Lower Urinary Tract Symptoms (includes ketamine cystitis)

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Lower Urinary Tract Symptoms (includes ketamine
cystitis)

• Dr Peggy CHU
• Tuen Mun Hospital

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Lower Urinary Tract Symptoms (LUTS)

• Storage symptoms
• Urgency, frequency, urge incontinence, nocturia
• Voiding symptoms
• Weak or intermittent stream, straining,
  hesistancy, terminal dribbling or incomplete
  emptying
• Post micturition symptoms
• Post micturition dribbling

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Anatomical causes of LUTS

• Bladder
• Overactive bladder, e.g post CVA
• UTI
• Prostate
• Benign prostatic enlargement
• Urethral
• Urethral stricture, e.g years post gonorrhoea
• Urinary sphincter

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LUTS

• ? as ages ?
• Can occur up to 30 man aged gt 65 yrs
• ? QOL
• May point to pathology of urinary tract

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LUTS Initial Assessment

• Med Hx to identify possible causes,
  co-morbidities, drugs
• P/E abd, genitalia, Digital rectal exam (DRE)
• IPSS (to allow assessment of subsequent symptom
  change)
• Freq vol chart
• Urine x dipstick blood, glucose, protein,
  leucocytes nitrites
• /- PSA

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LUTS IPSS QOL
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LUTS IPSS Chinese
www.hkua.org
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LUTS QOL Chinese
www.hkua.org
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LUTS Initial Assessment

• /- PSA testing in cases of
• LUTS are suggestive of benign prostatic
  enlargement
• Prostate feels abn on DRE

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Freq-vol chart
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Freq-vol chart
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frequency Compulsive water drinking
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C/O frequency urinary
incontinence
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LUTS when is referral necessary

• If LUTS Cx by
• Recurrent /persistent symptomatic UTI
• Urinary retention
• Renal impairment suspected to be caused by lower
  urinary tract dysfunction
• Suspected urological cancer
• Bordersome LUTS not responding to conservative
  management or drug

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LUTS Role of conservative Px

• LUTS with storage symptoms
• Fluid intake
• Lifestyle changes ( avoid coffee, tea etc)
• Supervised bladder training
• Temporary containment products ( pads)

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LUTS post micturition dribbling

• Loss of a few drops of urine after the main urine
  stream has finished
• Happens when rearranging trousers
• Can result in wet and stained clothing

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LUTS post micturition dribbling

• Aetiology
• urethra not emptied by muscles surrounding it
• sump of urine pools in urethra
• ? when ages ?
• Treatment
• push the last few drops of urine from the
  urethra with the fingers before the final shake

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LUTS post micturition dribbling

• Technique
• pass urine in usual manner wait for a few sec
  for bladder to empty
• Place finger tips of hand 3 finger widths behind
  scrotum and press gently towards base of penis
• Can be repeated

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LUTS Drug treatment
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LUTS Drug treatment

• Alpha blocker
• Same efficacy, difference in S/E (due to
  difference in T ½ and uroselectivity)
• Precaution in patients also taking beta blocker
• Postural hypotension
• Anticholinergic
• Avoid in closed angle glaucoma
• Dry mouth, constipation

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Ketamine Cystitis
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Ketamine (C13H16CINO)(2-(o-Chlorophenyl)-2-(methy
lamino) cyclohexan-1-one

• Anaesthetic agent, dissociative anesthesia
• Rapid onset, short duration of action
• N-dealkylated in liver, metabolized and excreted
  in urine (gt90)

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Hong Kong Statistics
Central Registry of Drug Abuse 58th Report
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Patients

• TMH
• Sep 2006 - Jun 2010
• 113 patients
• M F 90 43
• mean age 25.6 yrs (14 42)
• years of ketamine abuse 3/12 to 11 years
• referred by AE, GP, psychiatrist
• C/O LUTSve

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Lower Urinary Tract Symptomatology

• frequency, urgency, dysuria, urge incontinence,
  painful haematuria
• urine culture ve
• no response to multiple courses of oral
  antibiotics

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Normal bladder
ketamine bladder
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normal bladder
bladder of ketamine abuser
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Upper Urinary Tract

• blood creatinine
• /- hydronephrosis
• papillary necrosis
• ureteric stricture

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Blood Creatinine

• 10/113
• Creatinine 126 - 1069
• 2 required PCN

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Upper Tract Radiology

• all have renal USG
• 30 bilateral hydronephrosis
• 10 unilateral hydronephrosis

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Pathophysiology

• ? chronic submucosal inflammatory response
  resulting from chemical cystitis
• ? microvascular changes
• ? autoimmune (raised ESR C3/4)
• ? bacteriuria

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Treatment

• Antibiotics
• Antimuscarinic agent (oxybutynin, detrusitol)
• ? Cystoplasty
• ? ? ABSTINENCE

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New Problems with ketamine abuse
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Guidelines (before Jun 2008)
? 25 g within discretion of sentencer
25 400 g 2 - 4 yrs imprisonment
400 - 800 g 4 - 8 yrs
? 800 g ? 8 yrs
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Guideline (after Jun 2008)
? 1 g within discretion of sentencer
1 - 10 g 2 - 4 yrs imprisonment
10 - 50 g 4 - 6 yrs
50 - 300 g 6 - 9 yrs
300 - 600 g 9 - 12 yrs
600 - 1000 g 12 - 14 yrs
? 1000 g ? 14 yrs
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Thank You