PEDIATRIC TIP Fluoroquinolones aren’t used for children because of possible adverse effects on developing cartilage.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Neurogenic bladder:
Treatment
(Professional Guide to Diseases (Eighth Edition))
The goals of treatment are to maintain the integrity of the upper urinary tract, control infection, and prevent urinary incontinence through evacuation of the bladder, drug therapy, surgery or, less commonly, neural blocks and electrical stimulation.
Techniques of bladder evacuation include Credé’s method, Valsalva’s maneuver, and intermittent self-catheterization. Credé’s method — application of manual pressure over the lower abdomen — promotes complete emptying of the bladder. After appropriate instruction, most patients can perform this maneuver themselves. Even when patients perform this maneuver properly, however, Credé’s method isn’t always successful and doesn’t always eliminate the need for catheterization.
Intermittent self-catheterization — more effective than either Credé’s method or Valsalva’s maneuver — has proved to be a major advance in the treatment of neurogenic bladder because it allows complete emptying of the bladder without the risks that an indwelling catheter poses. Generally, a male can perform this procedure more easily but a female can learn self-catheterization with the help of a mirror. Intermittent self-catheterization, in conjunction with a bladder-retraining program, is especially useful for patients with flaccid neurogenic bladder.
Drug therapy for neurogenic bladder may include bethanechol and phenoxybenzamine to facilitate bladder emptying and propantheline, methantheline, flavoxate, dicyclomine, and imipramine to facilitate urine storage.
When conservative treatment fails, surgery may correct the structural impairment through transurethral resection of the bladder neck, urethral dilatation, external sphincterotomy, or urinary diversion procedures. Implantation of an artificial urinary sphincter may be necessary if permanent incontinence follows surgery for neurogenic bladder.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Neurogenic arthropathy:
Treatment
(Professional Guide to Diseases (Eighth Edition))
Effective management relieves pain with analgesics and immobilization using crutches, splints, braces, and restriction of weight bearing to the affected joint.
In severe disease, surgery may include arthrodesis or, in severe diabetic neuropathy, amputation. However, surgery risks further damage through nonunion and infection.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Bladder cancer:
Treatment
(Handbook of Diseases)
Appropriate treatment for bladder cancer varies.
Superficial bladder tumors
Superficial bladder tumors are removed by transurethral (cystoscopic) resection and fulguration (electrical destruction). This procedure is adequate when the tumor hasn’t invaded the muscle.
Intravesicular chemotherapy is used for superficial tumors (especially those that occur in many sites) and to prevent tumor recurrence. This treatment involves washing the bladder directly with an antineoplastic — most commonly, thiotepa, doxorubicin, mitomycin, or bacille Calmette-Guérin (BCG).
If additional tumors develop, fulguration may have to be repeated every 3 months for years. However, if the tumors penetrate the muscle layer or recur frequently, cystoscopy with fulguration is no longer appropriate.
Tumors too large to be treated through a cystoscope require segmental bladder resection to remove a full-thickness section of the bladder. This procedure is feasible only if the tumor isn’t near the bladder neck or ureteral orifices. Bladder instillations of thiotepa after transurethral resection may also help control such tumors.
Under study Immunotherapy may be used to fight cancer. BCG is an immunomodulating agent commonly used in the treatment of superficial bladder cancer following surgery to remove the tumor. Biologic response modifiers — such as interferons, interleukins, colony-stimulating factors, monoclonal antibodies, and vaccines — may also be used to alter the interaction between the body’s immune defenses and the cancer cells. The goal is to boost, direct, or restore the body’s ability to fight the disease.
Infiltrating bladder tumors
Radical cystectomy is the treatment of choice for infiltrating bladder tumors. The week before cystectomy, treatment may include external beam therapy to the bladder. Surgery involves removal of the bladder with perivesical fat, lymph nodes, urethra, the prostate and seminal vesicles (in males), and the uterus and adnexa (in females). The surgeon forms a urinary diversion, usually an ileal conduit. The patient must then continuously wear an external pouch. (See Caring for a urinary stoma.) Other diversions include ureterostomy, nephrostomy, vesicostomy, ileal bladder, ileal loop, and sigmoid conduit.
Males are impotent following radical cystectomy and urethrectomy because these procedures damage the sympathetic and parasympathetic nerves that control erection and ejaculation. At a later date, the patient may desire a penile implant to make sexual intercourse (without ejaculation) possible.
Advanced bladder cancer
For patients with advanced bladder cancer, treatment includes cystectomy to remove the tumor, radiation therapy, and systemic chemotherapy with such drugs as cyclophosphamide, fluorouracil, doxorubicin, and cisplatin. This combination sometimes is successful in arresting bladder cancer.
Cisplatin is the single most effective agent.
Investigational treatments
Such treatments include photodynamic therapy and intravesicular administration of interferon alfa and tumor necrosis factor. Photodynamic therapy involves I.V. injection of a photosensitizing agent such as hematoporphyrin ether, which malignant cells readily ab
sorb. Then a cystoscopic laser device introduces laser energy into the bladder, exposing the malignant cells to laser light, which kills them. Because this treatment also produces photosensitivity in normal cells, the patient must totally avoid sunlight for about 30 days.
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Source: Handbook of Diseases, 2003
Urinary tract infection, lower:
Treatment
(Handbook of Diseases)
Appropriate antimicrobials are the treatment of choice for most initial lower UTIs. A 7- to 10-day course of antibiotic therapy is standard, but recent studies suggest that a single dose of an antibiotic or a 3- to 5-day antibiotic regimen may be sufficient to render the urine sterile. After 3 days of antibiotic therapy, urine culture should show no organisms.
If the urine isn’t sterile, bacterial resistance has probably occurred, making the use of a different antimicrobial necessary. Single-dose antibiotic therapy with amoxicillin or co-trimoxazole may be effective in women with acute, noncomplicated UTI. A urine culture taken 1 to 2 weeks later indicates whether the infection has been eradicated.
Recurrent infections due to infected renal calculi, chronic prostatitis, or structural abnormality may necessitate surgery; prostatitis also requires long-term antibiotic therapy. In patients without these predisposing conditions, long-term, low-dosage antibiotic therapy is the treatment of choice.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Neurogenic bladder:
Treatment
(Handbook of Diseases)
The goals of treatment are to maintain the integrity of the upper urinary tract, control infection, and prevent urinary incontinence through evacuation of the bladder, drug therapy, surgery or, less commonly, neural blocks and electrical stimulation.
Bladder evacuation
Techniques of bladder evacuation include Credé’s method, Valsalva’s maneuver, and intermittent self-catheterization.
Credé’s method (applying manual pressure over the lower abdomen) and Valsalva’s maneuver (performing forced exhalation against a closed glottis) promote complete emptying of the bladder. (For patient-teaching information, see Dealing with neurogenic bladder.)
After appropriate instruction, most patients can perform Credé’s method themselves; however, even when performed properly, this method isn’t always successful and doesn’t always eliminate the need for catheterization.
CLINICAL TIP: Credé’s method can result in autonomic dysreflexia in patients with spinal cord injuries. With this medical emergency, blood pressure rises to potentially fatal levels because of stimulation of the sympathetic nervous system.
Intermittent self-catheterization — more effective than either Credé’s method or Valsalva’s maneuver — has proved to be a major advance in the treatment of neurogenic bladder because it allows complete emptying of the bladder without the risks that an indwelling urinary catheter poses.
Drug therapy
With neurogenic bladder, drug therapy may include bethanechol and phenoxybenzamine to facilitate bladder emptying, and propantheline, methantheline, flavoxate, dicyclomine, and imipramine to facilitate urine storage.
Surgery
When conservative treatment fails, surgery may correct the structural impairment through transurethral resection of the bladder neck, urethral dilatation, external sphincterotomy, or urinary diversion procedures. Implantation of an artificial urinary sphincter may be necessary if permanent incontinence follows surgery for neurogenic bladder.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Neurogenic arthropathy:
Treatment
(Handbook of Diseases)
Effective management relieves associated pain with an analgesic and immobilization, using crutches, splints, braces, and restriction of weight bearing.
In patients with severe disease, surgery may include arthrodesis or, in those with severe diabetic neuropathy, amputation. However, surgery risks further damage through nonunion and infection.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Urethral discharge:
Patient counseling
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Advise the patient with acute prostatitis to discontinue sexual activity until acute symptoms subside. However, encourage the patient with chronic prostatitis to regularly engage in sexual activity because ejaculation may relieve pain.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Urinary incontinence:
Patient counseling
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
To prevent stress incontinence, teach the patient Kegel exercises to help strengthen the pelvic floor muscles. If appropriate, teach the patient self-catheterization techniques. Reassure your patient that episodes of incontinence don’t signal a failure of the program. Encourage him to maintain a persistent, tolerant attitude.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Urethral discharge:
Nursing considerations
(Nursing: Interpreting Signs and Symptoms)
▪ To relieve symptoms, have the patient take hot sitz baths, increase fluid intake, void frequently, and avoid caffeine, tea, and alcohol.
▪ Monitor him for urine retention.
Patient teaching
▪ Advise the patient with acute prostatitis to discontinue sexual activity until acute symptoms subside.
▪ Encourage the patient with chronic prostatitis to regularly engage in sexual activity because ejaculation may relieve pain.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Urinary incontinence:
Nursing considerations
(Nursing: Interpreting Signs and Symptoms)
▪ Prepare the patient for diagnostic tests, such as cystoscopy, cystometry, and a complete neurologic workup. Obtain a urine specimen.
▪ Implement a bladder retraining program. (See Correcting incontinence with bladder retraining.)
▪ If the patient's incontinence has a neurologic basis, monitor him for urine retention, which may require periodic catheterizations.
Patient teaching
▪ Explain the underlying disorder and treatment plan.
▪ To prevent stress incontinence, teach the patient how to perform Kegel exercises to help strengthen the pelvic floor muscles.
▪ Teach the patient self-catheterization techniques, as appropriate.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
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