Thursday, May 23, 2024

Opioid Induced Urinary Retention Treatment

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Nalbuphine Can Relieve Opioid

What are the various treatment options for opioid-induced constipation (OIC)?

HealthDay News Nalbuphine can relieve opioid-induced urine retention, according to a case report published online Sept. 4 in the Annals of Internal Medicine.

Abdisamad M. Ibrahim, M.D., from the Southern Illinois University School of Medicine in Springfield, and colleagues describe how nalbuphine helped manage opioid-induced urine retention in a 59-year-old man with a history of alcoholic cirrhosis who was hospitalized for worsening right-sided abdominal pain. The patient was diagnosed with portal vein thrombosis and hepatocellular carcinoma.

The authors note that after treatment of pain with hydromorphone, the patient developed new-onset urine retention that did not respond to 1-blockers and required intermittent urinary catheterization. The patient found the intervention inconvenient and declined placement of a permanent catheter. A literature search revealed use of nalbuphine for reversal of postoperative urine retention without loss of pain control.

The patient consented to this treatment, and 10 mg nalbuphine was administered intravenously. During the first six hours after receiving the drug, the patient voided 850 mL, and pain remained controlled. On ultrasonography, bladder volume was 77 mL one day later. The patient required no additional nalbuphine treatment before being discharged to hospice the next day.

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Clinical Events And Treatment Of Aki Due To Opioids

Clinically, opioids can result in AKI from changes in GFR, dehydration, rhabdomyolysis and urinary retention. The presentation of opioid overdose may be with hypopnea or apnea, miosis, and stupor. The combination of decreased respiratory drive, hypoxia, a drop in renal blood flow and GFR results in renal tubular damage. Dehydration with signs of volume depletion and hypotension may be noted. Confusion or a change of mental status could be seen.

The drop in renal blood flow would activate renal sympathetics, furthering the effect of renal ischemia and tubular damage. Overall cardiac output and mean arterial pressure decreases are noted. Physical examination should include a careful evaluation for muscle tenderness the only finding in a comatose patient may be muscle edema that could reflect the start of muscle necrosis. Abdominal examination may reveal a palpable distended bladder from urinary retention.

Once this stage is reached, with decreased kidney function, metabolism of opioids may further change depending on the specific drug. With morphine, for example, there is an increase in the mean peak concentration and the area under the concentration-time curve for both active and principle metabolites which could further worsen respiratory depression.

In the setting of methodone use, an electrocardiogram should be done early to determine if there is QT interval prolongation that could lead to arrhythmias.

Data Abstraction And Data Management

We will review bibliographic database search results for studies relevant to our PICOTS framework and study-specific criteria. The use of previous systematic reviews to replace the de novo process will be explored when relevant or partially relevant systematic reviews are identified and judged to be of fair or good quality by using modified AMSTAR criteria.9 Search dates may be altered in the presence of high-quality systematic reviews for specific populations and/or interventions.

Review of bibliographic database searches will occur in two stages. First, titles and abstracts will be reviewed by two independent investigators to identify studies meeting the criteria in the PICOTS framework and study-specific criteria. At this stage we plan to include all interventions identified in the literature. At completion of this stage, we will consult with our Technical Expert Panel to ensure that we capture only studies examining relevant interventions . All studies identified as relevant by either investigator will undergo full-text screening. Two independent investigators will screen the full text to determine if our inclusion criteria are met. Differences in screening decisions will be resolved by consultation between investigators and a third investigator if necessary. We will document the inclusion and exclusion status of citations undergoing full-text screening.

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Use Of Opioids In Ckd

Metabolism of opioids with CKD is altered. For example, in 620 cancer patients, serum fentanyl concentrations and metabolic ratios were found to vary considerably between patients on transdermal fentanyl patches based on various factors including cytochrome genotypes and clinical factors like gender, other medications, presence of kidney disease, serum albumin and obesity .

In CKD, morphine has an increase in the mean peak concentration and the area under the concentration-time curve for both active and principle metabolites. With CKD, the metabolites of merperidine are present for longer and can decrease the seizure threshold and should be avoided for chronic use. Extended effects of codeine and dihydorcodeine with CKD have been reported. Pharmacokinetics of buprenorphine, alfentanil, sufentanil and remifentanil are not significantly altered in patients with renal failure .

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Is It Possible For Suboxone Subutex Zubsolv Or Bunavail To Cause Urinary Hesitancy In Males And Female Urinary Hesitancy

Buprenorphine Therapy for Opioid Use Disorder

Can Suboxone cause urinary retention? Has anyone had trouble urinating after taking Suboxone? This is an excellent question. Most Suboxone doctors would likely answer that they have not heard this complaint before.

Or, at least, they have not heard the complaint of difficulty urinating on Suboxone where it could not be explained by another cause. Urinary hesitancy in males, for example, can often be attributed to BPH, or benign prostatic hyperplasia.

BPH is an enlargement of the prostate, and it is very common in men in their 50s and older. The ultimate solution is a surgery known as a TURP, or transurethral resection of the prostate.

However, before going to surgery, the patient can try different options, such as changing their diet, natural supplements, and medications prescribed by their doctor. Flomax is an example of a medication that makes it easier to urinate for men with BPH.

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Initial Management Of Urinary Retention

Acute urinary retention should be managed by immediate and complete decompression of the bladder through catheterization. Standard transurethral catheters are readily available and can usually be easily inserted. If urethral catheterization is unsuccessful or contraindicated, the patient should be referred immediately to a physician trained in advanced catheterization techniques, such as placement of a firm, angulated Coude catheter or a suprapubic catheter.5 Hematuria, hypotension, and postobstructive diuresis are potential complications of rapid decompression however, there is no evidence that gradual bladder decompression will decrease these complications. Rapid and complete emptying of the bladder is therefore recommended.34

For hospitalized patients requiring catheterization for 14 days or less, a Cochrane review found that silver alloy-impregnated urethral catheters have been associated with decreased rates of UTI versus standard catheters.41 Another Cochrane review concluded that patients requiring catheterization for up to 14 days had less discomfort, bacteriuria, and need for recatheterization when suprapubic catheters were used compared with urethral catheters.42 In a recent meta-analysis of abdominal surgery patients, suprapubic catheters were found to decrease bacteriuria and discomfort and were preferred by patients.43 Although evidence suggests short-term benefit from silver alloy-impregnated and suprapubic catheters, their use remains somewhat controversial.

How Is Chronic Urinary Retention Diagnosed

History and physical exam: During the diagnosis process, your healthcare provider will ask about your signs and symptoms and how long you have had them. He or she will also ask about your medical history and your drug use. A physical exam of the lower abdomen may show the cause or give your provider additional clues. After this, certain tests may be needed. Men may have a rectal exam to check the size of their prostate.

Your urine may be saved and checked to look for infection.

Ultrasound of the bladder: The amount of urine that stays in your bladder after urinating may be measured by doing an ultrasound test of the bladder. This test is called a postvoid residual or bladder scan.

Cystoscopy: Cystoscopy is a test in which a thin tube with a tiny camera on one end is put into your urethra. This lets the doctor look at pictures of the lining of your urethra and bladder. This test may show a stricture of the urethra, blockage caused by a stone, an enlarged prostate or a tumor. It can also be used to remove stones, if found. A computed tomography scan may also help find stones or anything else blocking the flow of urine.

Urodynamic testing: Tests that use a catheter to record pressure within the bladder may be done to tell how well the bladder empties. The rate at which urine flows can also be measured by such tests. This is called urodynamic testing.

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Could Stigma Against Opioid

Another issue that may be involved is the stigma against people who take opioids and people who are addicted to opioids. Doctors are affected by the opioid stigma, even doctors who treat opiate addiction.

Imagine, in a busy methadone clinic or Suboxone clinic, a patient complains of difficulty peeing, and they believe the problem is due to their treatment medication. It is possible that clinic staff, counselors, and even doctors, will dismiss the symptom as unrelated. Or, they may just recommend that the patient see their primary care doctor.

Now, in the primary care, family doctor office, the patient is again faced with addiction stigma. The family doctor may believe that the patient cannot be taken seriously because they are simply an addict. The doctor assumes that it is probably a sexually transmitted illness or a urinary tract infection.

While it is important to evaluate the patient for these other conditions, it is also important that doctors and clinic staff take patients seriously. Side effects are real and they do occur. We must listen to what patients are trying to tell us.

When patients complain about side effects, sometimes doctors and their staff have a tendency to think that the patient is lying and trying to get away with something. This is particularly true with addiction patients.

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Multiple Classes Of Pain Medication Use And Ckd

A& P II Lab 20: Urinary Retention Secondary to Opioid Use – I Cannot Pee

A common scenario where pain control is needed is with renal calculi. In developed countries the lifetime risk of kidney stones is 8%10% and this is higher in the elderly. Pain control of acute symptoms is accomplished with a combination of parenteral opioids and non-steroidal anti-inflammatory agents to maximize the benefits of both agents and limit doses of both to keep side effects at a minimum. The benefits of NSAIDS include a decrease of inflammation along the urinary tract. With AKI or peptic ulcer disease present, opioids may be the only option for renal colic despite being less effective with regard to inflammation . In this setting it is important to monitor for opioid side effects including confusion, respiratory depression, and urinary retention . While the burden of stone disease is problematic, the component of pain medications , dehydration and AKI are difficult to dissect.

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Review Of Key Questions

For all Evidence-based Practice Center reviews, Key Questions were reviewed and refined as needed by the EPC with input from Key Informants and the Technical Expert Panel to assure that the questions are specific and explicit about what information is being reviewed. In addition, the Key Questions were posted for public comment and finalized by the EPC after review of the comments.

Mechanisms Of Urinary Continence

In healthy individuals, the urinary bladder senses the volume of urine by means of distention. Distention of the bladder excites afferent A-delta fibers that relay information to the pontine storage center in the brain. The brain, in turn, triggers efferent impulses to enhance urine storage through activation of the sympathetic innervation of the lower urinary tract . These impulses also activate the somatic, pudendal, and sacral nerves.1

The hypogastric nerves release norepinephrine to stimulate beta3-adrenoceptors in the detrusor and alpha1-adrenoceptors in the bladder neck and proximal urethra. The role of beta3-adrenoceptors is to mediate smooth-muscle relaxation and increase bladder compliance, whereas that of alpha1-adrenoceptors is to mediate smooth-muscle contraction and increase bladder outlet resistance.1 The somatic, pudendal, and sacral nerves release acetylcholine to act on nicotinic receptors in the striated muscle in the distal urethra and pelvic floor, which contract to increase bladder outlet resistance.1

Efferent sympathetic outflow and somatic outflow are stopped when afferent signaling to the brain exceeds a certain threshold. At this point, the parasympathetic outflow is activated via pelvic nerves. These nerves release acetylcholine, which then acts on muscarinic receptors in detrusor smooth-muscle cells to cause contraction. A number of transmitters, including dopamine and serotonin, and endorphins are involved in this process.1

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Other Clinical Findings With Opioid

In the gastrointestinal tract, opioids reduce propulsive peristaltic contractions, and increase muscle tone and intraluminal pressure by decreasing the release of acetylcholine in the ileum . In the setting of acute opioid intoxication and AKI, potassium exchange resins as a treatment for hyperkalemia that work in the gastrointestinal tract have limited effectiveness and need to be used with caution .

There Is Medication That Can Help With Opioid

Complication Rate After Antibiotic Prophylaxis with Fosfomycin Versus ...

After surgery, patients often have difficulty urinating. This may be due to potent opioids, such as fentanyl, given as part of general anesthesia.

Why is bethanechol not prescribed more often for urinary hesitancy? If a patient goes home from surgery and then cannot pee easily, why doesnt their doctor provide this medication? And, why dont Suboxone doctors prescribe bethanechol for urinary retention and hesitancy?

Maybe the issue is that this side effect is not taken seriously enough by doctors. Are doctors asking their patients about difficulty urinating when they are prescribed opioids? What about Suboxone doctors? Are they asking?

While bethanechol may cause additional side effects, if doctors prescribe it at low dosages, the chance of any problems with side effects will be reduced. Also, bethanechol treatment does not have to be a long-term solution. Most likely, the issue will resolve on its own in time.

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Searching For The Evidence: Literature Search Strategies For Identification Of Relevant Studies To Answer The Key Questions

We will utilize bibliographic database searching to identify previous systematic reviews, randomized controlled trials, and observational studies published from 1946 to the present for studies enrolling adults based on a diagnosis of CUR. Relevant bibliographic databases for this topic include MEDLINE® and the Cochrane Central Register of Controlled Trials . Our preliminary search strategy appears in Appendix A. This search strategy searches on only one concept, CUR, and employs relevant Medical Subject Headings and natural language terms to find studies on the topic. The concept search is supplemented with filters designed to select experimental designs. Bibliographic database searches will be supplemented with backward citation searches of highly relevant systematic reviews. We will update searches while the draft report is under public/peer review.

We will conduct additional grey literature searching to identify relevant completed and ongoing studies. Relevant grey literature resources include trial registries and U.S. Food and Drug Administration databases. We will search ClinicalTrials.gov and the International Controlled Trials Registry Platform . We will also review Scientific Information Packets sent by manufacturers of relevant interventions. Grey literature search results will be used to identify studies, outcomes, and analyses not reported in the published literature to assess publication and reporting bias.

Pharmacologic Agents That Cause Urinary Incontinence

A variety of drugs have been implicated in urinary incontinence, and attempts have been made to determine the mechanism responsible based upon current understanding of the processes involved in continence and the transmitters that play a role. Each of the processes described previously can be manipulated by pharmacologic agents to cause one or more types of incontinence.

The drugs commonly pinpointed in urinary incontinence include anticholinergics, alpha-adrenergic agonists, alpha-antagonists, diuretics, calcium channel blockers, sedative-hypnotics, ACE inhibitors, and antiparkinsonian medications. Depending upon the mode of action, the effect may be direct or indirect and can lead to any of the types of incontinence. Taking these factors into account, it is important to consider a patients drug therapy as a cause of incontinence, particularly in new-onset incontinence patients and in elderly patients, in whom polypharmacy is common.11,12

On the other hand, a pharmacologic agent or any other factor that results in chronic urinary retention can lead to a rise in intravesical pressure and a resultant trickling loss of urine. In this way, drugs that cause urinary retention can indirectly lead to overflow incontinence.2

It is useful to note that many antidepressants and antipsychotics exhibit considerable alpha1-adrenoceptor antagonist activity.1

note:For pharmacologic and neurologic causes of urinary retention, see Tables 2 and 3, respectively.

Obstructive

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Approach To The Patient With Urinary Retention

Possible Etiology of Urinary Retention Based on History and Physical Examination Findings

*Most patients will present with one or more lower urinary tract symptoms. Symptoms include frequency, urgency, nocturia, straining to void, weak urinary stream, hesitancy, sensation of incomplete bladder emptying, and stopping and starting of urinary stream.

Patients with 150 to 200 mL of retained urine may have a percussible or palpable bladder

Information from references 5, 6, 28, and 29.

Possible Etiology of Urinary Retention Based on History and Physical Examination Findings

*Most patients will present with one or more lower urinary tract symptoms. Symptoms include frequency, urgency, nocturia, straining to void, weak urinary stream, hesitancy, sensation of incomplete bladder emptying, and stopping and starting of urinary stream.

Patients with 150 to 200 mL of retained urine may have a percussible or palpable bladder

Diagnostic Testing in Patients with Urinary Retention

note:Imaging studies and diagnostic procedures are guided by the clinical context and suspected diagnoses.

CT = computed tomography MRI = magnetic resonance imaging.

Information from references 5, 6, and 28 through 30.

Diagnostic Testing in Patients with Urinary Retention

note:Imaging studies and diagnostic procedures are guided by the clinical context and suspected diagnoses.

CT = computed tomography MRI = magnetic resonance imaging.

Information from references 5, 6, and 28 through 30.

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