2 st B oN T/ A Pr 2 eB oN T/ Po A 3 st B oN T/ A Pr 3 eB oN T/ Po A 4 st B oN T/ A Pr 4 eB oN T/ Po A 5 st B oN T/ A 5
20
40
60
80
IIQ7 Scores
Pr eB oN T/ Po A 1 st B oN T/ A Pr 1 eB oN T/ Po A 2 st B oN T/ A Pr 2 eB oN T/ Po A 3 st B oN T/ A Pr 3 eB oN T/ Po A 4 st B oN T/ A Pr 4 eB oN T/ Po A 5 st B oN T/ A 5
30
months
20
10
TRPV1
P2X3
TRPV1
P2X3
TRPV1
NGF
ATP
ACh
P2X3 SP ATP/ACh
ATP M3 TRPV1 SP NK1 P2Y P2X3 TRPV P2Y ACh NK1 P2X3 M2
M2 ACh
TRPV1
SP
M2 M2
M3
M3
M2 M3
M2
American recommendations
Urodynamic investigations with filling cystometry and pressure/flow studies of voiding should be carried out only in those who are refractory to conservative treatment or bothered by their symptoms and wishing to undergo further interventions (Grade D).
UK Consensus Panel 2008
If clean intermittent self catheterisation is no longer possible, a long term indwelling catheter should be offeredsuprapubic rather than urethral catheter
Between 01/09/2005 and 30/06/2009, 259 incidents were reported to the NPSA relating to the insertion and management of suprapubic catheters. Of these, nine resulted in bowel perforation three deaths and seven cases of severe harm.
Degree of harm Death Severe harm Moderate harm Low harm No harm TOTAL No. of incidents 3 7 18 104 127 259 Bowel perforation 3 6 0 0 0 9
UTI
Urinary tract infections Urinary tract infections, may lead to exacerbation of neurological symptoms Cranberry preparations may reduce likelihood of infections Urine should not be routinely tested if doing CISC, unless the patient has symptoms suggestive of infection Cystoscopy and ultrasound should be carried out in patient with recurrent urinary tract infections, to exclude underlying abnormalities such as bladder stones If no cause is identified, it is reasonable to start low dose antibiotics prophylactically
When should urology services be involved? Haematuria Frequent urinary tract infections Symptoms refractory to treatment Consideration for intradetrusor injections of Botulinum toxin A Long term suprapubic catheter required Rarely consideration of surgery (for stress incontinence or ileal conduit)
Acknowledgements
Staff in Uro-Neurology