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| REVIEW ARTICLE |
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| Year : 2019 | Volume
: 30
| Issue : 3 | Page : 92-98 |
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Lower urinary tract symptoms associated with Double-J stent
Sheng-Wei Lee, Po-Jen Hsiao, Chao-Hsiang Chang, Eric Chieh-Lung Chou
Department of Urology, China Medical University Hospital, China Medical University, Taichung, Taiwan
| Date of Submission | 31-Dec-2016 |
| Date of Decision | 03-Aug-2017 |
| Date of Acceptance | 15-Jul-2018 |
| Date of Web Publication | 20-Jun-2019 |
Correspondence Address:
Po-Jen Hsiao
Department of Urology, China Medical University Hospital, China Medical University, No. 2, Yude Road, Taichung
Taiwan
 Source of Support: None, Conflict of Interest: None  | 4 |
DOI: 10.4103/UROS.UROS_56_18
Urinary drainage for hydronephrosis including the placement of an internal double J (D-J) or external percutaneous nephrostomy tube is common practice. Although D-J insertion is less invasive and may provide better quality of life than percutaneous nephrostomy, patients commonly complain of associated symptoms like discomfort, resulting in decreasing work performance and lifestyle changes. The incidence of lower urinary tract symptoms (LUTS) following D-J insertion is 50%–70%. Urologists who perform this procedure need to know how to prevent and manage common symptoms and educate patients. The physical activity of patients, material of D-J, size, and length of the stent are factors that increase the incidence of LUTS. Recently, several studies have suggested medical treatment for relief D-J-related symptoms. This article reviews the general background, factors, evaluation, and management of D-J associated LUTS.
Keywords: Double-J stent, lower urinary tract symptoms, ureteral stent
How to cite this article:
Lee SW, Hsiao PJ, Chang CH, Chou EC. Lower urinary tract symptoms associated with Double-J stent. Urol Sci 2019;30:92-8 |
| Introduction | |  |
Double-J (D-J) or percutaneous nephrostomy tube is usually placed for urinary internal or external drainage. The J-shaped catheter is self-retaining at both the ends – the renal pelvis and the bladder. The method of internal drainage of D-J insertion is less invasive without external wound and may provide a better quality of life and body figure than external percutaneous nephrostomy drainage.[1] More than four decades since the first description of an indwelling ureteral stent by Zimskind et al. in 1967,[2] D-J insertion is now the accepted procedure of choice for maintaining a patent ureter. It can be placed in a retrograde or antegrade method.
There are many indications for D-J stent insertion, such as upper urinary tract obstruction, infection caused by hydronephrosis, safety concerns (e.g., complication of iatrogenic ureteral edema, perforations, and injury), and renal failure secondary to ureteral obstruction. Thus, D-J insertion plays a big role in significantly reducing reoperative rate, days of hospital stay due to postureteroscopic procedure discomfort. However, there are some reports that note the unnecessary use of D-J insertion.[3] Lower urinary tract symptoms (LUTS) following D-J placement procedure are still common and include frequency (50%–60%), urgency (57%–60%), dysuria (40%), incomplete emptying (76%), and urge incontinence (25%).[4] This review focused on the etiology, cause, and management of D-J-related LUTS.
| Etiology | | |
The D-J-related discomfort may be due to: (1) irritation of the bladder mucosa, especially the trigone, by the bladder coil of the stent; (2) smooth muscle spasm; and (3) reflux of urine. These can result in symptoms such as LUTS, pain of voiding, and flank soreness.[5],[6] Besides urinary symptoms, some associated side effect caused by stent will be discussed separately.
Lower urinary tract symptoms
Frequency and urgency is caused by a mechanical stimulus from the bladder coil, which may also increase or unmask preexisting subclinical detrusor overactivity.[7] Together frequency with urgency affects a significant proportion of patients (60%).
However, nighttime frequency (nocturia) is a less frequent complaint, suggesting that mechanical stimulation relates to physical activities or awareness of this stimulation at daytime.[7]
Typically followed by urgency, urge incontinence occurs directly due to irritating by the bladder coil. Sometimes, incontinence occurs when the stent migrates into the proximal urethra, thereby irritation caused by the mechanism of continence by the urethral sphincter.[8] If the distal part of the stent migrates out of the urethra, continuous urine leakage (total incontinence) can be noticed.
Pain of voiding and flank pain
In a patient with D-J stent, painful voiding and renal colic are usually experienced at the end of voiding. Pain of voiding is considered to be the result of trigonal irritation by the bladder coil when it crosses the midline or forms an incomplete loop.[9] A recently published randomized clinical trial also implies that urgency and pain of voiding are more common with longer stents but negatively impacts on the patients' quality of life.[10] Renal colic is related to the movement of the D-J in the ureter and associated ureteral spasm. Pain is thought to occur from distention of the renal capsule because of urine reflux through D-J.[5] However, there should be caution in considering that all symptoms are associated stent morbidities. Sometimes, it may be caused by a consequence of urinary tract infection and encrustation. Thus, excluding morbidities by urinalysis and imaging is warranted.[11]
Sexual dysfunction
Sexual dysfunction has recently been considered secondary to D-J stenting. Bolat et al. published a randomized controlled study that included 72 patients and their conclusion suggested that D-J catheterization seemed to have negative effect on male sexual function, especially in erectile dysfunction and ejaculatory dysfunction. The International Index of Erectile Function Questionnaire and Male Sexual Health Questionnaire score were significantly lower in patients who placed D-J stent compared to control group for postoperative 1 and 3 months of period. During sexual intercourse and ejaculation, some irritable sensation and pain could be attributed to ureteral stents. As such, whenever possible, stenting should be avoided.[12]
Hematuria
Joshi et al. reported that hematuria is significant at the end of the 1st week and the symptom settled down during the period of stent use.[7] The possible cause of hematuria may relate to certain activities, especially torso aerobics movement. The restrictions on activity and prevent overexertion that could lead to hematuria can decrease occurring of hematuria.[13] Hematuria can result from radiotherapy or anticoagulation therapy even a little irritation or trauma from the stent if patients have certain underlying disease. The increase of urine amount and adequate fluid supply is important for these patients. Besides, urinary tract infection must be considered and appropriate treated when hematuria occurs.
| Risk Factors | | |
Physical activity
Stent position changes when standing, sitting, and bending under fluoroscopic imaging, which may explain why physical activity can influence stent discomfort. To improve stent discomfort for adapting physical activity, future stent designs must take into account the range of motion of the ureter during changes in body position. The stent movements may be a combination of bowing in the proximal ureter and moving within the bladder. A small study of six patients found up to 2.5 cm of movement of the renal coil or bladder coil, with associated bowing at the proximal ureter with alteration in patient position.[13]
Stent size and length
There is an in vivo measurement study of the ureter that suggests that a 5 Fr ureteral catheter is often assumed as the true ureteral width. Larger sizes of the stent may cause bladder irritation and foreign body sensation.
An innovative design was introduced in the Tail Stent ™ model (Microvasive Urology/Boston Scientific) to minimize irritating bladder symptoms. This stent has a proximal 7 Fr pigtail and a shaft that tapers to a lumenless straight 3 Fr tail that lies in the bladder.[14] Dunn et al. also supported the conclusion that the smaller tail stent size produces fewer irritating symptoms than the standard 7 Fr D-J stents in a randomized single-blind trial involving 60 patients.[15]
Along with stent size, stent length also seems to play a significant role in stent-related symptoms because it is directly related to bladder irritation. Longer bladder coil length presupposes more discomfort. However, bladder coil length that is too short may lead to upward migration of the ureter stent. Several different ways to assess the ideal stent length have been introduced. Lee et al.[16] developed a reference table and a corresponding stent length was selected for each given specific height range. Ho et al. prospectively assessed stent-related symptoms in 87 patients and determined that a 22-cm stent would be more suitable for those whose height range is 149.5–178.5 cm, with a median of 161.9 cm.[11]
Pilcher and Patel announced a predictive model for ideal stent length according to patient's height and found the following: <177.8 cm (5 feet 10 inches): 22-cm stent; 177.8–193.04 cm (5 feet 10 inches to 6 feet 4 inches): 24-cm stent; and >193.04 cm (6 feet 4 inches): 26-cm stent.[17] Mathematic formulas have also been proposed to calculate stent length. Hao et al. used the following: (Length = 0.125 × body height + 0.5 cm) or the vertical distance from the second lumbar vertebra to the pubic symphysis minus 2 cm.[18] Hruby et al.[19] suggested that the distance from the xiphoid process to the pubic symphysis distance as well as from the acromium process to the head of the ulna could both be used to predict suitable D-J length. Paick et al. reported that linear measurement from the ureteropelvic junction to the vesicoureteric junction directly on preoperative intravenous pyelography was a better predictor of actual ureteric length than the patient's height.[20]
Finally, another recent report demonstrated that actual ureteric length based on computed tomography-measured length is better than any other imaging-based measurement.[21] For pediatrics, the ideal stent length for children has been computed as "child's age + 10" cm [Table 1].[22] Lee et al. evaluated the stent position by plain film of the abdomen and suggest that the distal curling of D-J does not exceed the midline (symphysis pubis), the stent length was considered to be appropriate.[23]
Stent coating
The surface of the ureteral stent may provide biofilm formation, bacterial colonization, and encrustation. After biofilm formation, the encased bacteria will increase dormancy and resistance to antibiotics.[24] Research has therefore focused on preventing this process. Stent encrustation may lead to ureteral obstruction and distal D-J encrustation may be related to bladder irritation. Stents placement for longer than 12 weeks have a 76% incidence of encrustation.[25] To incorporate drugs into the core of the polymeric structure of the stent material, a triclosan-loaded stent was developed (Boston Scientific Triumph ™) and was shown to decrease bacterial growth in Proteus mirabilis-infected urine. The mechanism was probably through the prevention bacterial adherence to the biofilm of the drug-coated stent, which then leads to the prevention of stent encrustation.[26]
There are more new stents in the development process. Drug-eluting stents using the anticancer drug paclitaxel was tested in a porcine model, hoping to reduce the urothelial hyperplasia.[27] Watterson et al. announced coated circular silicone disks with an oxalate-degrading enzyme and implanted them in a rabbit model for 30 days. The results showed a 21% and 40% reduction in the dry weight of encrustation and calcium within the encrustation, respectively.[28] Riedl et al. conducted a study comparing heparin-coated polyurethane ureteral stents with uncoated stents for a 6-week period. Their results showed effective inhibition of both biofilm and encrustation formation by the first group.[29] Another study by Zupkas et al. used a rabbit bladder implantation model to compare silicon rings coated with pentosan polysulfate, a semisynthetic polysaccharide chemically similar to heparin, with uncoated silicon rings. The pentosan polysulfate-coated rings led to an eightfold reduction in encrustation formation.[30]
Furthermore, Multanen et al. demonstrated the advantages of silver nitrate and ofloxacin-blended copolymer-coated urospiral stents compared to pure copolymer-coated stents, including less tissue reaction and the prevention of biofilm and encrustation formation.[31] Glycosaminoglycan-coated stents were also found to increase resistance to encrustation in experimental studies.[32] Finally, Olweny et al. used a self-expandable mesh stent in order to preserve drainage while reducing symptom of irritation. Their study reported less inflammatory tissue reaction and a tendency toward better urinary flow at 1 and 6 weeks when comparing this new prototype to a standard 7 Fr double-pigtail polyurethane stent in a porcine model, although there was no statistical significance.[33]
Texture
Aside from encrustation and bacterial colonization, the texture or strength of the D-J stent should also be emphasized. Dual-durometer stents combine a firm biomaterial at the renal end that smoothly turns to a soft biomaterial at the bladder end for reducing mechanical irritation of the bladder urothelium. Sof-CurlTM and the PolarisTM stents are the available models. They are hydrophilic-bonded hydrogel coating that decreases their coefficients of friction. The Polaris™ shows lower flexural strength compared to five other stents and is believed to minimize bladder discomfort.[5],[6]
| Evaluation of the Symptoms | | |
The Ureteral Stent Symptom Questionnaire (USSQ) was developed by Joshi et al. to evaluate symptoms related to ureteral stents and their impact on the quality of life. In the USSQ, discomfort was divided into six sections [Table 2]. Used worldwide, it was validated in France, Italy, Germany, and South Korea. The authors reported that quality of life was influenced in 80% of stented patients. Moreover, 58% of patients reported reduced work capacity because of stent discomfort and approximately half needed medical professional help for stent-related symptoms.[4],[34] Leibovici et al. found that 45% of patients were unable to work for at least 2 days for a total of 435 workdays lost in 135 stented patients.[35]
A prospective cohort study reported that nearly one-third of patients required early removal of ureteral stents due to intolerable stent discomfort.[36]
| Management | | |
Precise indications for Double-J insertion
"Prevention as the best treatment" is a general concept that adequately applies in every surgery. Considering its significant morbidity, D-J should be used under cautious and evidence-based criteria. In the current meta-analysis or systemic review, D-J does not improve the stone-free rate, fever, incidence of urinary tract infection, unplanned medical visits, need for analgesia, and late postoperative complications. In addition, internal stenting is not mandatory for uncomplicated simple ureteroscopy and shock wave lithotripsy. Patients with stents seem to have significantly more bladder and LUTS than those without stents.[37]
Indication for D-J insertion, such as infection control, pain control, and prevention of postoperative morbidity (e.g., complications, ureteral edema, and perforation) should be considered. Cepeda et al. reviewed the indications for D-J insertion and divided theses into urgent (obstructive pyelonephritis, intolerable acute colic pain, and renal failure due to ureteral obstruction), safety-related (ureteral edema, ureteral perforation, steinstrasse, solitary kidney, and transplanted kidney), or relative (stone burden >2 cm before SWL, pregnancy, and passive dilatation of the ureteral orifice and ureter).[38] Significant ureteral edema was considered in patients who completed the URS procedure, were pregnancy, had a stone burden >2 cm, had long-standing impacted stone, and in those with a recent history of urinary tract infection or sepsis.[39] A prospective multi-institutional randomized study with 113 patients who underwent uncomplicated ureteroscopy for distal ureteral calculi demonstrated significantly more severe postoperative pain and LUTS in the stenting group compared to the nonstenting groups.[40]
In the stone management, there are benefits only in a selected pediatric population with large stone burden.[37] However, if a patient has a history of renal failure, solitary kidney, and transplant kidney, stent placement are reasonable after uncomplicated ureteroscopy.
Peri-ureteral injection or intravesical instillation
Peri-ureteral injection of botulinum toxin A has been introduced to safely reduce stent-related pain and the need for analgesic medication up to 1 week after stent placement.[41] Beiko et al. conducted a double-blind prospective trial on 42 patients randomized to three groups receiving one of three chemical intravesical instillations (oxybutynin, alkalinized lidocaine, and ketorolac) compared to saline (as control) immediately after stent placement at the time of SWL. There were no significant adverse events and the result showed that ketorolac was associated with a significant decrease in symptoms of irritation at 1 h after the intervention.[42]
Certainly, subsequent studies failed to find differences between intravesical agents for the relief of stent-related symptoms. Sur et al. conducted a randomized controlled trial of 22 patients to receive intravesical ropivacaine instillation or not. Their results suggested that the trends were positive for ropivacaine toward decreasing pain and avoiding symptoms.[43]
In general, intravesical instillation of nonsteroidal anti-inflammatory drugs may improve LUTS and prevent some discomfort, but the evidence needs larger studies.
Oral medications
Alpha-blockers
In 2006, Deliveliotis et al. investigated the role of α1-blockers for treating D-J-related LUTS through a prospective, randomized, placebo-controlled study that compared the impact of stent symptoms based on a validated questionnaire (USSQ). Patients who underwent cystoscopically-placed stents for stone-related hydronephrosis were given 10 mg alfuzosin once daily for 4 weeks. The results showed a decrease in mean urinary symptom index (P < 0.001) and in the frequency of stent-related pain (P = 0.027), as well as an improvement in the general health index score (P < 0.001) for patients in the alfuzosin group.[44]
Beddingfield et al. also evaluated alfuzosin for improving stent-related symptoms. Their study included 55 patients who were randomized to receive either 10 mg alfuzosin hydrochloride or placebo once a day for 10 days following D-J placement. The USSQ and narcotic use diary were also assessed. The results showed a significant improvement in the alfuzosin group, such as sleep interrupted by pain, frequency of painkiller use, pain interfering with life, and micturition-associated flank pain (P < 0.005). These same symptoms worsened in the placebo group.[45]
Damiano et al. reported that tamsulosin also proved to be efficacious in improving stent-related morbidity. Tamsulosin use decreased flank pain and urinary symptoms after 1 week and increased the general health index score. However, this study was neither double-blinded nor placebo controlled.[46]
A meta-analysis provided evidence for improved ureteral stent tolerability with tamsulosin.[47],[48] A meta-analysis of four RCTs with a total of 341 patients assessed the efficacy of α-blockers using the USSQ and revealed that the use of α-blockers significantly reduced urinary symptoms and pain while improving general health.[49] Finally, α-blockers were also used to mitigate stent discomfort and have been recommended in urolithiasis guidelines.[50]
Antimuscarinic
Aside from α-blockers, antimuscarinic drugs are also being considered to improve D-J-related LUTS for some symptoms such as frequency and nocturia. Park et al. conducted a study comparing alfuzosin with tolterodine ER and placebo.[51] Fifty-two patients were randomized after different endourologic procedures and stent placement to receive one of the following for a 6-week period: 10 mg alfuzosin, 4 mg tolterodine ER, or placebo. Both drugs improved pain and urinary symptom index scores compared to placebo (P = 0.02 and P = 0.008, respectively).
Antimuscarinic such as solifenacin and tolterodine can significantly reduce irritable urinary tract and pain symptoms,[51],[52] although some studies point to the contrary. Norris et al. recently published their experience in a double-blind, placebo-controlled study (with a small case number) that compared ER oxybutynin, phenazopyridine, and placebo in patients with stent placement after ureteroscopy.[53] Their result showed no differences for flank pain, suprapubic pain, urinary frequency, urgency, dysuria, narcotic use, or hematuria (except for phenazopyridine vs. placebo on day 2) based on USSQ score.
Combination therapy
The combination of tamsulosin and solifenacin appears to significantly improve stent-related irritable and obstructive symptoms compared to monotherapy with either agent alone.[54] Zhou et al. reviewed a meta-analysis that evaluated the effects of α-blockers, antimuscarinics, or a combination of both in reducing ureteral stent-related symptoms. Their results supported the beneficial effect of α-blockers alone and antimuscarinics alone. The significant advantages of combination therapy of α-blocker and antimuscarinic compared to α-blocker monotherapy have also been suggested. For instance, compared to α-blocker monotherapy, combination therapy has a significantly lower total International Prostate Symptom Score (I-PSS) (Median:-3.74; 95% Confidence interval,-4.94 to-2.54; P < 0.00001).[55]
Phosphodiesterase Type 5 inhibitor
Phosphodiesterase Type 5 inhibitor (PDE5 inhibitor) is proven to improve LUTS. A study reported that tadalafil was beneficial for stent-related LUTS. In the study, tadalafil was as effective as tamsulosin in relieving urinary symptom but was more effective in relieving sexual symptoms and body pain.[56]
Correct stent position
Positioning the proximal coil in the upper pole of the kidney rather than in the renal pelvis may be better tolerated by patients with stents.[27] Several authors have reported that stents crossing the midline of the bladder have a significant and deleterious effect on the associated discomfort. Hence, choosing the appropriate stent length may aid in ameliorating stent-related symptoms.[9],[10],[11],[57] A prospective randomized control trial assumed that appropriate stent position was with the distal coil not crossing over the bladder midline. This appeared to have more effect on stent-related symptoms than α-blockers or anticholinergics.[23]
| Conclusions | | |
D-J stent insertion after ureteroscopic procedure is widely used. However, an associated discomfort is commonly reported. This article reviews LUTS caused by D-J stent insertion and discusses the etiology and management. Precise and careful evaluation is necessary to determine if a D-J stent insertion is indicated. When indicated, proper information on the possibility of LUTS, such as frequency, urgency, or incontinence, must be conveyed to patients. Most importantly, they need to know how to avoid exacerbating symptoms, as these may lead to poorer life quality or work performance. The USSQ is a good assessment tool including six sections for the discomfort although the items may be too complicate in daily practice. In terms of management, the appropriate length of D-J stents can be calculated. Stent texture also affects stent-related discomfort. After stent insertion, intravesical or oral medication can be used to alleviate the LUTS and improve the quality of life.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]
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