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14er newbie - frequent urination while hiking, AMS??

FAQ and threads for those just starting to hike the Colorado 14ers.
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Re: 14er newbie - frequent urination while hiking, AMS??

Postby MountainMedic » Thu Sep 20, 2012 9:56 pm

Fishdude wrote:I am with the OP; it is TWB (teeny weeny bladder). Happens to me all the time. Less often if I am drinking gatorade and less often as I descend and am getting a bit dehydrated.


Yes. Her bladder shrunk because of the altitude. Furthermore, a small bladder often causes headache and nausea.

No. Just no. Sorry, but no. AMS. AMS. AMS. I'm done.

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Re: 14er newbie - frequent urination while hiking, AMS??

Postby Dancesatmoonrise » Thu Sep 20, 2012 10:20 pm

Medscape wrote:Fluid retention is characteristic of AMS, and persons with AMS often report reduced urination, in contrast to the spontaneous diuresis observed with successful acclimatization. As AMS progresses, the headache worsens, and vomiting, oliguria, and increased lassitude develop.


http://emedicine.medscape.com/article/768478-clinical


The practical answer is, as others have pointed out: Gatorade.

Anecdotally, drinking as much as two to three liters or more on rapid ascent during a daytrip to 14,000 feet may be associated with increased performance and decreased symptoms.

Also something I've been pioneering is an altered respiratory technique which appears to dramatically reduce symptoms of AMS on rapid ascent daytrips to 14k. I would actually like to do a study, and have considered asking for volunteers from this site. Not sure yet of details of study design, but there would be a control and a study group, and probably the use of some type of wriitten questionaire for defining the metric in terms of prior symptoms. Using the technique for a couple of years now, together with the gatorade, has substantially reduced both incidence and severity of AMS symptoms in the setting of 14er dayhikes.

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Re: 14er newbie - frequent urination while hiking, AMS??

Postby MountainMedic » Thu Sep 20, 2012 10:34 pm

Dancesatmoonrise wrote:
Medscape wrote:Fluid retention is characteristic of AMS, and persons with AMS often report reduced urination, in contrast to the spontaneous diuresis observed with successful acclimatization. As AMS progresses, the headache worsens, and vomiting, oliguria, and increased lassitude develop.


http://emedicine.medscape.com/article/768478-clinical


The practical answer is, as others have pointed out: Gatorade.

Anecdotally, drinking as much as two to three liters or more on rapid ascent during a daytrip to 14,000 feet may be associated with increased performance and decreased symptoms.

Also something I've been pioneering is an altered respiratory technique which appears to dramatically reduce symptoms of AMS on rapid ascent daytrips to 14k. I would actually like to do a study, and have considered asking for volunteers from this site. Not sure yet of details of study design, but there would be a control and a study group, and probably the use of some type of wriitten questionaire for defining the metric in terms of prior symptoms. Using the technique for a couple of years now, together with the gatorade, has substantially reduced both incidence and severity of AMS symptoms in the setting of 14er dayhikes.


I love Medscape - good find. It would be awesome to do a study like that. I'm bored shitless stuck down here convalescing, so let me know if you want help trying to set this up. I've been away from academic research for a year or so now, but would love to help. Oh, and BenfromtheEast is currently finishing up a master's in biostats...

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Re: 14er newbie - frequent urination while hiking, AMS??

Postby GregMiller » Fri Sep 21, 2012 6:50 am

MountainMedic wrote:Just to clarify: Ibuprofen is virtually worthless. Acetazolamide works well and acetominophen is decent. Ibuprofen is the third best choice and really does next to nothing. Furthermore, there's some evidence that, while acetazolamide mimics the body's natural adjustment to altitude, ibuprofen counters it. Don't go up there with a bunch of Advil assuming it will solve your problems, cause it won't.


Then what do you make of this study? I know it's only a recent study, so not proven medicine, so I do actually want to know what you think about it.
http://med.stanford.edu/ism/2012/march/altitude.html
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Re: 14er newbie - frequent urination while hiking, AMS??

Postby madbuck » Fri Sep 21, 2012 8:19 am

farcedude wrote:
MountainMedic wrote:Just to clarify: Ibuprofen is virtually worthless. Acetazolamide works well and acetominophen is decent. Ibuprofen is the third best choice and really does next to nothing. Furthermore, there's some evidence that, while acetazolamide mimics the body's natural adjustment to altitude, ibuprofen counters it. Don't go up there with a bunch of Advil assuming it will solve your problems, cause it won't.


Then what do you make of this study? I know it's only a recent study, so not proven medicine, so I do actually want to know what you think about it.
http://med.stanford.edu/ism/2012/march/altitude.html


We've discussed that before in previous threads, and I've been intrigued (although I'm not personally affected).
A great quote from the summary you linked:
“We suggest that availability alone makes ibuprofen an appealing drug for individuals who travel to high altitudes. In addition, ibuprofen was effective when taken six hours before ascent, in contrast to acetazolamide, whose recommendations include that it be started the day before travel to high altitude.”

I'm sold on the strong possibility of ibuprofen, especially in the specific situations we're talking about here. What are we talking about here?

Occasional dayhikes to moderately high elevations with little risk of major injury or death, close to first-class medical care.

It's easy for people in these situations to experiment (or consider experimenting) with relatively little risk, as compared to major vacations/international expeditions where people are more heavily invested in their trip AND the risk may be higher, such that they would pay money to see doctor*, get a Diamox prescription*, pay a little bit more for said prescription (vs. ibuprofen) and start taking it a few days ahead of time, dealing with the (possible) list of side effects. Medical outcomes indeed have social factors as well. The reality is, it costs people money and time, and treatments are based both on a tradeoff of efficacy and convenience, just like prophylactic drugs themselves are a tradeoff against long, slow, steady acclimatization.

(* Or buy it directly in a Latin American pharmacy, e.g.)

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Re: 14er newbie - frequent urination while hiking, AMS??

Postby edhaman » Fri Sep 21, 2012 1:01 pm

Anyone know of any studies on HABE? That's High Altitude Belching Expulsions. Gas has to go somewhere, so why not up?

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Re: 14er newbie - frequent urination while hiking, AMS??

Postby MountainMedic » Fri Sep 21, 2012 1:28 pm

Lots of great questions being raised here. I actually think it would be awesome to have a medical subforum or sticky - something so that those affected by AMS and the likes can get some advice on treatment, or better yet prophylaxis and acclimatization.

The "medical definition" of altitude ranges are as follows, per Auerbach, at least:
-High altitude: 1500-3500 M (4921-11483 ft)
-Very high altitude: 3500-5500 M (11483-18045 ft) <--- What I assume we're discussing, for the most part
-Extreme altitude: >550 M.

Multiple studies have shown that humans cannot acclimate to elevations >20K ft (this figure may differ by study, but the gist stays the same), and that HAPE and/or HACE will develop over time. This is where the true altitude drugs really come into play, and where ibuprofen is (from what I've read at least, unfortunately don't recall where) essentially worthless. Up there, every climbing group should carry a combination of acetazolamide, nifedipine, and/or dexamethasone. I've never been higher than 14.433, unfortunately, so this is just textbook stuff.

Hypoxic ventilatory response (HVR; essentially what I discussed in my first post on this thread) is key in acclimating to altitude. Caffeine, chocolate, and stimulants (anything that increases metabolism, really) increase HVR; alcohol and other depressants decrease it. Physical conditioning has been shown to have no effect on HVR.

HVR in turn does stuff. Here's what I posted earlier explained by Auerbach, he's much clearer than I am and I should have merely found this passage: "Other factors influence ventilation on ascent to high altitude. As ventilation increases, hypocapnia produces alkalosis, which acts as a braking mechanism on the central respiratory center and limits a further increase in ventilation. To compensate for the alkalosis, within 24 to 48 hours of ascent the kidneys excrete bicarbonate, decreasing the pH toward normal; ventilation increases as the braking effect of the alkalosis is removed. Ven- tilation continues to increase slowly, reaching a maximum only after 4 to 7 days at the same altitude (see Figure 1-3). The plasma bicarbonate concentration continues to drop and ventilation to increase with each successive increase in altitude. Persons with lower oxygen saturation at altitude have higher serum bicarbon- ate values; whether the kidneys might be limiting acclimatization or whether this reflects poor respiratory drive is not clear.102 This process is greatly facilitated by acetazolamide (see Acetazolamide Prophylaxis, later)." He doesn't mention the urination here, but the "water follows salt" thing is pretty straightforward, and acetazolamide is often used in hospitals as a diuretic (that is, it increases urination). The most common side effects with acetazolamide are peripheral parathesias (tingling in limbs/digits) and frequent urination.

Sorry. Now back to NSAIDs. First off, we have to look at the numbers in that study a little more carefully. 43% vs 69% suffering from self-reported AMS isn't exactly striking IMHO. A 26% difference is pretty impressive, but further research should include 1) a larger sample size and 2) a non-subjective measurement of AMS. For #2, I would think MRI would be very useful. One highly favored theory of AMS is that a number of hypoxia-induced factors result in a vasogenic edema (brain swelling due to changes in blood vessels), a phenomenon visible on MRI scans. Many of these factors are inhibited by NSAIDs. I don't recall the exact mechanism, but NSAIDs do inhibit prostaglandin synthesis, which may reduce this swelling. It's plausible, but purely speculative, that the brain swelling in AMS causes nausea by putting pressure on the area postrema, a hypothalamic nucleus largely responsible for causing vomiting. So yes, at "high" to "very high" altitudes, it is logical that NSAIDs could help. I was once told by a Denver Health ER doc that using NSAIDs to treat AMS is like "pissing on a bonfire." While the logic and physiology are there, their effect is just so minimal that it's not even worth risking the side effects of renal or GI damage, however slight. I've read elsewhere that aspirin and acetaminophen are more effective than ibuprofen. Personally, I'll take some vitamin I after or during a huge day, but only to prevent muscle soreness the next day.

Unlike acetazolamide, NSAIDs don't aid in acclimation and in cases of mild AMS they won't help with nausea, poor appetite, or dizziness - just headache. There are plenty of drugs out there that treat these symptoms.
-Ondansetron, for example, may relieve nausea, but may exacerbate headaches (it's also very expensive). Other side effects include dizziness and, rarely, transient blindness. In other words, don't screw with it. Its high altitude uses are mostly limited to base camps.
-Benadryl may be used to help relieve dizziness, and is actually quite effective. However, side effects may include a decrease in HVR, which can decrease ability to acclimate.
What I'm trying to get at here is that symptomatic treatment can be dangerous. More often than not, paying attention to one symptom of AMS alone will exacerbate another.

Sorry for the rant.

This excerpt from Harrison's is excellent. It's no Auerbach (I'm a snob), but it's the next best thing out there IMO.
http://www.nepalinternationalclinic.com/downloads/Harrison's%20Online%20-%20Alititude%20Illness%20Basnyat,%20Tabin.pdf

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Re: 14er newbie - frequent urination while hiking, AMS??

Postby GregMiller » Fri Sep 21, 2012 1:51 pm

So (to make sure I have this straight), for the purposes of 14ers, (and understanding that this is not actual medical advice as provided by a doctor for a single patient's conditions, etc etc etc):

a) Ibuprofen is okay to take to possibly prevent AMS (knowing it doesn't do that much, but might do something, and will help with pain and such on the hike).

b) Acetaminophen is preferable (of OTC meds) for non-professional treatment of AMS, combined with getting the person down the mountain.
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Re: 14er newbie - frequent urination while hiking, AMS??

Postby ClayDishman » Fri Sep 21, 2012 1:58 pm

[quote="milan"][quote="Kevo"]

I've been thinking about that but less preasure is not enough to cause so much of it. If we assume that the gas behaves as an ideal gas, then its behavior is described by this equation:
pV=nRT

Yes!!! pV=nRT… from an engineering standpoint finally someone that speaks my language… could we please continue the discussion with more quantifiable means rather than generalities? :-D



All seriousness… this is good stuff, thanks everyone (especially you MountainMedic) for the input.

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Re: 14er newbie - frequent urination while hiking, AMS??

Postby GregMiller » Fri Sep 21, 2012 2:11 pm

ClayDishman wrote:
milan wrote:
Kevo wrote:
I've been thinking about that but less preasure is not enough to cause so much of it. If we assume that the gas behaves as an ideal gas, then its behavior is described by this equation:
pV=nRT

Yes!!! pV=nRT… from an engineering standpoint finally someone that speaks my language… could we please continue the discussion with more quantifiable means rather than generalities? :-D



All seriousness… this is good stuff, thanks everyone (especially you MountainMedic) for the input.


If the change in pressure on the assumed steady mass of gas doesn't account for it, I wonder if there's another source: When you decrease partial pressure of a gas over a liquid of the same chemical composition, mass of the liquid evaporates to form more of the gas and try to balance the partial pressures (this is how astronauts can do spacewalks in spacesuits with an atmosphere of ~4 psi of pure oxygen, rather than 14 psi of nitrogen, oxygen, etc.). I wonder, with the decreasing atmospheric pressure, this isn't decreasing the partial pressure of 'flatulence' within the intestines, driving evaporation of more of the 'liquid' form into a gaseous form, resulting in increased mass, and thus volume, of flatulence being expelled. (and yes, being an engineer is awesome)

Thoughts?
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Re: 14er newbie - frequent urination while hiking, AMS??

Postby summerspirit » Fri Sep 21, 2012 4:04 pm

MountainMedic wrote:I am curious if the original poster experienced a relief in the constant urination once the headache and nausea started. If so, a strong pointer towards your statement (with a sample size of one, unfortunately).


Wow I didn't realize the thread was still going strong haha. To answer your question MountainMedic, I started peeing much more frequently as I descended and it actually continued through the end of the day (once at home I was still peeing quite a lot.) It really didn't go back to 'normal' until overnight/the next day. My headache lasted all night and into the next day/night, but a little bit less intense by the following night. My nausea was very brief, only lasting for about 20-30 minutes starting when we got back to the car and ending after we got on I70. Lying back in my seat made it worse, but sitting up straight I was ok... for whatever reason.

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Re: 14er newbie - frequent urination while hiking, AMS??

Postby Dancesatmoonrise » Fri Sep 21, 2012 9:53 pm

farcedude wrote:
MountainMedic wrote:Just to clarify: Ibuprofen is virtually worthless. Acetazolamide works well and acetominophen is decent. Ibuprofen is the third best choice and really does next to nothing. Furthermore, there's some evidence that, while acetazolamide mimics the body's natural adjustment to altitude, ibuprofen counters it. Don't go up there with a bunch of Advil assuming it will solve your problems, cause it won't.


Then what do you make of this study? I know it's only a recent study, so not proven medicine, so I do actually want to know what you think about it.
http://med.stanford.edu/ism/2012/march/altitude.html


Just from the article in the pop up link, the first question any researcher is going to ask is, was this study statistically significant? The numbers are small. Put another way, the study group (those taking Ib) had a 43% incidence of AMS symptoms. That's success? I think you see what I mean. If they did this with 1000 in each group, there would be better statistical significance. Bottom line interpretation, base soley on this description of a study published elsewhere, would be, Ib may work in some cases.

You might want to look up the March 20 Annals of Emergency Medicine and look at the original article.

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