My name is Debbie Twang, and I am currently one of the urologist working at university hospitals. Who's a medical center today, I will be speaking on neurasthenic bladder and cerebral vascular disease. Cerebral vascular accident or stroke is considered a common complication of cerebral vascular disease. In the United States, C. V A is considered a leading cause of morbidity and mortality. The CDC estimates the annual incidents in the United States to be greater than 795,000 cases about one third of cases of CVR fatal of the survivors. Many may experience post CVS equally. Noura, genic, bladder or lower urinary tract dysfunction may commonly develop in patients after C B. A. Dysfunction may be transient or permanent, and urinary symptoms may have a significant impact on physical function, psychosocial recovery and the quality of life for patients and caregivers. Noura Genic bladder is considered to be a general term that describes lower urinary tract dysfunction as related to neuromuscular disease, injury or dysfunction. The clinical presentation of Nora Genic bladder may vary. It can range from urinary retention toe, avoiding symptoms like urinary frequency and urgency. Thio urinary incontinence, the patterns of neuropathic voiding dysfunction depend on multiple factors. Thes include the area of the nervous system affected, the physiologic function of the affected organs and the type of lesion which may be destructive, inflammatory and or irritated. The patterns of dysfunction may differ in the acute and chronic phases. Before we discuss lower urinary tract dysfunction and C v A. I'd like to review normal lower urinary tract anatomy and function. The lower urinary tract is composed of the bladder and the urethra. The bladder is a hollow, muscular organ located within the bony pelvis. The average maximum capacity is around 500 mL. The bladder itself is composed of a body and a base, which includes the Trigana bladder neck. The base contains superficial and deep muscle layers, which are continuous with the true sir muscle, and the smooth muscle is innovated by the post gangly onek parasympathetic nerve fibers. The urethra is considered to be part of the bladder outlet. It contains both smooth and striated muscle. The strident muscle is most often referred to as the rhabdo sphincter or the external urethral sphincter. There are some key differences between the male and female lower urinary tract anatomy. The male urethra contains the bladder neck, which contains a ring of smooth muscle. This ring of smooth muscle is much less pronounced in the female urethra. The male urethra also contains the prostatic member nous, bulbous and P and L portions with the external urethral sphincter located within the member nous portion. The female urethra extends from the distal third of the interior vaginal wall, and the female you re threat consists of the bladder neck through the pelvic musculature, which contains the external urethral sphincter to the Metis. The lower urinary tract has three main functions, one it collects and stores urine in a low pressure reservoir. To it empties all of the stored urine when appropriate, and three, it protects the kidneys from a sending pathogenic microorganisms. The function of the lower urinary tract relies on the integration of many components. Historically, it was described as a complex of neural circuits in the brain and spinal cord that coordinated the activity of smooth stride and muscles in the bladder and urethra. More recent studies suggest that they're not only components within the nervous system, but also within the bladder wall in urethra such as the bladder. While you're Ethereum and the sub your ethereal and introduced true sir, interstitial cells and nerve plexus. The neural control of the lower urinary tract includes three sets of peripheral nerves, which include both different and Afrin axons. The parasympathetic system includes pelvic parasympathetic nerves that originate from the sacred level of the spinal cord. The nerves originate from the sacral parasympathetic nucleus, which is located in the lateral part of the sacral intermediate gray matter. They travel through the pelvic nerve to the peripheral ganglia, which are located in the pelvic plexus and the true Sir Wall. The post gangly onek nerves release acetylcholine. The parasympathetic system works to excite the bladder or promote the truth. You're contraction and you re throw. Relax ation. The sympathetic nerves originate from the lumbar, sympathetic nerves. They passed through the sympathetic chain ganglia through the inferior Mesen Terry ganglia through the hippo gastric nerves and to the pelvic ganglia, the post gangly onek fibers released nor adrenaline to the beta Adrianne ergic receptors. The sympathetic system works to inhibit the bladder body or prevent the truth or contraction, and excites the bladder base and urethra. The third set of nerves system is a somatic nerves These nerves originate in the own off nucleus, which is located in the lateral border of eventual horn, and extend through the Pew Dental nerve to the external urethral sphincter muscle. The function of the somatic system is to excite the external urethral sphincter. The peripheral nerves are modulated bye Afrin pathways as well. A super spinal pathways. The Afrin pathways send sensory signals that help to provide input to reflect circuits that then control bladder filling and emptying. The storage process is modulated by spinal reflexes, the voiding processes modulated by the spinal bubble spinal reflex. The super spinal pathways include the Barrington Nucleus or Ponting Maturation Center, or M region and higher brain centers. The PMC is located in the dorsal Ponting Teg Mentum and is considered the control center for avoiding. It also is known to indirectly inhibit the onus nucleus. Higher brain centers can include the thalamus, insula, prefrontal cortex, interior, singular gyrus, Perrier aqueduct, all gray medulla limbic system in frontal lobe. The higher brain centers are thought to provide tonic inhibition of avoiding reflects during storage. Now let's review basic storage and voiding patterns of the lorry urinary tract. So during storage, there is an absence of involuntary bladder contraction. This results from parasympathetic inhibition via low intensity Africa signals that decrease the day truce, her muscle tone. The bladder neck itself is closed, and this is as a result of sympathetic stimulation of smooth muscles. Finger tome. There's also concurrent sense somatic stimulation to the external urethral sphincter. The guarding reflects is a spinal reflects that helps to promote continents and bladder Afrin signals will activate the Pew Dental Nerves to help modulate this reflex during bladder storage. There are low intra vesicles pressures. Part of this is a result of bladder compliance, which relies on collagen, elastin and smooth muscle fiber rearrangement during bladder storage. In comparison, during voiding, Lloyd ing relies on neural E mediated a truce, a contraction, which is a result of parasympathetic stimulation that increases the day truce er tone. The bladder neck is open, and this is a result of the inhibition of the sympathetic pathway of smooth muscle. There's also inhibition of these somatic pathway to the external urethral sphincter. Avoiding reflex occurs once the bladder reaches a certain level of distension. Afrin signals from the pelvic nerves increased to activate the spinal bubble. Spinal pathway during voiding low. Intra vesicles pressures are also found within the bladder wall itself. There are also intrinsic networks of nerve plexus and motor sensory nerves that help promote voiding. Now that we have reviewed the normal function of the lower urinary tract, let's discuss dysfunction of the lower urinary tract. Dysfunction occurs when there's a breakdown of one or more of the three fundamental tasks which can lead to urinary symptoms of incontinence, voiding symptoms such as frequency, urgency and or hesitancy or inability to avoid or urinary retention. Identifying the dysfunction may be based on clinical presentation, which are symptoms and signs and or clinical testing results. The dysfunction may also evolve over time. Let's focus more on lower urinary tract dysfunction and cerebral vascular accidents. Lower urinary tract dysfunction is believed to be a common post C V. A sick, willing urinary incontinence is the most frequently described voiding dysfunction, with the prevalence ranging from 28 to 79% at the time of initial hospitalization for C B A. It is thought that most patients will have transient incontinence issues. Ah, study by Britain and colleagues in 1998 found that the prevalence of urinary incontinence decreased over time, with the prevalence ranging from 32 to 79% upon initial hospital admission, 2 25 to 28% upon discharge and then 12 to 19% several months later. Other studies have demonstrated similar trends, with the prevalence at three months ranging from 19 to 44% 12 months at 15 to 38% and around two years after a C B A. Uh, with urinary incontinence being seen and only about 1% of survivors. Many studies have found that urinary incontinence after C V A has been associated with increased risk of morbidity and mortality. A study by Fowler has suggested that the development of urinary incontinence within seven days of a C v a, maybe a prognostic indicator for poor survival and functional dependence. A study by Gara Bella found that urinary incontinence as a hazard ratio of 2.8 as a predictor of death from C V A a three months. However, they did note that this hazard ratio may also be a reflection of a higher risk of infection and baseline malnourishment. Other studies have suggested that persistent urinary incontinence at one year after C V A is considered to be a predictor of greater mortality and morbidity, higher risk for institutionalization and worse, functional recovery. The development of urinary incontinence after a C V A is thought to be multifactorial and ideology. Certainly, uh, the direct impact of the C V A on the neural circuit can lead to urinary incontinence. Larger in functions may increase the risk of urinary incontinence. Although the studies air controversial on this topic, it is also thought that impaired cognition or awareness, lower extremity, motor weakness, depression, functional disability of Asia or dis visa age greater than 75 years and heavy Paris's are all considered potential risk factors or ideologies. For post C V a. Urinary incontinence. Various patterns of urinary incontinence after a C V A have been described the most common euro dynamic finding in patients with incontinence after C v. A is the true sir over activity with associative urging continents. The prevalence of isolated urging continents is thought to range from 9 to 42%. The truth you're under activity and overflowing continents or urinary retention have been also described. The exact ideology is unclear, although after an initial C B A episode. It is thought that cerebral shock may contribute to do true sir under activity in the long term, the prevalence of the Troussier under activity ranges from 6 to 35% of survivors. It is also thought that perhaps the development of under activity is related to other co morbidity. Ease, such as diabetic neuropathy, functional and continents has also been described to occur as a result of other systems being affected, such as impaired cognition, poor motor skills and depression impaired awareness. And continents, where structures of attention and recognition in the brain are affected, has also been described. The prevalence ranges from 12 to 58% of survivors and stress. Urinary incontinence has also been described in about 10% of women greater than 50 years of age after a C B A. Stevie A may also intensify weekend pelvic floor muscles and urge component. So, as I previously mentioned, the truth, sir, over activity and urging continents is one of the most common post CVS equally in the urinary system. From an an atomic standpoint, it is thought that the neural circuit is directly disrupted. The higher brain centers that are affected by the C V A. Lose their ability to inhibit the Ponting make duration center. As a result of the decreased inhibition on the voiding reflex pathway, there is the true sir over activity. Sakakibara and his associates have found that localized lesions to the frontal lobe and basil ganglia may be associated with the truce er hyper reflexive. In these patients, the sensation pathways are usually intact, but maybe variable. This sphincter function is usually maintained and coordinated in these patients in patients who develop urinary incontinence after a C v A. The initial evaluation should include a complete medical history, which should include identification of medical co morbidity, ease evaluation of bowel habits and evaluation of the patient's avoiding history prior to the C V. A. Sometimes obtaining a voiding diary can help to evaluate the voiding pattern. The evaluation should also consist of a complete physical exam that notes the cognition, any motor deficits as well as prolapse. Testing can include basic lab work as well as a post void residual to evaluate for, uh, retention of urine versus over activity. Ah, you're a flow. Studies can help to evaluate the avoiding ah strength, and also for retention and Euro dynamic studies. If the other studies are unclear, Euro Dynamics is considered a very helpful tool for assessing new onset symptoms and incontinence. This type of testing may help to reveal conflicting results when compared to the clinical picture. For example, in patients who may describe symptoms of over activity, euro dynamic testing may reveal the presence of the truce or under activity. Various studies, including that from Bernie and his colleagues, have found that the type of C B A may be correlated with different euro dynamic patterns. For example, a scheme IC C B A. May be associated more with the truth, sir, over activity and hemorrhagic C B A. Maybe more says you with the truth or under activity. While Euro Dynamics is a very helpful study in the patient population, the use of it may be limited by patient anatomy, the level of cognition as well as patient mobility. The management of patients with urinary incontinence after c B A may depend on the type of urinary incontinence. The main management goals are to preserve the upper tracks, to control any infection risk to help maintain storage and emptying at low intra vesicles pressures to manage the patient in a way that is socially acceptable and adaptable, to limit the use of chronic catheters and to provide adequate and satisfactory control other than treating the incontinence, continued medical optimization of other baseline co morbidity is may help to improve overall recovery. So here I'll review some of the common management options that have been described in the literature for the truce or over activity. Lifestyle management, such as reducing bladder irritants improving overall hydration are improving. Hygiene have been discussed. Optimizing bowel regimen can also help to optimize management of incontinence. Bladder training protocols have been described, including time voiding, urge suppression or more formally sending patients for pelvic floor physical therapy for over activity. Anti Colin Ergic therapies have also been used. Um however, the side effects in the central nervous system that have been reported may limit the use of anti coal energy therapies in the elderly population in Blatter over activity Beta three Agron ergic agonists have been studied in the general population, but not as well studied in the patients after a C V. A. Other forms of management that have been mentioned but require further study include Botox injections per cutaneous tibial nerve stimulation and sacral neuromodulation. Okay, in patients with the truce er under activity, urinary drainage is important, and this can come in the form of intermittent straight catherization indwelling, catheters, super pubic catheters or urinary diversion. Double avoiding has often been described as a form of bladder training. Paris and Path Oh, mom. Medics such as botanical or carbon call have also been described in patients who have other concurrent conditions, such as men with BPH. There are enlarged prostates. Medical therapies air often recommended. Any surgical intervention, such as a trans urethral resection of prostate, are not recommended until after 6 to 12 months after a C B A. As once again, the incontinent symptoms may be transient in nature or may evolve over time. Alfa Adrianne ergic antagonists have been described for use in men, uh, to help reduce the outlet resistance. But as women do have some of these receptors, it has also been described for use in women to reduce outlet resistance in summary. Neurasthenic bladder or lower urinary tract dysfunction is a common complication seen in patients after a C V. A lower urinary tract dysfunction may have negative impact on physical and psychosocial function of affected patients and caregivers. The most common form of dysfunction is urinary incontinence primarily urge incontinence. With the truth, sir, over activity. Most patients will have resolution of their urinary incontinence. Persistent urinary incontinence, particularly after one year after a C B A, is associated with worse long term survival and outcomes. Comprehensive evaluation of patient voiding factors and risk factors is recommended in the evaluation and management of these patients, and treatment is often individualized and may often require multidisciplinary approach, as it may be based on the type of incontinence. Medical co morbidity, ease, patient cognition and awareness, and patient and caregiver goals of care. Thank you very much for this opportunity to speak at your symposium. I am happy to answer any questions. Thank you. My name is Melissa. Greatly. I'm the interim nurse manager on Lerner Tower for and in the Epilepsy Monitoring Unit. And today I'm gonna talk about decreasing fully usage on a mixed neuroscience, medical surgical and step down division. I have no disclosures Lerner Tower for is a mixed neuroscience unit caring for a diverse population of patients with a myriad of neurological illnesses. We have 15 telemetry capable beds and 15 stepped down level or intermediate care level beds. And our ratios are 1 to 3 to four for all shifts in the step down unit and 1 to 4 to six in our telemetry union unit. So in 2017, we had seven Catherine required urinary tract infections, and we were looking to make some changes to have better practice. So what we did is we said WTF, not the WTF you're thinking. But why the Foley T four pilot, a resource nurse that stayed until 3:30 a.m. A few shifts a week? This nurse was able to assist when the floor was busy, but also rounded with nurses to dig deep into why a patient had a fully and if there is any opportunity to remove it. Additionally, the resource nurse perform quality audits and provided feedback. We had many conversations around why the patient had a catheter and retention was and remains a common theme. Nurses know they will be asked why they're patient, has a fully and should be prepared to answer the question daily. We also looked at our nurse driven protocol for removal, clinical clinical indication, education and alternatives restrict input and output totals. So these are our rates going forward. So in 2018 we had five in 2019, we had three. They were at the beginning of the year and in 2020. We've only had one so far. So we've had a marked decrease in catheter use over the last several years. Um, we actually almost went a full year from February 2019 to February 2020 almost without a Kadi Onda. Our ultimate goal is to go at least a year, if not longer with no Cody's in 2020 we instituted Qadi champions. These nurses provide real time feedback to their peers and audit patients with Foley catheters. They also participate in hospital level Web axes to represent the bedside nurse when evaluating practice reform. And here's just a little graphic of our Kati usage. Now I'm gonna hand it over to Chase Lad, a ZN issue where he said he manages has been working on, uh, even more exciting processes than pilots and pilots. My name is Chase Village, and I am the nurse manager here at University Hospitals Cleveland Medical Center in the neuro I C U I am here to talk a little bit about are fully use in the neuro I C. U. And how we reduced our Foley Cath are fully utilization. I have no disclosures for this presentation, a quick background of our neuro I C and the patients that we see. We typically see patients coming in with ischemic and hemorrhagic strokes, seizures and tumorous sections. These patients are found to have the most Foley catheters placed. However, we do admit patients with other narrow related issues. Our patients historically were either admitted with a Foley or we would place one on admission, and most of the time it would remain end for the duration of their stay in the I. C. U. Additionally, we have seen that patients could have a fully and just for the pure reason that they were on a ventilator or because they were incontinent and unable to alert somebody they needed to use the restroom. Our patients would experience high rates of retention due to being brain injured, as well as being a mobile and on bed rest. Due to these issues, we found that we had a high rate of catheter use, and we wanted to find out if our infection, what our infection rates were to see if the N s you had a problem. So we needed to do some data collection, find out what our baseline was and see if we even had an issue. So we found that in 2017, the N S. You had a total of 21 catheter associated urinary tract infections or Cotti. This was a huge problem, and we needed to implement change to decrease our infection rates quickly. Our first step was to complete audits so we can assess our nursing practice, clinical indications and bundle adherents. We found we were not consistent in performing or documenting Perry care. Fully care nurses didn't always document that they used to. Clark exiting wipe on Foley's were not often found to be in the stat lock as well as we almost always had dependent loops on. That's one of the items in our audits was to look at if the loops were present. If you don't know what a loop is, are dependent loop, it's when the tubing of the catheter droops down below the bed back up into the urine chamber, which causes increased pressure on the bladder, which can contribute to higher attention rates. We also found that these catheters were remaining in for extended periods of time with no clinical reason, and we had a high rate of indwelling catheter used for retention. So we needed to create in their disciplinary team to focus on these issues and help reduce usage. Our team consisted of the nurse, manager, assistant nurse manager, bedside nurses, clinical nurse specialist physicians, nurse practitioners, infection prevention ist and our quality nurse. We provided education and staff meetings are daily morning huddles and via email on best practices, as well as how often to perform fully care and Perry care the need to use Clorox wipes on catheters, every shift and what documentation documentation is required. We also collaborated with our physician group to eight, and fully reduction education was then provided. And if a patient hadn't indwelling catheter, the need was to be addressed in rounds by the physicians. So what did we change? We already had the morning safety huddles every morning at 7 a.m. So we incorporated a daily roll call on all Foley catheters. Within the huddle, every patient with a catheter was discussed with the RN in this huddle and asked why the why the Foley was in place and if there was a continued need if no need was identified, then the nurse was asked to utilize the nurse driven photo protocol to remove the Foley on Lee if the criteria was met. Um, if the the nurses would continually be encouraged not to wait for this huddle and address the the need for the catheter every day and every shift, we did notice a change. The nurses started pulling the Foleys out on their own but still needed guidance. In addition to the huddle, we utilize male external devices, and we also trialed female external catheters as well. To help reduce are fully utilization. We decided we wanted to move towards utilizing a straight cath model in the N S U. Instead of the use of indwelling catheters, we created a specific criteria, uh, more of a guideline that may warrant the use of a Foley catheter. And this was helped, uh, helped the nurses uses as a guide as to whether a fully could remain in place or not, or even to place when it to begin with our interdisciplinary team then met with urology, and we created this guideline. In addition to the guideline, we wanted to incentivize the nurses, and so we wanted to create a mo mentum and very quickly. So we we started with Jen Points. We offered gem points to each nurse for every fully that they removed. Um, it worked. In the beginning, however, we noticed that the nurses were removing Foley's towards the end of their shift. And so we adjusted the the incentive model to give Mawr Gen points. The earlier they removed them in their shift and then overall for the month. Whoever removed the most, Foley's was given an additional gem point amount Azaz. An additional incentive to remove Foley catheters. Here is a copy of our straight cath guideline. Uh, it does list criteria whether a patient may warrant a fully or not, we incorporated RPC. Any group is well to aid in this process, so RPC in a group will bladder scan every patient without an indwelling catheter every four hours and depending on the volume, then that will determine if the patient needs straight cath. So just an example here. If you know the PC and it goes in and straight cats are bladder scans the patient, and it's less than 300. Then we can wait an additional four hours. However, if it's over 300 there's an algorithm here, so 3 to 400 the patient would need straight Kath and you have an hour timeframe to do so. Whereas if you go down the guideline and it's over 600 on the bladder scan, then the straight path we need to be done immediately. Um, we do realize that patients will need an indwelling catheter, some of the meat criteria and there is criteria listed specific to our patient population. So what were our results again? We started in 2017 with a base of 21 copies, and after all of these changes were implemented, we decreased our kati rate by over 50% for 2018. We continued assessing the need daily direct conversations with nurses and in 2020 we are in 2019. I'm sorry we decreased from 10 to 8 and for 2020 we have focused on daily discussions, the need for pair carefully care as well as implementation of the Straight Path guideline thus far in 2020 we have had one Qadi, and that was in February. And our goal does remain to be fully free in the N S u Arkady free as well. I'm sorry. So we could not have done this without the the participation and commitment of our nurses. They were instrumental in making this process successful. And we are. Our goal is to then have this process adapted in other units and make everywhere have less. Scotty's. Thank you. Hi, this is Sue Flick. I've been asked to give a short presentation off the care of a patient who has had a stroke. Uh, that is being seen and evaluated in the urology ambulatory clinic. I hope not to duplicate the wonderful presentation that Dr Chuang gave us. She covered the pathology quite well. I hope to focus on evaluation and treatment options for a patient that I would routinely be seeing a number one priority in the urology practice is to make sure that we're preserving renal function in any of the patients we're seeing. If there is a concern about their renal function, we would want to obtain some sort of image ing usually a renal ultrasound to start out with to evaluate whether there's any obstruction in the upper tracks, any hydro necrosis scene, any stones, present any problems, um, such as thes and address that those issues we need to do a thorough evaluation of the baseline, your urine function prior to the neurologic event as well as their current function. We use some standardized tools for this, um, or just interview the patient. Or if the patients unable to give a good history, hopefully they have come in with a caregiver that can help us to do the, uh, do a thorough assessment. If the patient does have an in drawing fully catheter, well, oftentimes do a trial void in the office setting and check how well they are able to empty their bladder on their own. Um, by checking a post void residual, we want to ask the patients specifically, um, the questions they're listed on this first slide about hesitancy, incomplete voiding, straining to avoid dribbling. Uh, ask them if they're stream starts or stops or is pretty consistent throughout the void. Some patients will have to Syria complain of frequency. Urgency knocked Iria as well as various types of urinary incontinence. Most patients we're seeing do have other coal mobility's like diabetes and maybe on diuretic. Certainly, diabetes can contribute. Thio telegenic, Glad off dysfunction. Um, and we want to get a thorough history of what they're eating, drinking, as well as if they're struggling with any constipation. Ah, urinary leakage post for dribbling materia are typically categorized as being a urine storage problem. We wanna really thoroughly discuss with the patients and the caregivers about urinary incontinence. Many of these patients will have functional and continents because now they're taking a few minutes to get up out of their chair. Now they have to use maybe a walker or a wheelchair and actually get to the restroom. Then they have to pull their pants down to be able to urinate. So just the process of that and not having good sensation off when they have to urinate well, oftentimes cause urinary leakage. The definition of urinary retention is thean ability to completely evacuate Ah, full bladder or even partially uh, inability to evacuate the bladder completely. Usually, this is a result of either to choose her failure, meaning that the bladder is just not appropriately filling, storing and then squeezing or, uh, it could be a urinary outlet obstruction, such as an enlarged prostate. Keep in mind that oftentimes we'll see patients with a history of some sort of urinary tract infection. When we see this, we have to think a little bit deeper that the U. T. I is typically because of incomplete bladder emptying, and that should be a trigger for us to do. Ah, work up and think in the differential diagnosis off. Urinary retention being a possible ability, the patients we see in urinary retention. Oftentimes they need to be managed with an indwelling fully catheter, as depicted in this slide off course, we're always trying to prevent, uh, infections in patients. So whenever appropriate, we really tried to teach the patients how to do intermittent self catheterizations in our office. And it's surprising how many patients really are capable of being able to do these catheterizations either on their own or with minimal help from a caregiver. Today, in my clinic, I saw ah, 100 year old man he's been unable to avoid for several years and has been doing intermittent self catheterizations uh 6 to 7 times per day over the last few months, actually, three to be exact. He's been in the emergency room with symptoms of urinary track infection. Eso We made the decision today to put in a indwelling catheter for him. Um, I think being 100 years old, your bladders just about had it, so hopefully he'll be able to manage better. I not doing intermittent straight calf ing. Um, there also is the question of compliance with patients, but a good way to monitor this is to ask them Thio, keep avoiding Diary, a diary that records how much the and when the patient is voiding as well as when they're doing self catheterizations and how much you're in, they're getting out. When they do catheter rise. It's always better if the patient's void first, before inserting the catheter in you kind of sterilizes the track on does a little bit of lubrication for them. It's really important with men with enlarged prostates that they're careful not to cause irritation to the prostate, and there taught appropriately how to do self catheterizations. All the catheters that we now use in the outpatient clinic are single use. Typically, they are pre lubricated and the patient minimally has to touch the catheter, which is helpful to prevent UT ice. I'm seeing patients back. I really encourage them. Thio Adopt a toilet or bladder retraining program. We want to ensure that they're having adequate fluid intake, which is a challenge for a lot of us and really be a, you know, potentially restricting fluids in the evening. If knocked. Iria is a big problem for the patients. Time voiding, boy, we sure get in bad habits with this. I know is being a nurse. Years ago, I would go almost a full shift with never avoiding on. We don't want to see that in the patients that are struggling with urinary retention, the more fluid that is in the bladder, the more difficult it is to empty the bladder. So we really want to occur to our people to be avoiding every, uh, three hours in some. You want to actually instruct them to avoid every two hours during the day. Aunt to avoid bladder irritants Limit certainly alcohol Azaz Well, any sodas or tea or even coffee that can't really irritate the bladder and cause, um, potentially spasms and potentially more leaking from those types of irritants. If they're not diabetic, I do encourage them to drink some juice is, uh soup counts milk and their serial counts towards the total fluid intake. Azaz. Well, Azaz, plain old water. Uh, we wanna have a strategy to help them to manage any chronic constipation and female certainly need to fully relax their pelvic muscles in order to empty their bladder. And that involves sitting on the toilet, relaxing, not hovering, and being in a hurry to get in and out of the bathroom. Um, we have wonderful incontinence products available on the market for women. We really want to encourage them to be changing those products frequently when they are soiled. If they are sitting in damp, wet pads, even though the pads do a good job off absorbing the fluid, they're still growing bacteria on the outside part of the pad. And it only takes a few inches to get into the bladder and cause problems for the patients, there is some research of the use of cranberry Cranberry, actually, we believe, produces an enzyme that coats the bladder and helps to prevent urinary track infections. You could find data plus or minus on that theory, but I do encourage patients that are interested in something like cranberries to use the supplements versus trying to drink enough cranberry juice to get enough enzyme into the bladder to be beneficial. We have a number of medications that we use routinely in urology. I've listed the four categories on this slide. Alfa blockers are really a mainstay with our male patients, UH, that are elderly middle age that do have some obstructive symptoms. Tam Slosson is the most common use drug. Right now, they are all on generic. Currently, basically, an Alfa blocker works by opening up the channel or the urethra to give better flow. Hence the name Flomax for tamps Allison, as well as to help more efficiently empty the bladder. Oftentimes, these patients should be on this medication before we even do the first trial void. If they have had complete urinary retention and have catheters in, we also oftentimes combine Alfa blocker with an Alfa reductase inhibitor such as finasteride, or do test ride thes medicines work. I, uh, decreasing slightly testosterone levels in men, which does help with a prostate shrinkage. The problem with these medicines is to fully work. It takes about six months. They do derive more benefit the longer they're on these medicines and certainly if the medicine is discontinued for any reason, uh, the prostate regrowth occurs. The anti poll interjects. Been around a long, long time. We have to be careful with these medicines in the elderly population. There's lots of reports of increased fall risks with these medicines. Most of them there's about five or six on the market. Do cross the book Blood brain barrier. Um, they do work very well for urgency type symptoms. Um, they come in three different dozing levels, which is great to be able to kind of tailor the amount of this drug that the patient will need. They look at research on these medicines. Oftentimes they're discontinued not because they didn't help the patient with urgency, but because of the side effects. Uh, they should not be used in certain types of glaucoma. They can cause dry mouth, dry eyes and constipation, or for the dry mouth and dry I side effects. Oftentimes, I'll advise the patients to take these medicines at bedtime to minimize those side effects. Potentially, Um, certainly the 23 blocker medicine. There's only one on the market. It is not generic. It's called more Petric. It comes in 25 mg and 50 mg. It's primarily used for urgency type symptoms. Um, but instead of having the similar side effects of anti pollen ergic medicines, this can cross over and cause some changes in blood pressure. So you do wanna be monitoring that in these patients. The drug typically is pretty expensive, although some insurances are now starting to, uh, have some affordable pricing on this medication. And we try to use samples on starting a patient out on this medicine because of the cost. Female patients We do have several procedures that we routinely do a neurology toe help to minimize the size of the prostate gland. I do advise patients that I see before I send them for consideration of thes various procedures to do euro dynamic testing. Your A dynamic testing is awesome at showing bladder function. Uh, and as well as measuring to some extent urinary obstruction, you would not want to shrink a prostate down in a patient that doesn't have good bladder function because all they're going to do is leak and be very unhappy with you. So I do try to do the your dynamic testing and then refer them to the urologist to consider which of these, uh, interventions best fits theme patients. Theme. American Urologic Association has a great flow sheet on their website, talking about the different procedures and well, as risk benefits thio each one. The goal, of course, would be to get them patients off oil medicines or at least minimize the medicines that they would need to. Maybe just tamp slows in daily at university hospitals. For the last several years, we've worked very hard to reduce or focus on who are the appropriate patients that do need indwelling, Foley catheters and to measure outcomes as faras reducing U T eyes. I've basically included this slide for your reference regarding some of the hard work that folks have done on these various committees looking at and defining protocols for patients of when we should be checking bladders, as in patients and when it's appropriate to use an indwelling fully catheter. I wanted to also include in this presentation some good references and some of the references that we've used at U H on the Kadi Prevention Committee for your reference patients that have had a neurologic event in their life, Uh, oftentimes going through major losses off things that they've taken for granted and done all of their lives. I think it's really important to evaluate sexual function in these patients. And I would encourage you to ask every patient that you see how this is impact them if they are experiencing loss of libido, loss of erections, uh, inability to sustain erections or difficulty with orgasm, Uh, and as well as females, Sexual function loss. Uh, and please consider making a referral to the urology office. We have staff that are interested and have specialty in both female and male sexual function. I would be happy to see any patients that you would want to refer for management. Sometimes we really can't, uh, find anything that helps them. But at least a try. Alot of some oil medicines or penile injections can really make a difference for many, many patients. So I would encourage you to be asking, Don't feel that you need to be an expert in this area. But if you do identify people that are really struggling with a loss of sexual function, please just refer them to one of us, uh, toe have a discussion. We can do a lot more than just Orel pills to help many of these patients. Thank you for your attention throughout this presentation. I hope you've, uh, found it to be helpful. I would be happy to hear from anyone via email. And I think we are having some live questions as part of the presentation. Thank you again. I appreciate your attention and look forward to meeting you one day in person. Thank you.