Daniel D. Lydiatt, MD, DDS, FACS

• Professor and Interim Chair, Otolaryngology/Head and Neck Surgery
• University of Nebraska Medical Center
• Medical Director, Head and Neck Surgery
• Nebraska Methodist Hospital
• Omaha, Nebraska

With the development of treatments for Cushing disease other than bilateral adrenalectomy antibiotics for uti and bv purchase generic amoxil, Nelson syndrome is rarely encountered today antimicrobial resistance fda order amoxil mastercard. Addison disease is an inadequate production of corticosteroids by the adrenal cortex caused by a defect within the adrenal cortex rendering them unable to synthesize normal amounts of steroid hormones antibiotic resistance today order genuine amoxil on-line. The most common cause of Addison disease is withdrawal of exogenous steroid therapy infection klebsiella buy amoxil overnight delivery. Additional causes include adrenal tuberculosis or lymphocytic adenitis with adrenal fibrosis antibiotic medical abbreviation buy discount amoxil 1000mg on-line, malignant infiltration of the adrenal antibiotic resistance veterinary medicine cheap amoxil 1000mg without a prescription, sarcoidosis, histoplasmosis, blastomycosis, and coccidioidomycosis. Additionally, Addison disease may occur with administration of aminoglutethimide, ketoconazole, mitotane, or suramin. What is the most common primary cause of adrenal insufficiency in Western countries In the Western world, the most common cause of primary adrenal insufficiency is autoimmune adrenalitis. Hyponatremia, hyperkalemia, and azotemia are the classic triad; however, the entire triad is present in only 50% to 60% of cases. Other disorders associated with Addison disease may include hypercalcemia, hyperthyroidism, hypothyroidism, and diabetes. Symptoms associated with Addison disease are weakness, prostration, dehydration, and coma. Cortisol is checked 60 minutes after administration and should be at least 18 g/dL if normal. Acute adrenal insufficiency can be caused by withdrawal of exogenous steroids, sepsis, bilateral adrenal hemorrhage, surgical bilateral adrenalectomy, or surgical removal of a functional adenoma in a patient with an atrophic contralateral adrenal. The treatment is administration of glucocorticoids along with replacement of saline. Accordingly, the zona glomerulosa continues to function appropriately in patients with secondary adrenal insufficiency. Only patients with primary adrenal insufficiency require mineralocorticoid replacement. This may explain the proximity of the adrenal medulla to the venous drainage system within the adrenal gland. Activation of tyrosine hydroxylase activity, which combines phenylalanine and tyrosine to form dopa as a precursor to norepinephrine. Stress, pain, cold, heat, asphyxia, hypotension, hypoglycemia, and sodium depletion, all cause catecholamine release. Pheochromocytomas and paragangliomas in adrenal and extra-adrenal sites, respectively. Headache (60%-90%), palpitations (50%-70%), sweating (55%-75%), pallor (40%-45%), nausea (20%-40%), flushing (10%-20%), weight loss (20%-40%), tiredness (25%-40%), psychologic symptoms (20%-40%), sustained hypertension (50%-60%), paroxysmal hypertension (30%), orthostatic hypotension (10%-50%), and hyperglycemia (40%). What percentage of adrenal incidentalomas will be deemed potential surgical lesions upon further evaluation The more common adrenal lesions are adrenal adenomas, myelolipomas, and adrenal cysts. Less commonly one encounters ectopic tissue, oncocytomas, ganglioneuromas, pheochromocytomas, aldosteronomas, and adrenal hemorrhage. How does adrenal hemorrhage following birth occur and which side is affected more often Adrenal hemorrhage can occur following difficult childbirth and more often affects the right side. This phenomenon has been attributed to an increase in intra-abdominal pressure that is transmitted through the short right adrenal vein and in to the parenchyma resulting in hemorrhage. Adrenocortical carcinoma, pheochromocytoma, neuroblastoma, and metastatic disease. What percentage of patients with an incidental adrenal mass will be diagnosed with pheochromocytoma Headache, palpitations, sweating, pallor, flushing, weight loss, fatigue, anxiety, hypertension, and hyperglycemia. The classic 10% rule for pheochromocytomas does not seem to reflect contemporary findings. In more recent series up to 25% will be extra-adrenal, up to 30% will be associated with a hereditary syndrome, and malignant disease will be seen in only 5% of cases. This is why it is important not to eliminate pheochromocytomas from your differential diagnosis in a normotensive patient with an adrenal mass. Children manifest a higher incidence of familial pheochromocytomas (10%) and bilaterality (25%). Additionally, there is a 15% to 30% incidence of multiple pheochromocytomas in children and a 15% to 30% incidence of extra-adrenal location as well. The organ of Zuckerkandl (close to the origin of the inferior mesenteric artery), bladder wall, heart, mediastinum, carotid, and glomus jugulare bodies. What symptom is classically associated with extra-adrenal pheochromocytoma involving the urinary bladder Free-fractionated plasma metanephrines and 24-hour urinary-fractionated metanephrine tests are the recommended studies to screen for and diagnosis pheochromocytoma. What clinical, biochemical, and histologic features distinguish malignant from benign pheochromocytomas All patients must be vigorously hydrated in preparation for surgery since elevated catecholamine levels lead to significant dehydration. Additionally, patients are started on an -adrenergic blocker such as phenoxybenzamine, with an initial divided dose of 20 to 30 mg orally, increasing to 40 to 100 mg as needed. Secondly, -adrenergic blockers can be added to the -blockers to protect against arrhythmias and permit reduction in the -blocker requirement. Labetalol (Normodyne) is a nonselective -blocker and a selective -adrenergic blocker that has been shown to control hypertension associated with pheochromocytoma. Calcium channel blockers may also be utilized for controlling hypertension associated with pheochromocytoma. There can be a marked rise in the total peripheral vascular resistance secondary to unopposed -adrenergic activity that can lead to circulatory collapse. What additional drug might be used in the preoperative preparation of patients with pheochromocytomas who have cardiomyopathies, multiple catecholamine-secreting paragangliomas, or resistance to -blockers How should the surgeon and anesthesiologist be prepared for fluctuations in blood pressure at the onset of anesthetic induction in surgery The patient must be volume-expanded with several liters of intravenous crystalloid prior to induction of anesthesia. Phentolamine, a short-acting -blocker (50 mg per 500 mL of ringers lactate), or sodium nitroprusside (50 mg per 250 mL of 5% dextrose in H2O) should be on hand. Esmolol or propranolol should be available for persistent tachycardias or arrhythmias. What are the indications, advantages, and disadvantages for using a modified posterior incision for adrenal tumors A modified posterior lumbotomy may be utilized in patients with right-sided adrenal aldosterone-secreting tumors or benign adenomas 5 cm. The main advantage over a flank or transabdominal incision is the excellent exposure of the vena cava in the region of the short right adrenal vein. The disadvantages include a limited visual field and compression of the abdominal contents and thoracic cavity that may impair respirations in the jackknife position. This approach is not recommended for pheochromocytomas or malignant adrenal tumors. Following surgical exposure of a pheochromocytoma, what anatomic structure must be initially addressed The adrenal vein should be divided initially to avoid systemic release of catecholamines during manipulation of the adrenal gland. What other therapy can be used in patients with hypertensive pheochromocytoma crisis that is refractory to sodium nitroprusside, -blockers, and -blockers It lowers catecholamine release and acts as a very effective -adrenergic antagonist and arterial dilator. It is also an excellent cardiac antiarrhythmic in the presence of high epinephrine levels. The use of magnesium sulfate has reportedly been lifesaving in a number of cases of refractory pheochromocytoma crisis. Hypotension due to lack of catecholamine vasoconstriction is the most common medical problem encountered postoperatively, although hypoglycemia may also appear. Cushing syndrome refers to the group of signs and symptoms that result from excessive glucocorticoids. What percentage of patients with endogenous Cushing syndrome will have Cushing disease Obesity, decreased libido, purple striae, hirsutism, hypertension, muscle weakness, glucose intolerance, depression, osteoporosis, and body bruising. What percentage of patients with adrenal incidentalomas will be diagnosed with subclinical Cushing syndrome Up to 10% of patients with adrenal incidentalomas will be diagnosed with subclinical Cushing syndrome upon functional evaluation. What 3 tests can be used for the initial assessment glucocorticoid function in patients with suspected Cushing syndrome Patients with Cushing disease have a normal or supranormal increase in 17-hydroxy corticosteroid urinary excretion. Name 3 agents used to reduce the secretion of functional steroids in patients with Cushing syndrome. Patients given aminoglutethimide must be observed for adrenocortical insufficiency, since aldosterone production is also impaired. What is Nelson syndrome and when has it been seen in the treatment of Cushing disease Historically, patients with Cushing disease often were treated with bilateral adrenalectomy. This could occur years after bilateral adrenalectomy and can be treated by prophylactic pituitary radiation. What is the currently accepted treatment of choice for Cushing disease and what are the cure rates Presently, transsphenoidal hypophyseal microsurgery for the removal of pituitary adenomas results in cure rates of approximately 60% to 80%. Adrenalectomy can be performed in cases of unilateral cortisol secreting adrenal tumors. Lifelong cortisol replacement therapy will be required in patients undergoing bilateral adrenalectomy. Hypokalemia with metabolic alkalosis suppressed peripheral renin activity together with elevated urinary and plasma aldosterone levels in hypertensive patients. What percentage of patients with primary hyperaldosteronism will have hypokalemia in contemporary series Hyponatremia can limit the evaluation of serum potassium and hypokalemia can limit the evaluation of urinary aldosterone. Plasma aldosterone-to-renin ratio should be used as the screening test for primary aldosteronism. Hypertension with hypokalemia, resistant hypertension (3 or more medications with poor control), adrenal adenoma with hypertension, early-onset hypertension, severe hypertension (160/ 110), whenever considering secondary cause of hypertension, and unexplained hypokalemia. Solitary adenoma, bilateral adrenal hyperplasia, adrenal carcinoma, unilateral adrenal hyperplasia, familial hyperaldosteronism, and ectopic aldosterone-producing tumor. Can the diagnosis of primary aldosteronism be made based on the aldosterone-to-renin ratio alone List the subtypes of primary aldosteronism that are best managed with medical therapy. List the subtypes of primary aldosteronism that can be managed with surgical therapy. Aldosterone-producing adenoma, primary unilateral adrenal hyperplasia, aldosterone-producing carcinoma, and ectopic aldosterone-producing tumors. Adrenal vein sampling of aldosterone is very sensitive in lateralizing these lesions. At the time of renal vein sampling to measure aldosterone, what else should be measured and why Cortisol, in order to confirm correct positioning of the catheter during sampling. After confirming functional status of the lesion, surgical extirpation would be appropriate. Adrenal vein sampling is not essential to lateralize the tumor, but can be helpful. What measures should be taken prior to surgical removal of a solitary adenoma associated with hyperaldosteronism Treatment of hypertension with an aldosterone receptor antagonist or a calcium channel blocker and correction of potassium depletion. In patients with primary aldosteronism secondary to bilateral adrenal hyperplasia, what is the medical management of choice and how does it work Medical therapy consisting of spironolactone or eplerenone, which are competitive antagonists of the aldosterone receptor. Studies have shown that tumors 6 cm in size pathologically are unlikely to be adrenal carcinomas. How does the presentation of adrenal carcinoma in children differ from that in adults The majority of these tumors are hormonally active, usually presenting with Cushing syndrome, virilization in the female, and isosexual precocious puberty in males. When evaluating functional status of an adrenal tumor suspicious for carcinoma what should be considered. Excess of glucocorticoid, mineralocorticoid, catecholamine, sexual steroid, and steroid precursors should be evaluated. What is the primary indication for biopsy of an adrenal tumor suspicious for adrenal carcinoma Biopsy is indicated in cases of unresectable, locally advanced, or metastatic disease in order to confirm the diagnosis prior to systemic medical therapy. Virilization in the absence of elevated urinary 17-ketosteroids in a female patient should raise the suspicion of what other lesion In addition to adrenocortical tumors that secrete testosterone, one should also consider testosterone-secreting ovarian tumors. A male patient with a functional adrenocortical tumor presents with gynecomastia, testicular atrophy, and impotence. This patient likely has an estrogen-secreting adrenocortical tumor that secretes androstenedione, which is converted peripherally to estrogens. Eighty percent of these lesions are malignant, with the 3-year survival being 20%. The Weiss criteria based upon mitotic rate, atypical mitoses, venous invasion, nuclear grade, presence of clear cytoplasm, growth pattern, necrosis, sinusoidal, and capsular invasion. Surgical removal of the primary tumor, with an attempt to remove the entire lesion with contiguous organs (spleen, kidney) en bloc if necessary, and a regional lymphadenectomy. What is the local recurrence rate of adrenal carcinoma following complete resection What drugs are available for the medical management of advanced adrenocortical carcinoma However, these compounds, in addition to metyrapone, have not been shown to improve long-term survival. A washout or decrease in contrast enhancement of 50% or more is indicative of an adenoma. True/False: It is recommended that all adrenal adenomas greater than 1 cm undergo metabolic evaluation. Surgical resection of metabolically active adenomas is suggested in acceptable surgical candidates. After the diagnosis of a nonfunctional adenoma, what does the recommended follow-up include Up to 20% of initially nonfunctional adrenal adenomas will become functional during follow-ups. Hypercortisolism is the most common perturbation to develop and two-thirds of these cases will be subclinical. Fifteen percent of adrenal cysts contain calcifications and this does not imply malignancy. Testing for aldosterone excess should be considered in patients with hypertension. In a healthy individual, what is the recommended size threshold for surgical resection of adrenal incidentalomas What is the reported complication rate for percutaneous needle biopsy of the adrenal gland and what complications are most likely Pancreatitis can develop following the biopsy of left-sided lesions, especially if an anterior approach is used. The most common metastatic lesions to the adrenal gland include melanoma and carcinoma of the breast and lung. Additionally, carcinomas of the kidney, contralateral adrenal gland, bladder, colon, esophagus, gallbladder, liver, pancreas, prostate, stomach, and uterus can metastasize the adrenal gland.

What are the most common causes of the bowel obstruction following construction of intestinal anastomoses True/False: the incidence of postoperative bowel obstruction in patients who have segments isolated from the colon is less than that occurring with ileum virus alert lyrics buy amoxil 500 mg visa. Postoperative bowel obstruction occurs in approximately 10% of patients who have bowel segments isolated from the ileum for urinary tract reconstruction compared to 4% of patients who have bowel segments isolated from colon antibiotics for uti buy buy amoxil 500mg online. Stenosis bacteria killing products buy discount amoxil line, obstruction antimicrobial examples generic amoxil 250mg fast delivery, pseudo-obstructions (Ogilvie syndrome) (acute colonic pseudo-obstruction characterized by massive colonic dilatation in the absence of mechanical cause) treatment for dogs with gingivitis purchase amoxil 250 mg with visa, intestinal leak virus and fever amoxil 650mg overnight delivery, hemorrhage, fistulas, wound infections, pelvic abscesses, and sepsis. Poor blood supply, local sepsis, drains placed in direct contact with an anastomosis, and performance of an anastomosis on previously irradiated bowel. Poor blood supply and local sepsis cause ischemia, whereas drains placed on the anastomosis increase the likelihood of an anastomotic leak. Which patients with asymptomatic bacteriuria and an intestinal diversion should be treated Only patients with predominant cultures of Proteus or Pseudomonas should be treated. Persistent infection of the intestine exposed to urine may result in strictures, bacterial seeding of the upper tracts, and renal deterioration. Persistent infection, lowered pH, stasis, enteric hyperoxaluria, and hypercalciuria are the other factors. It should be considered in all patients with continent urinary diversion who present with acute abdominal pain. The overall clinical features of the patient dictate the choice between conservative treatment with drainage and antibiotics versus surgical exploration (Baseman et al. What are the most common complications of an ileal conduit and how frequent are they Stomal and peristomal complications include skin lesions, stenosis, and retraction of the stoma. True/False: Continent urinary diversions have a higher overall complication and reoperation rates in contrast to ileal conduits. There is no difference between continent urinary diversions and ileal conduits in terms of overall complication and reoperation rates (Parekh et al. What should the maximum upper level of sustained bladder pressure be in a patient with a continent neobladder The loss of native bladder and its reflexes and the production of an increased urine volume are responsible for this complaint. How would you manage patients with a persistent, severe form of daytime incontinence Daytime continence is achieved earlier postoperatively compared with nighttime continence and 85% to 90% of patients with orthotopic bladder will be continent during the day at 1 year from surgery, those rates may decrease 4 to 5 years postoperatively, in part because of decreased tone of the urethral sphincter with advanced age (Madersbacher et al. Persistent severe incontinence after orthotopic urinary diversion may be treated by periurethral collagen injection, definitive placement of a urethral sling, or an artificial urinary sphincter (Tchetgen et al. What are the patterns of nighttime incontinence following orthotopic urinary diversion Nighttime continence requires a 6- to 12-month postoperative interval to reach maximum levels as the capacity and the compliance of the diversion increase. The reported prevalence of persistent nighttime leakage is between 27% and 50% at 1 year from surgery. The treatment of persistent enuresis includes limiting fluid intake after the evening meal, voiding before going to sleep, and timed voiding once or twice during the night. Use of imipramine hydrochloride 25 mg at bedtime is reported to decrease nighttime leakage in up to 25% of patients (El Bahnasawy et al. Which is the most common electrolyte abnormality in patients who have an ileal conduit and how often is it found What is the mechanism of hyperchloremic acidosis in patients with ileal diversions Ionized transport of ammonium is responsible for hyperchloremic acidosis in patients with ileal diversions. In addition, potassium channels in bowel lumen may contribute to ammonium entry to the blood. What are the symptoms of the electrolyte abnormality that occurs with ileal and colonic diversions True/False: Normal serum pH and bicarbonate exclude metabolic acidosis in patients with intestinal urinary diversions. Normal serum pH and bicarbonate do not exclude severely compensated metabolic acidosis, blood gas analysis and body weight measurement are required. If possible, these patients should not be given hydrogen antagonists and/or proton pump inhibitors, because these contribute to systemic acidosis by preventing hydrogen excretion with subsequent bicarbonate preservation on the cellular side (Mills and Studer, 1999). What is the optimal management of hyperchloremic metabolic acidosis in a patient with intestinal urinary diversion The key to successful management is proper diagnosis by exclusion of urinary infection and sepsis, as well as awareness of the salt-losing syndrome. Proper treatment includes catheter reinsertion to insure good drainage and to minimize further chemical reabsorption, rehydration with intravenous normal saline, and correction of acidosis with sodium bicarbonate at a dose of 1. Potassium citrate may also be used to avoid too high a sodium load and prevent hypokalemia. Patients with incomplete emptying and those with reduced renal function are most vulnerable to these metabolic problems (Racioppi et al. The treatment must involve both correction of the acidosis with bicarbonate and replacement of potassium. What is the treatment of persistent hyperchloremic metabolic acidosis in patients with ileal conduits if an excessive sodium load is undesirable These agents used alone do not correct the acidosis in humans, but they limit its development and thus reduce the need for alkalinizing agents. Chlorpromazine may be given in a dose of 25 mg tid and should be used with care in adults because there are many untoward side effects, including tardive dyskinesia. Nicotinic acid may be given in a dose of 400 mg tid or qid and should not be used in patients with peptic ulcer disease or significant hepatic insufficiency (Dahl and McDougal, 2007). Ileal segments reabsorb some of the potassium when exposed to high concentrations of potassium in the urine whereas colon does not. What are the causes of hypokalemia in patients with intestinal urinary diversion and what would be the treatment The potassium depletion is probably owing to renal potassium wasting as a consequence of renal damage, osmotic diuresis, and gut loss through intestinal secretion. Treatment with potassium citrate is often effective especially for patients with colonic reservoirs (Koch et al. What kinds of electrolyte abnormalities are seen in patients with a jejunal conduit What is the likely diagnosis of a patient with a jejunal conduit who has lethargy, nausea, vomiting, dehydration, muscular weakness, and an elevated temperature Hyponatremia, hypochloremia, hyperkalemia, azotemia, and acidosis are seen in patients with jejunal conduits. Which electrolyte abnormalities are seen when the stomach is used for urinary diversion Hydrochloric acid produced by the parietal cells in the body of the stomach has a negative feedback on antral gastrin secretion. When the body of the stomach is removed, this negative feedback mechanism may be impaired. What are the most likely causes of altered sensorium in a patient with a urinary diversion. Magnesium deficiency, drug intoxication, hyperammonemia, or diabetic hyperglycemia (this is not a consequence of the intestinal diversion). What are the causes of magnesium deficiency in patients with intestinal urinary diversion. Magnesium deficiency is usually due to nutritional depletion, but it may result from renal wasting, altered calcium metabolism, acidosis, and sulfate metabolism (McDougal and Koch, 1989). True/False: Acute changes in ammonia load result in significant changes in serum ammonia levels when hepatic function is normal. The hepatic reserve for ammonia clearance is immense, and it is unlikely that acute changes in ammonia loads would result in significant changes in serum ammonia levels when hepatic function is normal. Patients who have ammonia-induced coma accompanied by normal liver functions generally have a significant infection with a urease-producing bacterium. Direct access of bacteria and endotoxin to the liver via the portal circulation results in altered hepatic metabolism without significant alteration in hepatic enzyme concentrations (McDougal, 1992). In severe cases, arginine glutamate 50 g in 1000 mL of 5% dextrose in water intravenously to complex the ammonia in the gut and to prevent its absorption. True/False: Serum concentrations of urea and creatinine are less accurate measures of renal function after enteric diversion. What is the most accurate means of determining renal function in patients with a urinary diversion Drugs that are absorbed by the gastrointestinal tract and excreted unchanged by the kidney. Hypocalcemia is a consequence of depleted body calcium stores and excessive renal wasting. Chronic acidosis is buffered by carbonate in the bone, with subsequent release of calcium in to the circulation. The kidneys clear the released calcium, resulting in a gradual decrease in body calcium stores. Renal tubular absorption of calcium is also inhibited directly by sulfate and enhanced by acidosis. It has been shown in animals with urinary diversions that oral supplementation with bicarbonate can prevent demineralization even in the absence of significant systemic acidosis (Inman et al. What are the abnormalities in serum chemistry in a patient who develops osteomalacia The calcium is either low or normal, the alkaline phosphatase is elevated, and the phosphate is low or normal. Vitamin B12 deficiency results in macrocytic anemia and neurological degeneration. What length of time is required for the depletion of vitamin B12 stores in the complete absence of absorption in a patient who has an extensive terminal ileum resection Peripheral neuropathy, optic atrophy, subacute combined degeneration of the spinal cord, and dementia. True/False: In patients with ileal neobladder, vitamin B12 and folic acid levels should be measured on a regular basis starting 2 years after surgery. What is the lipid profile effect of a patient in whom 60- to 100-cm ileum are removed from the fecal stream What are the major consequences of lipid malabsorption seen in patients with ileal resection A deficiency of the fat-soluble vitamins (A, D, E, and K) and an increase in incidence of gallstones and renal stones. In which part of the intestinal segments used for urinary diversion does the least net water movement occur What is the most common histologic type of cancer seen in association with urinary intestinal diversion These patients should be followed by stool occult blood and/or colonoscopy after 5 years postdiversion. A patient is diagnosed with a recurrent invasive lesion in the urethra following radical cystectomy and neobladder construction. Convert to a continent diversion, if possible, or remove the reservoir and convert to a conduit. Which kind of neobladder is the most amenable for conversion of a patient to a conduit What is the preferred method of delivery in pregnant women with intestinal urinary diversion Elective cesarean section before the onset of labor is the preferred method of delivery in patients with urinary diversion, especially with an orthotopic bladder substitution. Vaginal delivery may result in damage to the pelvic floor muscles and subsequently affect continence mechanisms. What are signs and symptoms that result from these electrolyte disturbances and how is this often treated When it is fully manifested, lethargy, respiratory insufficiency, seizures, and ventricular arrhythmias may occur. Patients are generally successfully treated with an H2 blocker to reduce proton secretion by the gastric segment and rehydration. What is the electrolyte abnormality most commonly seen when jejunum is used in the urinary tract This syndrome can be quite debilitating, resulting in nausea, anorexia, lethargy, fever, and even death. The more proximal the segment used, the more likely the syndrome is to develop, secondary to the increased surface area available, due to increased villi and microvilli. The jejunum should be used only when there are no other acceptable segments available for use. What is the electrolyte abnormality most commonly seen when ileum or colon is used in the urinary tract Common signs and symptoms include easy fatigability, anorexia, polydipsia, and lethargy. This should be treated with drainage of the urinary intestinal diversion (foley or rectal tube), administration of neomycin ( to reduce the enteric ammonia load), minimizing protein intake, and treating the underlying condition. What commonly used drugs can be reabsorbed in intestinal diversions after excretion from the kidneys and result in toxic serum levels Phenytoin, methotrexate, lithium carbonate, and theophylline may be reabsorbed in their original form from intestinal diversions and lead to toxic serum levels. True/False: Incontinent urinary diversions are generally associated with fewer metabolic abnormalities. Given the longer dwell time of urine in contact with the intestinal segment used, both neobladders and continent urinary diversions are associated with a higher risk of electrolyte and metabolic abnormalities. True/False: Mechanical bowel preparation results in a reduction in bacteria per gram of enteric contents. Mechanical bowel preparation will reduce the total number of bacteria in the gut, but not their concentration. Which portions of the small intestine should one avoid using for diversion in patients with history of pelvic radiation The last 2 inches of the terminal ileum, which is often fixed in the pelvis by ligamentous attachments, and the 5 feet of small bowel beginning approximately 6 feet from the ligament of Treitz, the mesentery of which is the longest of the entire small bowel. The incidence is reported to be 20% to 24% for ileal conduits and 10% to 20% for colon conduits. Other complications include bleeding, bowel necrosis, dermatitis, parastomal hernias, and stomal prolapse. Which segment of bowel is most suitable for nonrefluxing ureterointestinal anastomoses Numerous anastomoses (Leadbetter and Clarke, Goodwin, Strickler, and Pagano) employ the seromuscular strength of the tenia to create a backing for the submucosal tunnel needed for the antireflux procedure. What type of ureteroileal anastomosis carries the highest risk of ureteral stricture In general, antirefluxing anastomoses carry a higher risk of stricture that persists for the life of the conduit. Although open and endourological methods of repair have been successful, open repair carries a higher success rate (approximately 75% vs 60% for endourological methods). As the left ureter crosses over the aorta and underneath the inferior mesenteric artery, it is both extrinsically compressed and angulated, which may result in stricture formation. In addition, aggressive stripping of the periureteral adventitia may result in vascular compromise at this level, also predisposing to stricture. It involves spatulating the distal end of the ureter, and stitching the full thickness of the bowel to the full thickness of the ureter. This anastomosis boasts both technical ease as well as a low complication rate (see the figure). Different techniques are described, but the concept is that the ureteral ends are spatulated and sewn together in to a common opening. This "common ureter" is then anastomosed to the end of the intestinal segment used. It has a lower stricture rate due to the wide anastomosis, but is not recommended for patients with extensive carcinoma in situ or a high likelihood of recurrence in the ureter. Recurrence in the distal aspect of one ureter could block the egress of both ureters, causing bilateral obstruction (see the figure). What is the generally accepted cut-off value of serum creatinine at which continent diversions and orthotopic neobladders are no longer considered Due to the extended dwell time of urine in contact with the intestinal segments used, continent diversions and orthotopic neobladders should be considered only for those patients with good renal function. What renal parameters must be met to consider continent diversion in a patient with serum creatinine greater than 2. Approximately 18% of patients with ileal conduit diversion will have progressive renal deterioration, which may lead to death from renal failure in approximately 6% of patients. What long-term effects can urinary intestinal diversion have on the bony skeleton Osteomalacia (or renal rickets) has been reported most commonly with ureterosigmoidostomy, but also with colon and ileal conduits, and ileal ureters. It is thought to be secondary to acidosis, vitamin D resistance, and excessive calcium loss by the kidney.

Intermittent 3-day antibiotic ancef buy cheap amoxil, self-start therapy or post-intercourse therapy may be used instead virus mutation purchase cheap amoxil line. Patients who have a protracted infection with Proteus risk formation of struvite calculi due to the alkalinization caused by the urea-splitting bacteria virus pro cheap amoxil 250mg visa. In fact antimicrobial silver cheap amoxil 650mg, they give rise to infections with organisms resistant to several antibiotics antibiotics online generic amoxil 1000 mg with visa. The contents of a hydatid cyst are highly antigenic and may cause anaphylaxis if it ruptures and spills during aspiration antibiotic gel generic amoxil 500mg. Endotoxin, a lipopolysaccharide component of bacterial cell wall, activates the macrophages and humoral pathways in septic shock. Most of the toxicity of endotoxin is contributed by lipid A, which is bound to the core oligosaccharide. Lack of estrogen causes changes in vaginal pH and microflora including loss of lactobacilli and colonization with E. True/False: In women with bacteriuria, acute pyelonephritis occurs more commonly in pregnant women than in nonpregnant women. Penicillins (including ampicillin and synthetic penicillins) and cephalosporins are safe throughout pregnancy. Short-acting sulfonamides and nitrofurantoin may be used in the first 2 trimesters. The former can cause neonatal hyperbilirubinemia and the latter hemolytic anemia in newborn if used near term. In contrast to young adults, in whom bacteriuria is 30 times more prevalent in women than in men, the ratio in women to men with bacteriuria progressively decreases to 2:1. Most elderly patients with bacteriuria are asymptomatic; estimates among women living in nursing homes range from 17% to 55%, as compared with 15% to 31% for their male cohorts. Prospective randomized comparative trials of antimicrobial or no therapy in elderly male and female nursing home residents with asymptomatic bacteriuria consistently document no benefit of antimicrobial therapy. Therefore, asymptomatic bacteriuria in elderly residents of long-term care facilities should not be treated with antimicrobial agents. Unresolved bacteriuria implies that the urinary tract is not sterilized during therapy. Bacterial persistence means recurrence of infection with the same organism after initial clearance. Numerous squamous cells in the urine would indicate preputial, vaginal, or urethral contamination. The resistance is transferable and produces multiple-resistant strains making therapy difficult. Diabetic patients often have glomerulopathy, with difficulty concentrating antimicrobials. They are also more prone to complications such as papillary necrosis and emphysematous pyelonephritis. Unifocal lesions are indistinguishable from other inflammatory lesions and neoplasia. As untreated candiduria can lead to the formation of obstructing candidal fungal balls, they should be treated promptly with fluconazole or with low-dose amphotericin plus rucytosine if it fails. Both drugs are actively secreted in the vagina and bowel, thereby inhibiting growth of uropathogens at these sites. Reinfection (new infection from bacteria outside the urinary tract) is the most common cause. Leukocyte esterase is produced by neutrophils and catalyzes the hydrolysis of an indoxyl carbonic acid ester to indoxyl. Nitrofurantoin is rapidly excreted in urine, but does not achieve therapeutic levels in most body tissues including the kidney. Periodic instillation of a chemical, for example, hydrogen peroxide in to the collecting bag may delay the onset of infection. Either staphylococcal or streptococcal infections may be solely responsible, although it is increasingly recognized that mixed infections, including gram-negative and anaerobic organisms, are the rule rather than the exception. Intravenous hydration and multiple antibiotics with adequate surgical debridement are mainstays of treatment. The testicles have a separate blood supply and can often be preserved by placement in a thigh pouch even if the scrotum is removed. Lipid-soluble drugs, weakly basic antibiotics that are concentrated in the prostate are most suitable. Carbapenems (ertapenem, imipenem, and meropenem) are active against gram-positive pathogens, gramnegative pathogens, and anaerobic bacteria and maintain efficacy against most -lactamase-producing bacteria. Doripenem, the new carbapenem, and meropenem have activity against some strains of Pseudomonas. The delivery of antibiotics to the urinary tract, including the kidneys, is compromised because of the reduced blood flow to the kidneys, low urine volume, and reduced renal drug-concentrating ability. Patients may have complete and spontaneous relief from the symptoms, have a waxing and waning course, may be completely asymptomatic with intermittent "flares," or have a chronically progressive course of increasing symptoms over several years. Obstructive symptoms including a sensation of incomplete bladder emptying and double voiding may be present. Cystography and voiding cystourethrography may be used to evaluate the bladder for other causes of irritative lower urinary tract symptoms, including intravesical masses, stones, bladder diverticula, urethral diverticula, urethral stricture, meatal stenosis, or findings suggestive of a neurogenic or nonneurogenic voiding dysfunction. On filling cystometry, most patients have a hypersensitive bladder with small volume at first sensation to void and at capacity. Prior to hydrodistention-normal appearing bladder and urethral lumen, and rarely a Hunner ulcer (found in 10% of patients). Following hydrodistention under anesthesia-glomerulations (petechial hemorrhages), submucosal hemorrhages, mucosal cracking, and bloody effluent upon drainage (terminal pinking). Nonulcerative disease (90% patients)-capacity 400 mL, no ulcers, scars, or mucosal cracking. A significant number of patients have transient relief of their symptoms following hydrodistention. Neoplasia, infectious cystitis, radiation cystitis, chemical cystitis, and a defunctionalized bladder (patients on dialysis or after urinary diversion). However, many patients report improvement after altering their diet (changes in caffeine, alcohol, carbonated beverages, and juices). In the only prospective randomized trial performed, there was no benefit to diet modification and no association with a certain diet. To date, only sodium pentosanpolyphosphate (Elmiron) has shown some benefit (and only modestly) in a randomized placebo controlled trial. Although its mechanism of action is not fully understood, Elmiron is thought to resemble glycosaminoglycans and adheres to the bladder epithelium in preclinical models. In this way, Elmiron may act as a buffer to control cell permeability, preventing irritating solutes in the urine from reaching epithelial cells. Temporary symptomatic improvement can be expected in up to 30% to 60% of patients. Which types of individuals are likely to respond to hydrodistention and how long does it last There have been reports of bladder necrosis and bladder perforation after hydrodistention. It is sometimes administered in combination with steroids, alkalinizing agents, and heparin. In the absence of a satisfactory response to other less invasive therapy, urinary diversion with or without cystectomy can be considered. However, in such cases, though the urinary frequency may be improved, pelvic pain may remain and even be aggravated following surgery. Thorough and complete patient counseling is necessary when urinary diversion is being considered for these nonmalignant, nonneurogenic cases. Urethral syndrome is a very nonspecific constellation of symptoms including urinary frequency, urgency, dysuria, and suprapubic discomfort without any objective findings of a urologic abnormality to account for the symptoms. The concept of urethral syndrome, chronic or acute, is now essentially historic, as this terminology is no longer used. What is the percentage of patients who develop radiation cystitis after external beam therapy Early radiation cystitis usually occurs at 3 to 6 weeks after therapy in approximately 20% of patients. The risk of radiation cystitis varies with the dose and mode of delivery of the radiation. Radiation changes, including fibrosis and compliance changes, may occur years following the radiation treatments. What is the risk of transitional cell carcinoma of the bladder after pelvic radiation Progressive obliterative endarteritis resulting in mucosal ischemia, telangiectasias, submucosal hemorrhage, and ulceration. How effective is hyperbaric oxygen therapy for control of radiation cystitis induced hematuria and how does it work In uncontrolled studies, resolution of hematuria occurs in neovascularization and generalized vasoconstriction. Such therapy promotes 280 Urology Board Review How many hyperbaric treatments are usually necessary for control of symptoms related to radiation cystitis What percentage of patients receiving cyclophosphamide will develop hemorrhagic cystitis in the absence of prophylactic measures This increased further in patients receiving high doses of cyclophosphamide in preparation for bone marrow transplantation. When is the usual onset of hemorrhagic cystitis in patients treated with cyclophosphamide Which metabolite of cyclophosphamide is thought to be responsible for hemorrhagic cystitis Which agents or therapies can be used to reduce the development of cyclophosphamide-induced hemorrhagic cystitis Hydration-hemorrhagic cystitis secondary to cyclophosphamide therapy is most prevalent in patients who are dehydrated. Foley catheter-often placed to ensure immediate drainage of the bladder to minimize exposure. There is a 9-fold increased risk of bladder cancer with a short latency period (6-12 years). Inhibits clot lysis by blocking plasminogen activation and fibrinolysis thereby promoting clot formation over bleeding surfaces. Stop infusion and check serum aluminum as well as potassium or ammonia levels depending on the solution used. Once in the blood stream, aluminum can accumulate in the bone (leading to bone mass loss), liver, kidney and in very large doses, can cause cardiac arrest. What are the drawbacks of intravesical formalin for intractable hemorrhagic cystitis Intravesical administration is quite painful requiring regional or general anesthesia. Reflux of formalin in to the upper urinary tract may result in ureteral fibrosis, obstruction, and papillary necrosis. Formalin has occluding and fixative actions on telangiectatic tissue and capillaries. What x-ray study should be performed prior to the initiation of intravesical formalin for hemorrhagic cystitis A cystogram should be performed to exclude vesicoureteral reflux, as reflux of formalin in to the upper tracts can have potentially devastating consequences. Adenovirus types 11, 21, 35; papovarirus; influenza A; cytomegalovirus in immunodeficient states. What virus is associated with hemorrhagic cystitis following a bone marrow transplant This is a human polyomavirus that is present in approximately 60% of healthy adults and is usually acquired in childhood by the respiratory route. Catheter placement should be avoided if possible because of the immunocompromised state of the patient. Physical examination reveals a vesicular eruption over the mons pubis and right buttocks. Herpes zoster may result in detrusor underactivity secondary to sacral root involvement. This is a pathologic diagnosis made on bladder biopsy in the setting of an eosinophilic infiltrate of the bladder lamina propria and detrusor. Bladder wall thickening may be seen on bladder sonography or other cross-sectional imaging. It is a rare inflammatory condition associated with abnormal microtubule assembly. This impairs the function of monocyte lysosomes, leading to inefficient killing and degradation of bacteria, resulting in incomplete eradication of bacterial infections. Chronic urinary tract infections; 40% have associated systemic diseases such as immunodeficiency, malignancies, or autoimmune disease. Grossly, the lesions consist of raised yellow-brown plaques with hyperemic borders. Immunodeficiency states (especially organ transplantation patients on immunosuppressants), carcinoma, and autoimmune diseases. This is a bladder infection characterized by gas within the bladder wall, which can spread to surrounding tissue or the upper urinary tracts in severe cases. Diabetes mellitus (50%), neurogenic bladder, chronic cystitis, bladder outlet obstruction, and immunodeficiencies. Surgical intervention (debridement or cystectomy) can be used in extreme cases, which fail conservative management. It represents anywhere from 3% to 12% of urology office visits for men, and is the most common presenting diagnosis for men younger than 50 years. Prostatitis affects men of all ages, with the highest incidence between the ages of 20 and 49 years, but there is a second increase in incidence after the age of 65 years. What is the most common histologic pattern of inflammation seen in prostatitis specimens Lymphocytic infiltrate of prostatic stroma located immediately adjacent to the acini. Category I describes acute bacterial prostatitis seen in patients with acute febrile illness, a new onset of significant lower urinary tract symptoms, and possibly other systemic symptoms (chills, malaise, etc). Patients may have constant, long-term symptoms or have recurrent episodes of acute episodes of prostatitis with asymptomatic periods. It is a histologic diagnosis only, typically made after evaluation of semen, prostate chips, or prostate biopsy specimens. The enterobacteriaceae family of rod-shaped, gram-negative organisms is the most common bacteria implicated in both acute and chronic prostatitis.

Another method of alternative behavior modification is responsibility reinforcement ebv past infection buy cheap amoxil line, such as reward and motivation antimicrobial questions order amoxil cheap online. It has been reported that the most effective therapy of treating enuresis is conditioning therapy antibiotics for acne flucloxacillin order 250mg amoxil with mastercard, as in the bell alarm (buzzer alarm) method antibiotics for uti cats order amoxil 650mg. A 20-year-old army recruit was referred to an Army hospital after his confession of enuresis infection night sweats buy generic amoxil 500mg online. Enuresis is found in approximately 1% of the adult population infection control guidelines order 500 mg amoxil otc, often with overt abnormalities on urodynamic studies such as uninhibited bladder activity. The extent of the investigation is usually more thorough than those carried out in younger enuretics. Cessation of compounds that might increase nocturnal urine output, such as caffeine, and behavioral modification, such as nighttime fluid restriction, should be strongly advised before recommending other forms of treatment. Workup with history and physical examination, neurologic examination, urinalysis, and urine culture are normal. A careful history, physical examination, and urinalysis with culture are needed for all children with bed-wetting and are usually sufficient. In patients with diurnal enuresis, normal history and physical examination, no evidence of neuropathy and a negative urine examination, the urinary tract anatomy should be screened. This can be accomplished noninvasively and satisfactorily with an ultrasound examination of the kidneys, ureters, and bladder before and after voiding. A 7-year-old girl with urgency and diurnal incontinence wets her bed about 3 times a week. Radiographic imaging studies including abdominal ultrasonogram and voiding cystourethrogram are negative. Timed voiding programs alone will be successful in the majority of children, but require several months to be effective. A 6-year-old girl with diurnal enuresis also has severe constipation and fecal soiling. However, radiographic studies of her spine and neurologic examination are normal as well as urinalysis and no residual urine is noted. This best describes postvoid dribbling, which is typically when urine gets trapped in the vagina during voiding and dribbles out soon after standing in otherwise normal toilettrained girls with no other associated urinary symptoms. Vesicovaginal reflux itself is harmless and tends to resolve with age, but it can create a damp environment prone to infection. Therefore, the child may be taught to empty her vagina by simply voiding with her thighs apart and leaning forward after voiding before getting up. What percentage of secondary nocturnal enuresis is due to psychological factors and what specific disorder is involved most often Secondary enuresis defined as reoccurrence of enuresis after at least 6 months of symptom-free period is related to psychological factors in about 50%, usually anxiety provoking factors. However, enuretic children suffer from low self-esteem as long as they wet their beds. How significant is the benefit of treating the psychological factors to improving the outcome over just treating the nocturnal enuresis directly There is no significant proven benefit in treating the underlying anxiety disorder compared to just treating the enuresis. Overactive bladder associated with nocturnal enuresis responds best to which therapy The gubernaculum anchors the testis to the genital region condenses to allow descent. What transcription factor is associated with testicular descent from the abdominal cavity to the inguinal canal (transabdominal) Production of this protein rises in the second trimester of gestation and works in conjunction with testosterone to promote testicular descent. What transcription factor is critical for gonadal differentiation toward the male lineage Thus, Mullerian duct development is promoted and Wolffian duct development is suppressed. At what time point in fetal development does the gonad differentiate to become a testis or ovary Between the 6th to 8th week of gestation, the indifferent (bipotential) gonad differentiates in to either a testis or an ovary. Which active steroid hormone is important for Wolffian duct induction and proliferation The presence of testosterone results in the proliferation of the Wolffian duct system and the development of the efferent ductules, rete testis, epididymis, vas deferens, and seminal vesicles. The most common cause is Klinefelter syndrome (incidence in the United States is approximately 1:500 live births). What laboratory tests are most often used to confirm the presence of congenital adrenal hyperplasia What are the 2 most common enzyme defects resulting in congenital adrenal hyperplasia Use of the abdomino-pelvic ultrasound ( to look for the presence of a uterus) and a fluoroscopic genitogram to look for a vaginal connection to the urogenital sinus are extremely helpful. These patients appear as normal phenotypic females with normal development of secondary sexual characteristics. Development of the external male genitalia does not occur due to the lack of androgen receptor activation. On examination, these patients have a short, blind-ending vagina with no internal Mullerian duct structures. Primary amenorrhea (peripubertal) and female patients with bilateral inguinal hernias. Females with clinically significant hernias may benefit from vaginoscopy at the time of surgery to confirm the presence of a cervix. Congenital adrenal hyperplasia is associated with what potentially lethal condition If not recognized, the resulting hypotension can cause vascular collapse and death. A perfectly normal-appearing, phenotypic male presents with an inguinal hernia on one side and an impalpable testis on the other. Whether or not to leave the gonads in situ until the child completes pubertal development. Neurogenic control of the bladder in infants is by what part of the central nervous system also known as the primitive voiding center This nucleus is a collection of sacral somatic nerve cells that originate from the lateral border of the ventral horn of the sacral spinal cord (S2-S4). The pudendal also innervates the penis as well as the ischiocavernosus and bulbocavernosus muscles. The ganglions are located near the organ and the neurotransmitter is acetylcholine. The receptors are muscarinic (M2/M3) and stimulation results in bladder contraction. Its exact function in the bladder is unknown, but it is thought to be involved with the neuromodulation of bladder compliance. The M2 receptors are primarily cardiovascular where they help mediate heart rate and cardiac output. Which muscarinic receptor is most involved with cholinergic stimulation of the detrusor M3, even though it only represents about 20% of the total muscarinic receptors in the bladder. M1 receptors are primarily located in the central nervous system and salivary glands. This is why a selective M3 antimuscarinic agent should theoretically have fewer central nervous system and dry mouth side effects than nonselective agents. Sympathetic preganglionic nerves exit from the lumbar spinal cord to synapse in the sympathetic chain ganglia. The postganglionic sympathetics then travel through the inferior splanchnic nerves to the inferior mesenteric ganglia. They finally travel in the hypogastric nerve to the pelvic plexus and the urogenital organs. Alpha (bladder base and prostate) and beta (bladder body) receptors exist on the bladder and alpha receptors are on the prostatic capsule. These fibers can be recruited after injury/inflammation to form new functional afferent pathways (becoming mechanosensitive) that can cause pain and urge incontinence. A vanilloid, capsaicin stimulates and desensitizes unmyelinated C fiber axons to produce pain and release neuropeptides. It is located at the smooth musculature of the bladder neck and the proximal urethra. In contrast, the striated sphincter is anatomic and includes the skeletal muscle surrounding the membranous urethra in men and the middle segment of the urethra in females. This sphincter also includes the striated muscle surrounding the urethra in both men and women. Which neurotransmitter is involved in urethral smooth muscle relaxation during voiding According to Wein, what are the 3 factors necessary for (A) normal bladder and urine storage to occur, and (B) normal bladder emptying to occur A closed outlet at rest and one that remains so with increases of intra-abdominal pressure. As the bladder fills with urine, low-level vesical afferent activity via the pelvic nerve causes external sphincter contraction through somatic pathways. In turn, the somatic afferents from the sphincter inhibit parasympathetic efferent signals suppressing bladder activity and allowing urine to be stored in the bladder. It is thought that alterations in these primitive reflex pathways contribute to neurogenic bladder dysfunction. In general, the bladder contains viscoelastic properties that allow the bladder to maintain a low pressure of 10 cm H2O throughout the filling phase. Compliance (C) is defined as the change in bladder volume divided by the change in intravesical pressure, C V/ P. Along with smooth muscle, approximately 50% of the bladder wall contains collagen and 2% elastin. Injury, denervation, and obstruction can all cause increases in collagen content of the bladder wall. This is followed by relaxation of the bladder neck/proximal urethra by sympathetic fibers from T11-L2. Almost simultaneously the detrusor contracts and detrusor pressure rises via the S2-S4 parasympathetic efferents. Voluntary voiding is dependent on intact neuronal pathways between the frontal cortex and the septal-preoptic region of the hypothalamus as well as intact connections between the paracentral lobule and the brainstem. Injury to these areas of the cortex results in increased bladder activity due to loss of cortical inhibitory signals. Children younger than 2 to 3 years of age lack the cerebral maturity to emit inhibitory signals to prevent voiding reflexes. These neonatal pathways that cause detrusor overactivity do not disappear with age. Neurologic disease and advanced age can cause these primitive reflexes to reemerge and cause urgency and urge incontinence. Define "detrusor hyperreflexia" and explain how it differs from "detrusor instability. Without evidence of a relevant neurological disorder, the term "detrusor hyperreflexia" cannot be used, and instead the term "detrusor instability" is used. Spinal cord lesions can damage axonal pathways allowing primitive spinal bladder reflexes to occur. New reflexes secondary to C fiber bladder afferent neurons can disrupt normal sacral activity. From cranial to caudal, explain how neurological lesions typically effect voiding dysfunction. The sympathetic efferents that effect bladder function are known to cause detrusor relaxation during the filling phase of the micturition cycle. Therefore, a -3 adrenoceptor selective agonist drug can be used to prevent detrusor activity. A test that can be performed to check for the reemergence of primitive neonatal voiding reflexes. It is performed by instilling 100cc of sterile normal saline at 4 C in the bladder. In a normal adult a cold sensation will be felt but there will be no bladder instability. In an infant, or in an adult with voiding pathology, the cold saline will induce an involuntary detrusor contraction. The reflex is initiated by temperature-sensitive receptors that are supplied by unmyelinated c-fibers afferents. It is important to distinguish between spinal column segment (bone level) and the corresponding cord level. After the cerebral shock phase wears off, what type of bladder condition is found most often What is the voiding pattern observed in a complete cord injury above the sacral reflex Most commonly, these lesions result in urge incontinence from detrusor hyperreflexia, absent sensation below the level of the lesion, smooth sphincter synergy, and striated sphincter dyssynergia. Lesions above the sympathetic outflow tract T7 or T8 (spinal column level of T6) may also result in smooth sphincter dyssynergia. Urinary retention is the most common finding initially, and is typically managed with a Foley catheter. The areflexic period generally lasts 6 to 12 weeks, but may persist up to 1 to 2 years. A construction worker falls from a rafter on the job site and suffers a sacral spinal cord injury. After spinal cord shock has resolved, what are his expected neurological and urodynamic findings In general, the patient can be expected to have depressed deep tendon reflexes with varying degree of flaccid paralysis below the level of the complete lesion. Classically, the bladder outlet is found to have a competent but nonrelaxing smooth sphincter with a striated sphincter that retains some fixed tone, but is not under voluntary control. The main goal of treatment is to maintain low bladder storage pressures to prevent upper tract damage from occurring. Which drugs have been used to treat outflow obstruction at the level of the striated sphincter Baclofen, benzodiazepines, and dantrolene have all been investigated for their efficacy in treating outlet obstruction secondary to a tonically closed striated sphincter. Unfortunately, none of these medications have been shown to satisfactorily inhibit sphincter spasticity. Contributing factors include elevated filling and voiding pressures, as well as infection. Potential treatments depend on the specific clinical circumstance and include pharmacotherapy, urethral dilation, neuromodulation, deafferentiation, augmentation cystoplasty, or sphincterotomy. It arises from massive autonomic discharge in patients with cord injuries above the sympathetic outflow tract (T6). Prevention is based on the use of spinal anesthesia in susceptible patients and administering oral nifedipine (10 mg) 30 minutes prior to the procedure. Initial management of symptoms is immediate withdrawal of the bladder stimulus, alpha blockade, and bladder decompression with Foley catheter. Those with cervical injuries as well as those who have had this symptom complex previously and are known to be prone to it. What is the key symptom in a spinal cord injured patient that should alert caregivers to a possible autonomic dysreflexia problem Sudden, severe headache should alert caregivers to the possibility of an autonomic dysreflexic episode.

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