Urinary disorders are very frequent during palliative care. They may be related to the patient's progressively altered general state and to certain necessary drugs. They may also be related to genital or urinary cancer.
Incontinence :
There are several forms of incontinence within the palliative setting. A urologic consultation is often advisable.
Treatment usually involves the use of an indwelling Foley catheter in female patients and condom drainage or penile clamp in male patients (and, if required, also a Foley catheter).
The complicated surgical interventions and rehabilitation required for artificial sphincters are most inappropriate in palliative settings.
Acute urine retention:
Occasionally, diagnosis should be made before the appearance of overflow incontinence: the patient cannot avoid micturition with a full bladder due to retention.
Investigation of the cause should involve:
clinical examination of urethral meatus and urethra to discover any evident mechanical obstruction,
prostate examination,
neurological examination looking for cord compression,
looking for metabolic disorders (such as hypercalcaemia).
neurological lesion (paraplegia) related to bone or meningeal metastases,
with atony of bladder muscles,
hypertonic internal sphincter (organic lesion of paraympathetic nerves).
hypercalcaemia,
use of anticholinergic drugs (such as phenothiazine, haloperidol, antihistaminic, cyclic antidepressants),
constipation may also compress urethra in a bedridden patient.
either by a suprapubic catheter (non-infected urine, acute and short-lasting situation), or urethral Foley catheter, modifications in medication (if necessary) surgical treatment if the patient's general status is good (stent, prostatic resection).
Urgency incontinence:
The bladder musculature in this type of incontinence is normal: the detrusor muscle is too active for a too weak urethral sphincter tonicity. The urge to urinate is so pressing that the patient cannot control it and urinary loss may be abundant. Bedridden patients are often incapacitated to such an extent that they cannot reach the toilet in time.
In palliative cancer setting, the main causes are:
a tumour close to the trigone (bladder, prostate, cervix),
inflammatory reaction of the bladder wall related to irradiation, post-chemotherapy bladder irritation or infection.
In patients with good prognosis, treatment may involve sphincter surgery. In palliative care, parasympathetolytic drugs such as flavoxate, trospium or tolterodine or possibly low doses of tricyclic antidepressants (imipramine) can be used.
Acute urine retention :
Occasionally, diagnosis should be made before the appearance of overflow incontinence: the patient cannot avoid micturition with a full bladder due to retention.
Investigation of the cause should involve:
clinical examination of urethral meatus and urethra to discover any evident mechanical obstruction,
prostate examination,
neurological examination looking for cord compression,
looking for metabolic disorders (such as hypercalcaemia).
hypertonic internal sphincter (organic lesion of paraympathetic nerves).
hypercalcaemia,
use of anticholinergic drugs (such as phenothiazine, haloperidol, antihistaminic, cyclic antidepressants),
constipation may also compress urethra in a bedridden patient.
either by a suprapubic catheter (non-infected urine, acute and short-lasting situation),
or urethral Foley catheter,
modifications in medication (if necessary)
surgical treatment if the patient's general status is good (stent, prostatic resection).
Unilateral ureteral compression :
Unilateral ureteral compression is most often asymptomatic. It is revealed during systematic examinations (ultrasonography or TDM) which are part of the usual post-therapeutic follow-up procedures.
However, major pain may occur in relation to pyelic or renal calyce dilatation.
It is often related to retroperitoneal uni- or bilateral sclerosis due to previous radiotherapy.
Sometimes, pelvic cancer can be discovered by ureteral dilatation.
Symptomatic treatment is ureteral derivation .
If dilatation cannot be satisfactorily reduced, and when major clinical complications are involved (repeated pyelonephritis) with poor unilateral renal function, if the other kidney is functional, and within a palliative setting, it may be possible to propose unilateral nephrectomy which is a simpler surgical act than ureteral reimplantation.
Urinary fistula :
Urinary fistula is one of the most devastating complications of cancer during palliative and terminal phases. The psychological consequences of such total incontinence often lead to complete patient (and family) discouragement.
Urinary diversion (urethral catheter reducing intravesical pression) may lead to healing when the fistula is not a complication of progressing carcinoma.
When no local cancer progression is evidenced, surgical treatment of fistula may be proposed (epiploic flap technique).
In rare cases, bilateral ureteral diversion may be proposed.
When surgery is contraindicated (palliative terminal care) and catheterism is inefficient, a vaginal pack may be a temporary solution.
Physiology of micturition
Notre vessie comporte deux sphincters : Our bladder has two sphincters:internal sphincter, intimely related to bladder muscles (detrusor), with an innervation which is:
sympathetic (through hypogastric and lumbar nerves, and whose neurotransmitter is adrenalin),
parasympathetic (through pelvis nerves originating from S2-S3).
Bladder distension stimulates mechanical receptors inside the bladder wall and provokes a motor parasympathetic response with the contraction of bladder muscles and the opening of the internal sphincter.
external sphincter
constituted by striated muscle fibres originating from pelvic floor (distal region of prostate in men and median third of urethra in women).
The external sphincter is controlled of nerves originating from the sacrum (pudental nerve).
For a normal micturition, three elements are necessary:
a free passage from the bladder to the urethral meatus, tonic bladder wall muscles (muscle contraction for micturition),
a good neurological coordination.CONTENTS:
Incontinence,
Acute urine retention,
Ureteral bilateral compression and urinary stoppage,
Ureteral unilateral compression,
Urinary fistula.
Incontinence :
There are several forms of incontinence within the palliative setting. A urologic consultation is often advisable.
Total incontinence
Total incontinence is related to complete sphincteric incompetence. Three main pathologies may be responsible:Endoscopic examination or urodynamic evaluation are rarely necessary in a palliative setting.tumour invasion,
previous surgical procedure,
neurological damage of spinal or nerve root
Treatment usually involves the use of an indwelling Foley catheter in female patients and condom drainage or penile clamp in male patients (and, if required, also a Foley catheter).
The complicated surgical interventions and rehabilitation required for artificial sphincters are most inappropriate in palliative settings.
Overflow incontinence
Strictly speaking, this is not incontinence but an acute urine retention . The bladder is full as demonstrated by percussion or palpation .Acute urine retention:
Diagnosis
Diagnosing acute urine retention is simple when faced with an agitated patient (particularly a semi-comatose patient). It simply requires percussing and palpating the suprapubic abdominal wall.Occasionally, diagnosis should be made before the appearance of overflow incontinence: the patient cannot avoid micturition with a full bladder due to retention.
Investigation of the cause should involve:
clinical examination of urethral meatus and urethra to discover any evident mechanical obstruction,
prostate examination,
neurological examination looking for cord compression,
looking for metabolic disorders (such as hypercalcaemia).
Causes of major urinary retention in a palliative setting
prostate hypertrophy (benign or malignant),neurological lesion (paraplegia) related to bone or meningeal metastases,
with atony of bladder muscles,
hypertonic internal sphincter (organic lesion of paraympathetic nerves).
hypercalcaemia,
use of anticholinergic drugs (such as phenothiazine, haloperidol, antihistaminic, cyclic antidepressants),
constipation may also compress urethra in a bedridden patient.
Treatment
Treatment should bring the return of a normal urinary flow:either by a suprapubic catheter (non-infected urine, acute and short-lasting situation), or urethral Foley catheter, modifications in medication (if necessary) surgical treatment if the patient's general status is good (stent, prostatic resection).
Urgency incontinence:
The bladder musculature in this type of incontinence is normal: the detrusor muscle is too active for a too weak urethral sphincter tonicity. The urge to urinate is so pressing that the patient cannot control it and urinary loss may be abundant. Bedridden patients are often incapacitated to such an extent that they cannot reach the toilet in time.
In palliative cancer setting, the main causes are:
a tumour close to the trigone (bladder, prostate, cervix),
inflammatory reaction of the bladder wall related to irradiation, post-chemotherapy bladder irritation or infection.
Such incontinence may be treated by anticholinergic drugs such as oxybutynin to reduce detrusor activity.
Stress incontinence
This type of incontinence is rarely of concern in a palliative setting. It involves minor involuntary urethral loss when coughing, sneezing, jumping, laughing, standing or walking.In patients with good prognosis, treatment may involve sphincter surgery. In palliative care, parasympathetolytic drugs such as flavoxate, trospium or tolterodine or possibly low doses of tricyclic antidepressants (imipramine) can be used.
Acute urine retention :
Diagnosis
Diagnosing acute urine retention is simple when faced with an agitated patient (particularly a semi-comatose patient). It simply requires percussing and palpating the suprapubic abdominal wall.Occasionally, diagnosis should be made before the appearance of overflow incontinence: the patient cannot avoid micturition with a full bladder due to retention.
Investigation of the cause should involve:
clinical examination of urethral meatus and urethra to discover any evident mechanical obstruction,
prostate examination,
neurological examination looking for cord compression,
looking for metabolic disorders (such as hypercalcaemia).
Causes of major urinary retention in a palliative setting
prostate hypertrophy (benign or malignant),
neurological lesion (paraplegia) related to bone or meningeal metastases, with atony of bladder muscles,hypertonic internal sphincter (organic lesion of paraympathetic nerves).
hypercalcaemia,
use of anticholinergic drugs (such as phenothiazine, haloperidol, antihistaminic, cyclic antidepressants),
constipation may also compress urethra in a bedridden patient.
Treatment
Treatment should bring the return of a normal urinary flow:either by a suprapubic catheter (non-infected urine, acute and short-lasting situation),
or urethral Foley catheter,
modifications in medication (if necessary)
surgical treatment if the patient's general status is good (stent, prostatic resection).
Unilateral ureteral compression :
Unilateral ureteral compression is most often asymptomatic. It is revealed during systematic examinations (ultrasonography or TDM) which are part of the usual post-therapeutic follow-up procedures.
However, major pain may occur in relation to pyelic or renal calyce dilatation.
It is often related to retroperitoneal uni- or bilateral sclerosis due to previous radiotherapy.
Sometimes, pelvic cancer can be discovered by ureteral dilatation.
Symptomatic treatment is ureteral derivation .
If dilatation cannot be satisfactorily reduced, and when major clinical complications are involved (repeated pyelonephritis) with poor unilateral renal function, if the other kidney is functional, and within a palliative setting, it may be possible to propose unilateral nephrectomy which is a simpler surgical act than ureteral reimplantation.
Urinary fistula :
Urinary fistula is one of the most devastating complications of cancer during palliative and terminal phases. The psychological consequences of such total incontinence often lead to complete patient (and family) discouragement.
Vesicoenteric fistula
Vesicoenteric fistula is generally in association with a colic pathology.Symptoms are emitting of foul smelling urine, passage in urine of gas or froth or even feces.
Most often, repetitive severe urinary infections are observed.
Cystoscopy reveals an oedematous zone with gas or feces emission at the fistula mouth. This opening is generally very small and difficult to find.
The best treatment (when feasible) is surgery (intestinal or colic resection) and should be attempted.
In a purely palliative setting, colic diversion (colostomie) may be proposed to dry the fistula.
Vesicovaginal fistula
Generally occurs during gynaecological cancers, either as a complication of local disease progression or after radiotherapy or salvage surgery (non standard conditions).
Clinical diagnosis is simple, with urine in the vagina, and is confirmed by cystoscopy. Pyelography enables the elimination of a ureterovaginal fistula.Urinary diversion (urethral catheter reducing intravesical pression) may lead to healing when the fistula is not a complication of progressing carcinoma.
When no local cancer progression is evidenced, surgical treatment of fistula may be proposed (epiploic flap technique).
In rare cases, bilateral ureteral diversion may be proposed.
When surgery is contraindicated (palliative terminal care) and catheterism is inefficient, a vaginal pack may be a temporary solution.
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