Term
| what is the mechanism of bladder storage? |
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Definition
| the relaxed/compliant detrusor allows filling. the bladder neck, proximal urethra and periurethral striated muscles contract and the *cerebral cortex suppresses lower brain centers - allowing compliance w/o urgency. |
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Term
| what is the mechanism of bladder evacuation? |
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Definition
| a sensory awareness to void occurs as filling nears detrusor capacity, to which the cerebral cortex responds by sending the command to void. contraction of the detrusor occurs w/simultaneous relaxation of the bladder neck, proximal urethra, and periurethral striated muscles. |
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Term
| what are important aspects of a health history for voiding dysfunction pts? |
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Definition
| evaluate the pt's level of frequency (normal amount 3-5x/day), urgency, dysuria, intontinence, nocturia, and flow. acquire a good systemic hx. inquire about family hx, for ex. DM etc. |
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Term
| what are important aspects of the physical exam in terms of voiding dysfunction pts? |
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Definition
| lower extremity edema, deep tendon/bulbocavernosus reflexes, palpation of abdomen (include bladder distention check), and DRE for prostate and anal sphincter tone. |
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Term
| what innervation is responsible for bladder/detrusor contraction (voiding)? |
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Definition
| parasympathetic (if you inhibit this via anticholinergic - the bladder will relax, is the tx for overactive bladder pts) |
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Term
| what innervation is responsible for contraction of the proximal urethra, bladder neck, and prostate gland muscles (storage)? |
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Definition
| alpha sympathetic. this is responsible for the storage of urine, and *blocking this innervation is tx for an enlarged prostate (relaxes these muscles and improves flow in a pt w/ an enlarging prostate gland) |
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Term
| what type of sympathetic innervation relaxes the bladder/vesical base and contracts the proximal urethra? |
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Definition
| beta sympathetic (minor involvement) |
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Term
| which sphincter is voluntary? |
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Definition
| the striated sphincter, which can voluntarily stop the flow of urine |
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Term
| what can a UTI, bladder outlet obstruction, neurogenic bladder dysfunction result in? |
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Definition
| urinary incontinence or retention |
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Term
| how can urgency, increased frequency, and dysuria result in urinary incontinence? |
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Definition
| this can occur if the pt is unable to find a suitable location to void quick enough |
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Term
| how can urgency, increased frequency, and dysuria result in urinary retention? |
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Definition
| retention may be a result of pain due to bladder distention or dysuria(more common in kids) |
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Term
| can urinary retention lead to urinary incontinence? |
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Definition
| yes, this is referred to as paradoxical or overflow incontinence |
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Term
| what are the urodynamic sequelae associated with a lower UTI? |
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Definition
| sensory and motor urgency. reduced capacity w/stable detrusor. urinary sphincter may spasm, producing increased pressure when voiding (due to inflamed, irritated membranes), and increasing amount of residual urine (depends on degree of spasm or inflammation) |
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Term
| what are the urodynamic sequelae associated with bladder outlet obstruction? |
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Definition
| sensory and motor urgency. reduced cystometric capacity. increased urethral pressure at rest and increased detrusor pressure w/voiding (muscle is enlarged - like hypertrophy in the heart). increasing residual depending on the degree of obstruction and detrusor decompensation. |
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Term
| what % of pts w/bladder outlet obstruction have detrusor hyperactivity? how many of these pts will experience relief w/the hyperactivity after obstruction is removed? |
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Definition
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Term
| what is the etiology of urinary retention? |
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Definition
| *bladder outlet obstruction: secondary to enlarged prostate, stenosis of vesical neck/urethra and spasm/dysenergia of the external urinary sphincter. *detrusor atonia: secondary to neuropathy (DM), chronic overdistention, sacral cord disease/injury, anticholinergic or alpha agonist-like medication. |
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Term
| what is external urinary sphincter dysenergia? |
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Definition
| inappropriate contraction of the striated muscle of the bladder - often occurs in MS, spinal cord injuries to upper spine (cervical, thoracics) |
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Term
| what are the changes which occur following outlet bladder obstruction? |
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Definition
| hypertrophy of the detrusor - trabeculation and cellule formation of the detrusor (thickening), formation of vesical diverticulum (between trabeculae), formation of bladder calculi, and hydronephrosis |
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Term
| what is the epidemiology of urinary incontinence? |
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Definition
| prevalance increases w/age and more males are affected as they age |
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Term
| what are the different types of urinary incontinence? |
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Definition
| urge, stress, paradoxical/overflow (not true incontinence), mixed (combination stress/urge), functional (physical/cognitively impaired), ureteral ectopia (rare anomaly where the ureter opens up beyond the sphincter area - need sx), and a fistula (connection between bowel/vagina - need sx) |
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Term
| what are common causes of urge incontinence? what is urge incontinence? |
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Definition
| *UTI (most common), overactive bladder (2nd most common - unstable detrusor, neurogenic dysfunction), bladder outlet obstruction, and/or bladder calculus. *urge incontinence occurs b/c pressure in the bladder is greater than the urethral closing pressure.* there are 2 kinds (wet/dry) of this strong sensation to void. |
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Term
| what is stress incontinence? what are the different types? |
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Definition
| stress incontinence occurs when intraabdominal pressure is greater than urethral closing pressure *w/o sensation to void*. types I and II are due to *hypermobility of the urethra and bladder neck in females. type III is due to a *decrease in sphincter tone/injury/deficiency. chronic urinary retention can lead to stress incontinence (paradoxical). *acute detrusor overdistention can also lead to stress incontinence - happens when intraabdominal pressure is greater than urethral closing pressure without sensation to void, like w/cough, sneeze, laugh, jump, etc. (the lack of sensation to void is what separates stress from urge incontinence) |
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Term
| what is paradoxical incontinence? |
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Definition
| due to pressure as when the bladder is filled totally to capacity (as happens w/BPH) and pts do not void due to lack of awareness/denial or atonic or chronically obstructed bladder (lack of sensation to void). intraabdominal pressure eventually is great enough that urethral holding pressure gives way to urine flow. |
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Term
| what are conditions in children which can affect urinary bladder function? |
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Definition
| maturation lag enuresis, tumor, aneurysm or A/V malfuction, trauma, or hydrocephalus |
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|
Term
| what are conditions in adults which can affect urinary bladder function? |
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Definition
| dementia, cerebral vascular disease (strokes - very common), parkinsonism, MS, brain tumor, or trauma |
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Term
| what are conditions of the spinal cord affecting bladder function? |
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Definition
| trauma (MVAs/gunshots), MS, amytrophic lateral sclerosis, herniated disk (sometimes w/o pain), tumors, inflammatory disease (guillain-barre, anything that impacts L4-S3), myelodysplasia and other anomalies (spina bifida, etc) |
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Term
| what are conditions of the peripheral nervous system affecting bladder function? |
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Definition
| DM, trauma, pelvic sx, guillain-barre, hypothyroidism, alcoholism, and sacral agenesis |
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Term
| how can problems with the cortex and lower centers of the brain affect bladder function? |
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Definition
| problems with the cortex and lower centers of the brain can lead to hyperreflexia - producing urgency and urge incontinence |
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Term
| how can problems with the just the lower centers of the brain affect bladder function? |
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Definition
| problems with just the lower centers of the brain can produce occasional atony |
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Term
| does brain dysfunction usually affect normal sphincter physiology? |
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Definition
| not usually - b/c dyssynergia is hard to tx |
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Term
| what are the possible effects on bladder function due to cervical and thoracic spinal cord injury? |
|
Definition
| detrusor hyperreflexia (urgency and urge incontinence) and sphincter/detrusor dyssynergia (urgency, urge incontinence, increasing amounts of residual urine, urinary retention, and paradoxical incontinence - can give the signs and symptoms of bilateral hydronephrosis and renal failure) |
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Term
| what are the possible effects on bladder function due to lumbar and sacral spinal cord injury? |
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Definition
| if at the level of the reflex arch, possible detrusor atonia/hyperreflexia - but not dyssynergia |
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Term
| how can damage to peripheral nerves affect bladder function? |
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Definition
| damage to peripheral nerves may produce detrusor atonia |
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Term
| what medications may affect bladder function? |
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Definition
| anticholinergics, decongestants, alpha/beta blockers, alpha agonists, antidepressants, and tranquilizers |
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Term
| what is a cystometrogram (CMG)? |
|
Definition
| a bladder test which evaluates the detrusor function - records the response of the detrusor and sphincter to bladder filling (can also subtract the intraabdominal pressure to get the true bladder pressure at the same time) |
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Term
| what is overactive bladder referred to as if neurologic problems are found to be involved? |
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Definition
|
|
Term
|
Definition
| this records the volume and rate of flow - which can tell you if there is problem w/obstruction or atonicity |
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|
Term
| what is normal bladder capacity? |
|
Definition
|
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Term
| what are general considerations for voiding dysfunction tx? |
|
Definition
| *obstruction should be relieved if present, if voiding dysfunction persists - urodynamic evaluation and pharmacotherapy should follow. *a UTI must be treated before urodynamic and urologic evaluation can be carried out. *if only neurogenic voiding dysfunction is present, pharmacotherapy should be instituted and a neurologic evaluation should be carried out. |
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Term
| what is tx for an atonic detrusor? |
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Definition
| cholinergic medication (bethanechol), need to increase parasympathetic stimulation, but this is best treated with intermittent catheterization. |
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Term
| what is tx for an overactive/unstable bladder? |
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Definition
| anticholinergic medication (oxybutynon , tolterodine often work) or intravesical detrusor injection of botox |
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Term
| what is tx for striated sphincter spasm or inappropriate contraction - dyssynergia? |
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Definition
| intramuscular botox, alpha blocking (prazosin, tamsulosin) is not that effective b/c it only affects smooth muscle |
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|
Term
| how is sphincter weakness treated? |
|
Definition
| alpha agonists (ephedrine) may help w/this |
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|
Term
| how is urinary retention due to outlet obstruction treated? |
|
Definition
| sx: TURP (transurethral resection of prostate), TUIP, and DVIU. medical: alpha sympathetic blocking agents, 5 alpha reductase (AR) inhibitors |
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|
Term
| how is urinary retention due to detrusor atonia treated? |
|
Definition
| sx: widening of bladder outlet. medical: bethanachol along or w/alpha sympathetic blocking agent - *intermittent catheterization is tx of choice. |
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|
Term
| what is tx for detrusor overactivity (most common)? |
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Definition
| treat etiology (ie UTI), pharmacotherapy (oxybutynon, tolterodine, other anticholinergics and/or imipramine an antidepressant), botox if refractory, behavior modification, and last resort: sx (neuromodulation of spinal cord/peripheral nerves or bladder augmentation/denervation) |
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|
Term
| what are the different modalities of tx for stress incontinence in females? |
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Definition
| conservative: alpha sympathetic agonists, serotonin release inhibitors, perineal exercises (kegel), and behavior modification. sx: if significant and can be accompanied by periurethral injection of collagen to bulk up area. |
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|
Term
| what are the different modalities of tx for stress incontinence in males? |
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Definition
| conservative: alpha sympathetic agonists, serotonin release inhibitors, perineal exercises (kegel), and behavior modification - usually don't work. sx: periurethral injection of collagen, *sling procedure (if not severe), and *artificial urinary sphincter (if severe and 2ndary to radical prostatectomy - very effective) |
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Term
| when should a permanent catheter be used? |
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Definition
| when all else fails. a supravesical diversion is usually preferable to a catheter. permanent catheters can cause stones, recurrent infections, and fistulas. |
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