Comparison of efficacy of oxybutynin and tolterodine for prevention of catheter related bladder discomfort: a prospective, randomized, placebo-controlled, double-blind study

Background. Bladder discomfort related to intraoperative catheterizationof urinary bladder is a distressing symptom and more so in patientsawakening from anaesthesia. These symptoms are similar to symptomsof overactive bladder. Muscarinic receptor antagonists havebeen reported to be effective in the treatment of overactivebladder. This study was therefore undertaken to evaluate theefficacy of oxybutynin and tolterodine in preventing catheterrelated bladder discomfort. Methods. Two hundred and thirty-four consecutive adult patients,ASA I and II, of either sex, undergoing elective percutaneousnephrolithotomy surgery requiring urinary bladder catheterizationwere randomized into three equal groups of 78 each. Group C(control) received placebo, Group O (oxybutynin) received oxybutynin5 mg and Group T (tolterodine) received tolterodine 2 mg orally1 h before surgery. After induction of anaesthesia patientswere catheterized with a 16 Fr Foley's catheter and the balloonwas inflated with 10 ml distilled water. The bladder discomfortwas assessed at 0, 1, 2 and 6 h after patient's arrival in thepost-anaesthesia care unit. Severity of bladder discomfort wasgraded as mild, moderate and severe. Results. Incidence of bladder discomfort observed in the controlgroup was higher, i.e. 58% (45/78), compared with oxybutyninand tolterodine groups where it was 35% (28/78) and 33% (26/78),respectively (P<0.05). Significant reduction in the severityof bladder discomfort was also observed after oxybutynin andtolterodine therapy compared with control (P<0.05). Conclusion. Pretreatment with either oxybutynin or tolterodinereduces the incidence and severity of catheter related bladderdiscomfort.     

加巴喷丁用于预防尿管相关性膀胱不适的有效性评估：前瞻、随机、安慰剂对照的双盲研究

背景导尿管引起的尿管相关性膀胱不适（CRBD）令人痛苦。本研究评估了加巴喷丁用于预防CRBD的有效性。方法108例行择期经皮肾切开取石术的成年患者，ASAI～Ⅱ级，男女不限，随机分为2组，每组54例患者。对照组用安慰剂，G组用加巴喷丁600mg。2组患者均在手术前1小时口服药物。患者在麻醉诱导后将16F的Foley导尿管插入膀胱，气囊注入生理盐水10ml。手术后患者进入麻醉恢复室，分别在到达恢复室（0小时）、1、2和6小时的时间点评估CRBD的发生率与严重程度（轻、中、重度）。结果对照组CRBD的发生率达80％（43／54），而加巴喷丁组CRBD的发生率降低到50％（27／54）（P〈0．05）。加巴喷丁还可减轻CRBD的严重程度和手术后疼痛程度，该组手术后需要芬太尼镇痛的人数和芬太尼使用的总量都减少（P〈0．05）。结论手术前1小时口服加巴喷丁（600mg）可以减少CRBD的发生率和严重程度，减少手术后疼痛，使手术后需要芬太尼镇痛的患者例数和芬太尼需求量明显减少。     

甲状腺乳头状癌患者术前不予留置尿管效应研究

目的 减少甲状腺乳头状癌患者术后尿管相关不适感,促进康复。方法 将820例拟行全麻下甲状腺全切术的甲状腺乳头状癌患者分为对照组607例、观察组213例;对照组于全麻后留置尿管,观察组不予留置尿管。结果 观察组术后未发生尿管相关不适,对照组术后尿管相关不适发生率为87.5%;观察组术后首次下床时间显著早于对照组、睡眠质量显著高于对照组、住院时间及住院费用显著少于对照组（均P＜0.05）;两组均未发生尿路感染;对照组拔管后尿潴留重置尿管2例、观察组术后1例不能自排小便留置尿管。结论 对全麻下行甲状腺全切术的甲状腺乳头状癌患者,术前不予留置尿管可显著改善手术治疗体验,降低费用,促进康复。     

脊柱麻醉下股骨头置换术后尿液潴留发病率及风险因素

目的探讨经椎管麻醉进行人工股骨头置换术,术后发生尿液潴留的几率及可能的风险因素。 方法回顾性分析2015年2月至2018年4月期间,在海南省人民医院使用椎管麻醉(硬膜外麻醉、蛛网膜下腔麻醉)下行初次股骨头置换术共164个患者,168例股骨头置换的资料。纳入标准：年龄大于18岁,言语表达清晰。排除标准：拒绝参与者;术前间断插尿管者,目前仍留置尿管者;透析患者;既往前列腺、尿道及肾脏的手术病史者;骨肿瘤患者。患者术前均可自行排尿,均未留置尿管。所有的患者都详细记录身体质量指数(BMI)、性别、美国麻醉师协会(ASA)分级、手术时间、术后口服止痛药物,尿失禁与多尿症病史,术后尿液排泄与潴留情况(包括尿液的颜色、体积、腹部症状,体征,并使用膀胱超声确认膀胱中的剩余尿量)。使用卡方检验分析分类变量,使用t检验分析连续变量。 结果最终纳入161名患者,5名患者要求麻醉后留置尿管而被排除,38名患者术后出现了尿液潴留,需使用尿管进行导尿。共计有17个病人留置导尿管3～5 d,5位患者因拒绝导尿而出现尿路感染,使用尿管导尿的患者有3例最后发生了尿路感染。术后尿液潴留与既往潴留病史(t ＝8.935,P <0.05)及术中的输液量(t ＝6.213,P<0.05)呈正比例相关。未发现留置尿管与BMI指数,性别,ASA分级,手术时间、术后口服止痛药物,尿失禁与多尿症病史存在明显的相关性(P >0.05)。 结论椎管麻醉下进行人工股骨头置换术,既往尿液潴留病史及手术过程中输入较多的液体量是术后发生尿液潴留的高风险因素。     

Voiding in patients managed with or without ultrasound monitoring of bladder volume after outpatient surgery.

The goal of this study was to determine whether recovery room monitoring of bladder volume would affect patient outcome after ambulatory surgery. Incidence of urinary retention and times to void and to discharge were compared in 161 patients managed with ultrasound bladder monitoring versus 173 controls without bladder monitoring. Urinary retention was diagnosed by clinical means or by ultrasound, confirmed by bladder catheterization. Patients were required to void or were catheterized before discharge. In the control patients without underlying risk factors for retention, median time to void was 95 min, and retention occurred in 0.8%, which was not significantly different from the ultrasound group (80 min and 0%, respectively). After hernia/anal surgery or spinal/epidural anesthesia, voiding was delayed (130 and 213 min), incidence of retention was increased (17% and 13%), and there was a trend toward earlier voiding (168+/-99 vs. 138+/-68 min) with bladder monitoring. We conclude that most patients at low risk of retention void within 3 h of outpatient surgery; their outcome is unaffected by bladder monitoring. After hernia/anal surgery and spinal/ epidural anesthesia, the likelihood of urinary retention is increased, and ultrasound monitoring facilitates deciding whether such patients should be catheterized. IMPLICATIONS: Incidence of bladder catheterization and urinary retention were compared in patients managed with and without ultrasound monitoring of bladder volume after outpatient surgery. Monitoring did not alter outcome in patients at low risk of retention, but it facilitated determining when to catheterize patients at high risk of retention (hernia/anal surgery, spinal/epidural anesthesia).     

Incidence and Risk Factors for Postoperative Urinary Retention in Total Hip Arthroplasty Performed Under Spinal Anesthesia

Background

The objective of this study is to determine the risk factors for postoperative urinary retention (POUR) following total hip arthroplasty (THA) under spinal anesthesia.

Inconfort lié à la sonde vésicale en période postopératoire

Catheter-related bladder discomfort (CRBD) is an unrecognized clinical event. Symptoms of CRBD secondary to an indwelling urinary catheter mimic those of an overactive bladder, i.e. urinary frequency and urgency with or without urge incontinence. Stimulation of muscarinic receptors located in the bladder wall by the catheter is the triggering factor. Postoperative pain may be increased by the CRBD. Antimuscarinic drugs, as oxybutynin, are today the main treatment. Further studies are warranted to confirm efficacy of ketamine, tramadol and gabapentin in this situation.     

Bladder management after total joint arthroplasty

This study was undertaken to determine the impact of an indwelling Foley catheter on bladder dysfunction and incidence of urinary tract infections after total joint arthroplasty. A prospective randomized controlled trial was conducted assigning use of an indwelling Foley catheter (group 1) or intermittent catheterization (group 2) for 48 hours following operation. Postoperative cultures were obtained on days 2 and 5, and the number of intermittent catheterization events and void and catheterization volumes were recorded. Concurrent cost-effectiveness analysis was conducted. One hundred nineteen of 174 consecutive patients having elective primary total joint arthroplasty completed the study. Five of 62 patients (8%) in group 1 and 7 of 57 patients (12%) in group 2 developed urinary tract infections (NS, P = .45). Twenty patients (35%) in group 2 and 12 (19%) in group 1 required straight catheterization for inability to void 48 hours after surgery (P = .05). Seventeen patients (35%) in group 2 and eight patients (16%) in group 1 required straight catheterization after epidural analgesia was discontinued (P = .024). Bladder management by indwelling Foley catheter saved more than 150 minutes of direct nursing contact per patient and $3,000 in total hospital costs. Indwelling Foley catheters reduced the frequency of postoperative urinary retention, were less labor intensive than intermittent straight catheterization, and were not associated with an increased risk of urinary infection. In the setting of epidural anesthesia and postoperative analgesia for total joint arthroplasty, management by indwelling catheter is a cost-effective strategy to facilitate postoperative return of normal bladder function.     

Non-invasive measurement of bladder volume as an indication for bladder catheterization after orthopaedic surgery and its effect on urinary tract infections.

A non-invasive ultrasound imaging technique (BladderScan) was used prospectively in an attempt to reduce the need for catheterization of the urinary bladder and the incidence of urinary tract infections after orthopaedic surgery. Over a 4-month period, in which 1920 patients were included, catheterization was performed if there was no spontaneous diuresis by 8 h after surgery. A total of 31% of these patients were catheterized, and 18 patients developed urinary tract infections. In a subsequent 4-month period, there were 2196 patients, catheterization was performed only if the bladder volume was more than 800 mL 8 h after surgery. The rate of catheterization decreased to 16%, and five patients developed urinary tract infections. In our patients, measuring bladder volume reduced the need for a urinary catheter and the likelihood of urinary infection.     

Urinary tract complications in spinal cord injury patients

The characteristics of urinary tract complications in a series of 202 spinal cord injury patients are described. Repeated urinary infection was the most usual problem. Upper urinary tract changes were detected in 61 patients (30%). 56 patients (28%) underwent bladder outlet surgery for problems with voiding. Urinary diversion was done to 8 patients (4%), and 12 (6%) were treated with permanent indwelling catheter or self-catheterization. The high incidence of bladder stones (29%) and urethral complications (14%) was regarded as due to indwelling catheterization at the early stage post-injury. Despite the high urinary tract morbidity, only one patient has so far died of renal failure.     

初次髋膝关节置换术中不留置尿管的可行性和安全性研究

目的探讨单侧初次髋或膝关节置换术中不常规留置尿管的可行性及安全性,以减少不必要的导尿,提高患者就医舒适度和满意度。 方法本文回顾性分析中日友好医院骨关节外科2015年11月至2016年10月期间109例无明显尿潴留高危因素、无术前尿路感染、无尿路刺激征及重度肝肾功能不全、且接受单侧初次髋或膝关节置换术、术中不留置尿管(NIC)患者的资料。根据配对条件,与同期行常规术前留置尿管(IC)的单侧初次髋或膝关节置换患者按照1 ∶1进行配对研究,应用SPSS 19.0统计学软件对正态分布计量资料采用配对t检验,非正态分布计量资料采用Wilcoxon符号秩和检验,计数资料采用χ²检验分析比较两组患者术后的尿潴留、二次尿潴留、尿管相关膀胱不适、尿路刺激症、尿路感染、不良事件发生率,以及术后住院时间及患者满意度,分析并评价不留置尿管在单侧初次髋、膝关节置换术中的可行性及安全性。 结果两组患者术后尿潴留、二次尿潴留、尿路感染发生率比较,差异无统计学意义(P>0.05),NIC组术后尿管相关膀胱不适、尿路刺激征、不良事件发生率及术后住院时间均明显低于IC组,而患者满意度高于IC组,两组比较差异有统计学意义(χ²＝10.844,P<0.05),单侧初次髋或膝关节置换术中不必要的导尿高达81.7%。 结论初次髋或膝关节置换术中不常规留置尿管安全可靠,能有效减少尿管相关膀胱不适、尿路刺激征及不良事件的发生,同时可缩短术后住院时间,提高患者早期满意度。     

Managing recurrent urinary catheter blockage: problems, promises, and practicalities.

Long-term urinary catheterization is rarely completely free of complications, and encrustation by mineral salts leading to catheter blockage is common in around 40% to 50% of long-term catheterized patients. Recurrent blockage is a problem, which is both distressing to patients and caregivers and costly to health services in terms of time and resources. This article addresses the causes of recurrent urinary catheter blockage, proactive approaches to care, and the evidence for use of catheter maintenance solutions to reduce buildup of mineral deposits.     

Catheter-associated bacteriuria in patients in reverse isolation

We determined the incidence and source of bacterial colonization of the bladder in 18 consecutive renal transplant recipients who required postoperative indwelling urethral catheterization and who were in reverse isolation. The patients were catheterized for an average of 6 days. Bladder bacteriuria occurred in 5 patients (27 per cent): 2 owing to urethral organisms, 2 after breaks in the drainage system and 1 owing to an unidentified source. The drainage bag urine was contaminated rarely and never was a source of bladder bacteriuria. The data suggest that bacterial contamination of the drainage bag may be an infrequent source of bladder bacteriuria in patients with limited contact with a hospital environment.     

Evaluation of povidone-iodine as vesical irrigant for treatment and prevention of urinary tract infections

This is a preliminary study evaluating diluted solutions of povidone-iodine (PVP-I) as urinary bladder irrigants for the treatment and prevention of urinary tract infection. Diluted povidone-iodine solutions were used as indwelling catheter irrigants and as instillations into the urinary bladder following intermittent catheterization. The diluted PVP-I solutions had no efficacy in either the treatment or prevention of urinary tract infections when used as indwelling urethral or suprapubic catheter irrigants. There was a suggestion of a slight decrease in the incidence of urinary tract infections during the use of PVP-I in the intermittent catheterization group in this uncontrolled study, but the percentage of positive urine cultures was greater than desired. The absence of any unfavorable data has led us to conclude that the diluted PVP-I caused no undesirable side effects in any of the patients treated with this agent. PVP-I bladder irrigation warrants further investigation in special cases such as lower urinary tract fungal infections.     

The efficacy of resiniferatoxin in prevention of catheter related bladder discomfort in patients after TURP - a pilot,randomized, open study

Background

Resiniferatoxin (RTX) has been shown to have variable efficacy in the treatment of intractable lower urinary tract symptoms and symptoms associated with neurogenic detrusor overactivity. It has also been used successfully in treating overactive bladder (OAB). In order to evaluate the potential and efficiency of RTX in treatment of catheter related bladder discomfort (CRBD) over post-operative period of transurethral resection of the prostate (TURP), we conducted the current pilot, randomized open study.

Methods

The study was comprised of 48 patients undergoing TURP in a single institute from September 2007 to September 2008. Patients were randomly divided into Group-RTX and Group-control. CRBD was classified into 4 degrees: degree 0, 1, 2, and 3. Patients with the most severed CRBD (degree-3) were treated with tolterodine.

Results

There were no statistical difference of patients'' age, prostate volume, IPSS score, storage score and void score in IPSS, and QOL score between the two study groups(P=0.213, 0.356, 0.471, 0.554, 0.055 and 0.380, respectively). RTX pre-treatment reduced incidence of CRBD. 25% of the patients in RTX group had CRBD, at 6 hours/1 day and 3 days after TURP, significantly lower than the control group in which 75% of the patients during the same period (P=0.001). During the three days post-operative period, RTX also reduced severity of CRBD, compared with the control group. No patient in Group RTX sufferred CRBD of degree 3, a clear contrast to the control group in which 7 patients had degree 3 CRBD, during three days post-operative. Finally, less patients in RTX group required tolterodine, compared with control, P=0.009. Interestingly, the difference of CRBD incidence between Group RTX (50%) and control (75%) diminished 5 days after TURP, P=0.135.

Conclusions

Pretreatment with intravesical resiniferatoxin significantly reduces the incidence and severity of catheter related bladder discomfort in patients after TURP.     

Management of temporary urinary retention after arthroscopic knee surgery in low-dose spinal anesthesia: development of a simple algorithm

Introduction

In practice, trauma and orthopedic surgery during spinal anesthesia are often performed with routine urethral catheterization of the bladder to prevent an overdistention of the bladder. However, use of a catheter has inherent risks. Ultrasound examination of the bladder (Bladderscan^®) can precisely determine the bladder volume. Thus, the aim of this study was to identify parameters indicative of urinary retention after low-dose spinal anesthesia and to develop a simple algorithm for patient care.

Materials and methods

This prospective pilot study approved by the Ethics Committee enrolled 45 patients after obtaining their written informed consent. Patients who underwent arthroscopic knee surgery received low-dose spinal anesthesia with 1.4 ml 0.5% bupivacaine at level L3/L4. Bladder volume was measured by urinary bladder scanning at baseline, at the end of surgery and up to 4 h later. The incidence of spontaneous urination versus catheterization was assessed and the relative risk for catheterization was calculated. Mann–Whitney test, χ² test with Fischer Exact test and the relative odds ratio were performed as appropriate. *P < 0.05.

Results

Seventy percent of the patients were able to void spontaneously; in 30%, a Foley catheter had to be inserted because bladder volume exceeded 500 ml and/or urination was insufficient (P < 0.01). Bladder volume differed independently of the fluid infused. Additionally, patients with a bladder volume >300 ml postoperatively had a 6.5-fold greater likelihood for urinary retention.

Conclusion

In the management of patients with short-lasting spinal anesthesia for arthroscopic knee surgery we recommend monitoring bladder volume by Bladderscan^® instead of routine catheterization. Anesthesiologists or nurses under protocol should assess bladder volume preoperatively and at the end of surgery. If bladder volume is >300 ml, catheterization should be performed in the OR. Patients with a bladder volume of <300 ml at the end of surgery may be transferred to the ward or recovery room. In these patients, bladder volume must be checked at least every 60 min for a maximum of 3 h or until spontaneous voiding is possible or bladder volume is >500 ml.

     

BLADDER CANCER IN PATIENTS WITH MULTIPLE SCLEROSIS TREATED WITH CYCLOPHOSPHAMIDE

Purpose

We define the risk of bladder cancer in multiple sclerosis related to the use of indwelling catheters and cyclophosphamide administered as an immunomodulating agent.

Materials and Methods

We retrospectively reviewed the records of 2,351 patients with multiple sclerosis referred to the National Center for Multiple Sclerosis.

Results

Of the 2,351 patients 2 women and 5 men (0.29%) had bladder cancer. Of the 850 chronically catheterized patients the incidence was 0.7%. One patient with cancer performed intermittent catheterization for a rate of 0.23% in this group. In a subgroup of 70 patients treated with cyclophosphamide 5 chronically catheterized patients (5.7%) had bladder cancer. Hematuria was the most common presenting symptom. These data were compared with those in the literature on bladder cancer in spinal cord injury.

Conclusions

These data suggest a possible synergistic role of cyclophosphamide and chronic catheterization in the induction of secondary bladder cancer. Regular cystoscopy is warranted in these patients to allow early detection of bladder tumors. Nitric oxide metabolism may be an important factor in the carcinogenesis of this type of bladder cancer.     

The role of bladder catheterization in total knee arthroplasty

The use of a urinary bladder catheter in the perioperative period for patients undergoing total knee arthroplasty is controversial. In the current study, two bladder management protocols were studied. One group of patients had an indwelling catheter inserted into the bladder before total knee arthroplasty. The other group of patients was observed and treated for urinary retention as necessary. From 1993 to 1998, 652 patients undergoing primary, unilateral total knee arthroplasty were randomized by surgeon into two groups: one group underwent preoperative insertion of an indwelling bladder catheter (306 patients), and one group (346 patients) had a catheter inserted postoperatively as necessary. Sixty-six percent (229 of 346) of these patients required catheterization (203 had indwelling catheters and 26 had intermittent straight catheters). A urinary tract infection developed in five patients (1.6%) in whom a catheter was inserted preoperatively. A urinary tract infection developed in six patients (1.7%) in whom a catheter was inserted if necessary. Five of these urinary tract infections developed in patients with delayed indwelling bladder catheters. A urinary tract infection did not develop in any patient in whom a straight catheter was inserted. There was no significant difference in the length of stay in the hospital between the two groups. The group in whom a catheter always was inserted generated $491 greater cost for total knee arthroplasty than patients in whom a catheter was inserted if necessary.     

Complicated urinary tract infection caused by Pseudomonas aeruginosa in a single institution (1999–2003)

BACKGROUND: Pseudomonas aeruginosa has been an important uropathogen that causes complicated urinary tract infection. We investigated the clinical characteristics of complicated urinary tract infection caused by Pseudomonas aeruginosa in a single institution. METHODS: We studied those patients who had basal disease in their urinary tract that was diagnosed as urinary tract infection caused by more than 10(4) colony forming units (CFU)/mL of Pseudomonas aeruginosa isolated from their urine. In those patients, we analysed infectious risk factors, treatment methods including the use of antimicrobial agents, the presence of a urinary tract catheter, and the relationship between febrile infection and urinary tract catheter. In addition, we examined the various antimicrobial susceptibilities against Pseudomonas aeruginosa. RESULTS: We studied 76 patients (59 men and 17 women). Of their basal diseases of the urinary tract, bladder tumor was the most prevalent (42.1%). Of the 39 patients who had an indwelling urinary tract catheter, 26 (66.7%) experienced a high-grade fever, a higher rate than that of the 37 patients who were not catheterized (40.5%). Seven patients were treated with anticancer chemotherapy drugs and 31 cases of urinary tract infection caused by Pseudomonas aeruginosa were diagnosed in the perioperative period. Piperacillin showed lower susceptibility against Pseudomonas aeruginosa in these 2 years (P<0.05). CONCLUSIONS: Our results indicated that those patients with urinary tract catheterization had a higher incidence of fever than patients without catheterization. Therefore, we must improve not only the antimicrobial treatment of Pseudomonas aeruginosa but also our management of catheters.     

托特罗定治疗前列腺术后留置导尿致膀胱痉挛临床疗效分析

目的 :评价托特罗定 (tolterodine)治疗前列腺术后留置导尿致膀胱痉挛的疗效。　方法 :对 82例前列腺术后留置导尿出现膀胱痉挛的患者给于托特罗定治疗 ,2mg/次 ,2次 /d ,至拔除导尿管前 2 4h。评价指标包括痉挛是否发生、发生频率、持续时间等。　结果 :用药 2 4h后 ,膀胱痉挛完全缓解 2 1例 (2 5 .6 % ) ;部分缓解 4 5例 (5 4 .9% ) ;未缓解 16例 (19.5 % )。 72h后 ,膀胱痉挛完全缓解 4 5例 (5 4 .9% ) ;部分缓解 30例 (36 .6 % ) ;未缓解 7例 (8.5 % )。治疗过程中无严重不良反应发生。　结论 :托特罗定为治疗前列腺术后留置导尿致膀胱痉挛快速、有效、持久、安全的药物。