Tuesday, October 4, 2022

Why Do Opiates Cause Urinary Retention

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

Acute Urinary Retention – what you need to know for finals

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.

Sleeping Pills And Incontinence

Only a small percent of people with incontinence have a problem with bed-wetting, according to Anger, who estimates that about 10% of patients with incontinence wet the bed. However, sleeping pills may pose a problem for those with incontinence at night.

“Sleeping pills can make things worse, because people don’t wake up ,” she says.

As an alternative, cut down on caffeine so you sleep better on your own, Anger suggests.

Sleep will come more easily if you keep a regular bedtime and wake-up schedule, according to the National Sleep Foundation. You can also develop a relaxing bedtime ritual, such as reading a book or listening to soothing music.

Fentanyl Analogs Sold As Heroin On The Streets Are Complicating Early Suboxone Treatment

With synthetic fentanyl analogs on the street being sold in place of heroin, the difficulties in helping patients through precipitated withdrawal are even greater. Because of the way fentanyl analogs linger in a persons system for days, precipitated withdrawal can occur unexpectedly, even if the patient waits well past the usual 24 hours.

With caring, trust, and communication, a doctor can work closely with their patient and help them through this sometimes difficult transition. The same goes for other side effects and adverse reactions. We do not want patients scared away from treatment during the early stages of recovery when they are most vulnerable.

After getting a patient through the induction process, helping them to go from quitting street opioids to taking Suboxone successfully, we must monitor closely for any issues with side effects. What if a patient has an uncomfortable side effect, such as insomnia, sweating, constipation, or urinary hesitancy? Could a side effect lead a patient to quit treatment and go back to using opioids?

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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.

Use Of Opioids In Ckd

Opioid Use For Chronic Pain

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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What About Female Urinary Hesitancy

Can Suboxone cause difficulty urinating for women? If a woman complains of difficulty urinating after starting Suboxone, we still must consider the possibility of other causes. Could the symptom of urinary retention and urgency be due to a urinary tract infection?

Or, is it possible that the symptoms of peeing problems are related to recent street drug use. Opioids do cause urinary hesitancy as a side effect. When a person is taking large amounts of heroin, fentanyl, oxycodone, or other potent opiate drugs, they may have this symptom, but not think about it in the haze of ongoing active addiction.

It is possible that side effects of street drug use may persist in the first weeks of opioid addiction treatment. So, it is possible that the symptom will subside over time. Still, it is important to consider the possibility of an infection, in men and women, and perform appropriate testing.

Both men and women are susceptible to urinary tract infections, but women tend to get UTIs more frequently. This is due to a shorter urethra, the tube that goes from the bladder to carry urine to leave the body. Regarding Suboxone and urinary tract infections, we must first rule out the UTI before considering any other cause.

An untreated infection could lead to much more serious problems. After the doctor has tested for infections and ruled out this possibility, the next step may be to address possible Suboxone-induced urinary hesitancy.

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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Nalbuphine Can Relieve Opioid

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.

Pharmacologic Agents That Cause Urinary Incontinence

Incomplete Bladder Emptying (Urinary Retention)

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

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Causes Of Urinary Retention

Selected Causes of Urinary Retention

Obstructive

Cause

Benign prostatic hyperplasia meatal stenosis paraphimosis penile constricting bands phimosis prostate cancer

Organ prolapse pelvic mass retroverted impacted gravid uterus

Aneurysmal dilation bladder calculi bladder neoplasm fecal impaction gastrointestinal or retroperitoneal malignancy/mass urethral strictures, foreign bodies, stones, edema

Infectious and inflammatory

Balanitis prostatic abscess prostatitis

Acute vulvovaginitis vaginal lichen planus vaginal lichen sclerosis vaginal pemphigus

Bilharziasis cystitis echinococcosis Guillain-Barré syndrome herpes simplex virus Lyme disease periurethral abscess transverses myelitis tubercular cystitis urethritis varicella-zoster virus

Other

Penile trauma, fracture, or laceration

Postpartum complication urethral sphincter dysfunction

Disruption of posterior urethra and bladder neck in pelvic trauma postoperative complication psychogenic

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

Information from references 1 and 5 through 7.

Selected Causes of Urinary Retention

Obstructive

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

Information from references 1 and 5 through 7.

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 .

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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.

What Causes Chronic Urinary Retention

PPT

Urinary retention can happen for several different reasons. These causes can include:

  • A blockage to the way urine leaves your body.
  • Medications youre taking for other conditions.
  • Nerve issues that interrupt the way your brain and urinary system communicate.
  • Infections and swelling that prevent urine from leaving your body.
  • Complications and side effects of medications given to you for a surgical procedure.

Blockage

When something blocks the free flow of urine through the bladder and urethra, you might experience urinary retention. The urethra is the tube that carries urine from the bladder to the outside of your body. In men, a blockage can be caused when the prostate gland gets so big that it presses on the urethra. This is the most common cause of chronic urinary retention in men. One cause in women is a bladder that sags. This is called cystocele. It can also be caused when the rectum sags into the back wall of the vagina a condition called rectocele. Some causes can happen to both men and women. The urethra can get narrow due to scar tissue. This is called a stricture. Urinary stones can also block the flow of urine out of your body.

Medications

Nerve issues

  • Trauma to the spine or pelvis.
  • Pressure on the spinal cord from tumors and a herniated disk.
  • Vaginal childbirth.

Urinary retention from nerve disease occurs at the same rate in men and women.

Infections and swelling

Surgery

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There Is Medication That Can Help With Opioid

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.

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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Multiple Classes Of Pain Medication Use And Ckd

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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