11.Urinary Dysfunction 2 Pediatrics, Neurologic, Male Flashcards
What is neurogenic bladder (NGB)?
Lower urinary tract dysfunction caused by nervous system lesions or trauma that can be life threatign if not managed
What are some conditions associated with neurogenic bladder?
- Spina bifida
- Parkinson’s disease
- Multiple sclerosis (MS)
- Spinal cord injury (SCI)
What are common symptoms of urge urinary incontinence (UUI) in people with NGB?
- Increased urinary frequency
- Urgency
- Leakage, preceded by a sudden urge to void
due to distored detrusor pressure and trouble regulating emptying
What psychological effects can UUI have on individuals?
- Depression
- Embarrassment
- Social withdrawal
- Low self-esteem
What are the complications associated with surgery for UUI for NGB?
Surgery has complications and is expensive
What was the outcome of comparing electrical stimulation to PFMT in UUI due to multiple sclerosis?
Significant reduction in UUI symptoms with NMES and IVES versus PFMT
What was the findings for PFMT routine for UUI due to stroke?
insignificant reduction in daytime voiding frequency for PFMT vs no tx
- Low quality evidence
What were the findings of electrical stimulation versus no treatment on UUI due to stroke?
Significant effect with good study methodology on UUI symptoms measured with OAB-V8 and bladder diary
What was the quality of evidence regarding BT’s effect on UUI in Parkinson’s disease?
insignificnat effect, Quality of evidence was low.
What significant effect did TTNS have for people with Parkinson’s disease?
Significant improvement in QoL
parameters: 5 to 12 weeks, a frequency of 10 Hz at an intensity of 200 µs, and a duration of 20–30 min.
What are the NICE guidelines recommendations for PFMT?
PFMT is recommended for NGB when voluntary pelvic floor muscle contraction is preserved
what Hz should be used with IVES for NGB
IVES at frequencies below 12 Hz is suggested for beneficial effects,67 as frequencies below 12 Hz stimulate the pudendal nerve, reducing involuntary detrusor contractions
What are the NICE guidelines recommendations for PFMT with UUI ?
perform a voluntary contraction of the pelvic floor muscles, avoid pelvic floor relaxation, until the urination urge is suppressed- known as the ‘guard reflex’
What is required for PFMT according to NICE guidelines?
Perform a voluntary contraction of the pelvic floor muscles for a minimum of 3 months, with at least eight contractions three times per day
What were the conclusions regarding electrical stimulation for multiple sclerosis?
Electrical stimulation (IVES and NMES) is beneficial for decreasing the symptoms of UUI
What were the conclusions regarding electrical stimulation for stroke?
Electrical stimulation (NMES and TENS) was also found to be beneficial for reducing the symptoms of UUI
What were the conclusions regarding TTNS and BT for Parkinson’s disease
TTNS & BT bladder training were able to improve QOL in people with NGB due to Parkinson’s disease
What remains uncertain regarding PFMT and BT’s effects on UUI?
Specific effects of PFMT and BT on UUI remain uncertain
What potential future intervention is suggested for exploration?
TMS to be explored next
What treatment was found to be more effective than placebo in decreasing the number of daily voids in patients with PD?
Anticholinergics
No significant difference from baseline was found for incontinence episodes and nocturia.
What was the effect of Mirabegron compared to placebo in patients with MS?
More effective in increasing cystometric capacity
No significant difference was observed for symptom scores and bladder diary parameters.
What treatment showed effectiveness in decreasing the number of nocturia episodes compared to its sham-control for NGB ?
TTNS
No significant changes of OAB symptom scores were reported.
What was the outcome of PFMT compared to conservative advice for NGB?
More effective in decreasing the ICIQ symptom score
The number of incontinence episodes was not significantly different between groups.
What was the conclusion regarding the efficacy of the treatments considered for NGB?
Moderate efficacy without proving the superiority of one therapy over the others. Combination treatment using different pharmacological and non-pharmacological therapies could achieve the best clinical efficacy.
Fill in the blank: Anticholinergics were more effective than placebo in decreasing the number of daily voids in patients with _______.
PD
True or False: Combination treatment using different therapies could achieve the best clinical efficacy.
True
What type of bladder treatment was shown to be more effective than sham-control in reducing nocturia in NGB?
TTNS
What is the primary benefit of PFMT over conservative advice for NGB?
Decreasing the ICIQ symptom score
What are considerations for male prevalence and triage of first contact PFD complaints in male pts referred to a pelvic care centre ?
- Dysfunctions appeared independent of each other except constipation having a correlation with voiding dysfunction and sexual dysfunction
- 1 of 7 pts referred to PCC with 1 indication saw at 2-3 specialists
- voiding concern was #1 concern of those listed
- Multidisciplinary approach is good
- Pts may not mention complaints that are not asked about
What is Uroflowmetry?
A non-invasive test that measures the rate and pattern of urine flow during voiding
The patient is asked to urinate into a special toilet or device connected to a uroflowmetry machine that measures the rate of urine flow (flow rate). The patient is instructed to void normally, and the device records the time it takes to empty the bladder and the flow rate during urination.
Provides insights into bladder function and potential obstructions
What does post-void residual (PVR) urine volume indicate?
The amount of urine remaining in the bladder after urination. amount of remaining urine is measured using an ultrasound or catheterization. A bladder scanner or catheter is used to determine the post-void residual volume
Assessed to evaluate bladder emptying efficiency
What is the purpose of Cystometry?
To measure bladder pressure and volume during filling. Tests ability to hold urine for OAB
* The patient’s bladder is filled with a sterile liquid (usually saline) through a catheter inserted into the bladder while pressure sensors are placed inside the bladder and rectum. The patient is asked to report sensations as the bladder fills, and measurements are taken of bladder pressure, capacity, and compliance
Assesses bladder compliance, capacity, and sensation
What does a Pressure-flow study evaluate?
Detrusor muscle function and identifies potential obstructions.
* filling the bladder through a catheter while simultaneously measuring the pressure in the bladder and the urine flow rate during voiding. The patient is asked to void while the measurements are taken, often using a pressure catheter in the bladder and another device to measure urine flow
Measures bladder pressure and urine flow rate during voiding
What is assessed in the evaluation of urethral function?
The urethra’s ability to maintain continence and facilitate voiding
* his may involve various tests, such as urethral pressure profilometry, where a catheter with a pressure sensor is inserted into the urethra to measure the pressure along its length. Another method is the Valsalva maneuver, where the patient is asked to cough or strain to assess urethral resistance during increased intra-abdominal pressure.
Often involves tests like urethral pressure profilometry
What does urethral pressure measurement quantify?
The pressure along the length of the urethra
Assesses sphincter function and identifies areas of weakness or obstruction
What is the abdominal leak point pressure (ALPP)?
The minimum bladder pressure at which urine leakage occurs during increased abdominal pressure
* patient is asked to cough or strain while a catheter is placed in the bladder, and the pressure at which urine begins to leak is measured. This test is typically performed with a full bladder, while increasing abdominal pressure is applied.
Used to assess urethral resistance and continence
What is the purpose of the Pelvic Floor Distress Inventory-20 (PFDI-20)?
Evaluates the severity of pelvic floor disorders and their impact on quality of life.
MCID: A change of 45 points indicates a clinically significant improvement.
What is the purpose of the Pelvic Organ Prolapse Distress Inventory-6 (POPDI-6)?
Assesses distress related to pelvic organ prolapse symptoms.
MCID: A change of 10 points signifies a meaningful improvement.
What is the purpose of the Urinary Distress Inventory-6 (UDI-6)?
Measures distress from urinary symptoms.
MCID: A change of 10 points indicates a clinically important improvement.
What is the purpose of the Pelvic Floor Impact Questionnaire-7 (PFIQ-7)?
Assesses the impact of pelvic floor disorders on daily activities and quality of life.
MCID: A change of 10 points reflects a meaningful improvement.
What is the purpose of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12)?
Evaluates sexual function in women with pelvic floor disorders.
MCID: A change of 5 points indicates a clinically significant improvement.
What is the purpose of the Global Pelvic Floor Muscle Strength Scale (GPFMSS)?
Assesses the strength of pelvic floor muscles.
MCID: A change of 1 point signifies a meaningful improvement.
What is the purpose of the Incontinence Impact Questionnaire-7 (IIQ-7)?
Measures the impact of urinary incontinence on daily life.
MCID: A change of 10 points indicates a clinically important improvement.
What is the purpose of the King’s Health Questionnaire (KHQ)?
Assesses the impact of urinary incontinence on quality of life.
MCID: A change of 10 points reflects a meaningful improvement.
What is the purpose of the Pelvic Floor Muscle Endurance Test (PFMET)?
Evaluates the endurance of pelvic floor muscles.
MCID: A change of 10 seconds indicates a clinically significant improvement.
What is the purpose of the Pelvic Floor Muscle Strength Test (PFMST)?
Assesses the strength of pelvic floor muscles.
MCID: A change of 1 point signifies a meaningful improvement.
McGill Pain Questionnaire (MPQ):
Purpose: Assesses the quality and intensity of pain.
MCID: A reduction of 1.5 points on the MPQ Short-Form is considered a clinically significant improveme
Female Sexual Function Index (FSFI):
Female Sexual Function Index (FSFI):
Purpose: Measures sexual function in women across six domains.
MCID: A change of 1.3 points in the total FSFI score is considered a clinically significant improvement
Female Sexual Distress Scale (FSDS):
Purpose: Assesses sexual distress in women.
MCID: A change of 6 points on the FSDS is considered a clinically significant improvement.
Pelvic Pain and Urgency/Frequency (PUF) Questionnaire:
Purpose: Evaluates symptoms of interstitial cystitis/bladder pain syndrome.
MCID: A change of 6 points on the PUF score is considered a clinically significant improvement
What is a first degree tear?
Injury to perineal skin and/or vaginal mucosa
This type of tear is the least severe and involves only superficial structures.
What characterizes a second degree tear?
Injury to perineum involving perineal muscles but no anal sphincter
This type of tear is more extensive than a first degree tear.
Define a third degree tear.
Injury to perineum involving the anal sphincter, comes in 3 grades: A, B, C
This tear is classified into three subcategories based on the extent of the injury.
What does a 3A third degree tear indicate?
<50% thickness of external anal sphincter torn
This classification denotes a partial tear.
Describe a 3B third degree tear.
> 50% thickness of external anal sphincter torn
This indicates a more severe partial tear.
What is a 3C third degree tear?
External and internal sphincter torn
This is the most severe category of third degree tears.
What defines a fourth degree tear?
Tearing of EAS and IAS and anorectal mucosa
This is the most severe type of perineal tear.
What is a botton hole tear?
Obstetric rectovaginal perforation. Injury of anal mucosa and vaginal epithelium without involvement of the anal sphincters
Also known as a buttonhole tear.
What is a cloacal defect?
Confluence of anus and vagina with no perineum to divide the two
This is a congenital defect.
What is an iatrogenic childbirth related postpartum fistula?
Fistula directly due to inadvertent injury to urinary/colorectal tract during operative delivery
This type of fistula is caused by medical intervention.
Define mixed obstetric iatrogenic fistula.
Fistula related to operative delivery for prolonged obstructed labor
This type can occur from complications during delivery.
What is a fistula in-ano?
Abnormal connection between the anal canal epithelium and skin epithelium
This condition can lead to complications like infection.
What does the Fenton’s procedure accomplish?
Increases genital hiatus and widens introitus by excising scar tissue and/or area of constriction at vaginal entrance
This procedure is often performed to improve vaginal function.
Describe the Z plasty procedure used to treat introital stenosis.
Central incision along constriction and 2 lateral incisions at angle of 60 degrees to form a Z.
This surgical technique helps to alleviate narrowing.
Can PFMT help with SUI? UUI?
Yes , PFMT may be more effective than no treatment. May have more of an effect than UUI
What percentage of older women have urinary incontinence (UI)?
1 in 3 older women
This statistic highlights the prevalence of UI among older women.
What are risk facotrs for Urinary incontince in woman
- Age – increases at 50 stabilizes at 65 and then increases.
- Race/ ethnicity Stress UI lower in African-Americans and Asians compared to whites.
- Childbirth – vaginal delivery maternal age in fetal weight.
- Oral hormone therapy- conjugated estrogens along or combo with medroxyprogresterone
- BMI - each 5 units increases by 60%
- cognitive impairment
- Mobility impairment
- Diabites
- Hysterectomy- conflicting data
- Menopause (surgical) natural may be protective
- having UI in past year > leads to developing monthly occurances
What are some consequences associated with urinary incontinence in older women?
- Increased social isolation
- Falls
- Fractures
- Admission to long term care facilities
These consequences can significantly impact the quality of life for older women.
What factors should be assessed during the exam history portion of urinary incontinence?
- Type
- Severity
- Duration
- Burden
- Modifiable factors
These factors help in tailoring appropriate treatment plans.
What is the ICIQ-UI SF?
A 3 item questionnaire used to classify urge and stress incontinence
It has a sensitivity of .75 and .86, and specificity of .77 and .6.
What is the initial management of urinary incontinence based on?
History and urinalysis
does urlianysis really matter?
This foundational assessment guides further treatment.
What are some behavioral treatments for urinary incontinence?
- Bladder diary
- Scheduled voiding
- Delayed voiding
- Pelvic floor muscle training (PFMT) (no diff in outcomes for wth or wihtout ES)
- Stress and urge management techniques
Behavioral therapies are often the first line of treatment.
What is the goal of pelvic floor muscle training (PFMT) in stress urinary incontinence (SUI) vs UUI?
SUI- Increase strength and structural support
UUI- conscious pelvic floor muscle contraction, urge suppression techniques
This involves using pelvic floor muscles consciously to close the urethra during SUI activities.
What is the effectiveness comparison between medications and behavioral therapy for urinary incontinence UI?
81% reduction with behavioral therapy vs 69% with medications
This suggests that behavioral therapy may be more effective.
What do antimuscarinic medications do?
Block acetylcholine induced stimulation of postganglionic muscarinic receptors on detrusor smooth muscle
This action helps manage bladder contractions.
Which antimuscarinic medications undergo first-pass hepatic metabolism?
- Oxybutynin
- Arifenacin
- Tolterodine
- Solifenacin
These medications are processed by the liver before entering systemic circulation.
What is the role of estrogen in treating urinary incontinence?
Improves frequency, nocturia, urgency, incontinence, and bladder capacity in postmenopausal women
Hormonal therapy can significantly alleviate symptoms.
What is the recommended care for pessaries?
Clean and reinsert every 4-6 weeks
Pessaries are used for prolapse and stress urinary incontinence.
What is PTNS and its treatment duration for urinary incontinence?
Neuromodulation through projections from post tibial nerve to sacral nerve plexus, lasting 30 mins 1x/week for 12 weeks 3rd line tx
PTNS stands for Percutaneous Tibial Nerve Stimulation.
What is a potential side effect of Botox injections for urinary incontinence?
May cause urinary retention and risk of UTI - 3rd line treatment
Botox is not FDA approved for UI but has Level A evidence for its use.
What surgical option is available for stress urinary incontinence?
Midurethral sling 3rd line
This procedure provides support for the urethra.
What special considerations should be taken for patients with cognitive impairment regarding UI urinary incontinence treatment?
- Rule out constipation
- Simplified behavioral program for mild CI
- Timed voiding
- Prompted voiding from caregiver for severe CI
These adaptations ensure effective management of UI in cognitively impaired patients.
True or False: Cholinesterase inhibitors used to improve cognition may precipitate urinary incontinence.
True
This is an important consideration in managing patients with cognitive impairment.
What approach is suggested for the treatment of urinary incontinence?
Stepwise approach:
1 review goals of incontinence treatment and patient preferences
2. identify risk factors and treat modifiable factors
3. trial of behavioral treatment for reinforced during 4- 6 weeks for 1 t-2 visits
4. Assess aderance
5. Depending on adherence and symptom level of bother consider further treatments
A gradual, systematic method allows for tailored treatment based on individual needs.
If there is an inadequate response to behavioral treatments for stress incontinence what are further treatment options to consider in sequence
- More intensive behavioral therapy 2. Pessary 3. Surgery
If there is an inadequate response to behavioral treatments for urge incontinence what are further treatment options to consider in sequence
Medication
2. Modification of medication and dosage
3. Continue or intensify behavioral treatments
4. If treatment is still ineffective consider PTNS sacral module lesion Botox as last resort (botox has grade a?)
A patient demonstrates not adherence with behavioral treatments for urinary incontinence what should be done next
Consider screening test for cognitive impairment.
* If positive cognitive impairment screen consider: simplified behavioral program caffeine reduction times avoiding. If severe CI: prompted voiding from caregiver. Cholinesterase inhibitors can be used to improve cognition but can precipitate UI. Use antimuscarinics with caution
What is prolapse?
A falling, slipping, or downward displacement of a part or organ.
What does pelvic organ refer to?
Most commonly refers to the uterus and/or different vaginal compartments and their neighboring organs such as bladder, rectum, or bowel.
Define pelvic organ prolapse (POP).
An anatomical change that may be considered within the range of normality for certain women.
What are the symptoms of pelvic organ prolapse?
Symptoms of downward displacement of pelvic organ.Departure from normal sensation, typically worsen gravity dependent situations noticeable in times of abdomino straining liked defecation. Vaginal symptoms can include complaint of bulge or lump, pelvic pressure, bleeding/discharge, infection. May require splinting or digitation, low back ache. Symptoms can also be at the urinary tract with the sensation of lump at external urethral meatus and complaints of bulge at Anus/rectum
What is the anatomical definition of a sign of POP?
The descent of 1 or more of the anterior vaginal wall, posterior vaginal wall, uterus, or apex of the vagina.
What should the presence of descent in POP be correlated with?
Symptoms.
List the stages of pelvic organ prolapse (POPQ).
- Stage 0: no prolapse
- Stage 1: 1cm above level of hymen
- Stage 2: between 1cm above hymen and 1cm below hymen
- Stage 3: 1cm beyond plane of hymen but everted at least 2cm less than total vaginal length
- Stage 4: complete eversion or eversion at least 2 cm of total length of lower genital tract.
What is uterine/cervical prolapse?
Observation of descent of uterus or uterine cervix.
What does anterior vaginal wall prolapse commonly represent?
Bladder prolapse (cystocele).
What may anterior vaginal wall prolapse occasionally include?
Anterior enterocele (hernia of peritoneum and possibly abdominal contents).
What is posterior vaginal wall prolapse commonly known as?
Rectocele.
What is observed in vaginal vault or cuff scar prolapse?
Observation of vaginal vault (cuff scar after hysterectomy).
Vaginal Vault Prolapse:
This occurs when the upper part of the vagina (the vaginal vault) sags or drops down from its normal position. It typically happens after a hysterectomy, where the uterus has been removed. Without the support of the uterus, the vaginal vault can collapse.
What is the purpose of a digital rectal-vaginal exam?
To differentiate between high rectocele and enterocele.
A high rectocele is a disruption of posterior vaginal wall tissue while an enteroseal is prolapse of the small intestine into the vaginal canal, typically in the upper portion of the vagina.
What does Q-tip (urethral) testing measure?
Urethral axial mobility at rest and straining.
What parameters are assessed in voiding function due to prolapse?
- Postvoid residual
- Uroflowmetry
- Flow rate
- Voided volume
- Max flow rate (Qmax)
- Flow time
- Avg flow rate (Qave).
What are the types of ultrasound used in prolapse imaging?
- Transabdominal
- Perineal
- Introital
- Transvaginal.
- 3D US
What are some clinical applications of ultrasound in prolapse?
- Bladder neck descent/mobility
- Urethral funnelling
- Post void residual
- Bladder abnormalities
- Urethral abnormalities.
What imaging technique provides fine detail of ligamentous and muscular pelvic floor structures?
Magnetic resonance imaging (MRI).
Has high cost however useful for diagnosis and staging
CT of pelvis can offer what benefits
Accurate visualization of pelvic floor soft tissue and bony structures
Such as attachment of right and left puborectalis
What is the purpose of conservative treatments for POP?
To avoid exacerbation of POP by decreasing intra-abdominal pressure.
List some lifestyle interventions for managing POP.
- Weight loss
- Avoid heavy lifting or coughing
- Ceasing tobacco smoking.
- Pessary support
- PFMT
What types of devices are used in conservative treatment for POP?
- Pessary
- Ring
- Gellhorn
- Donut
- Cuboid
- Self.
What are the components of pelvic floor physical therapy (PT)?
- Physical activity
- Cognitive behavioural therapy
- Bladder training
- Bowel habit training
- Muscle training
- Coordination training
- Biofeedback
- Electrical muscle stimulation.
What are some surgical treatments for POP?
Vaginal repairs with and without mesh, anterior or posterior vaginal approach, Vaginal vault repair with or without uterus consideration. Article 11.9 has good descriptions of each
What is a colpocleisis and a total colpectomy
Colpocleisis - vagina is surgically closed, either partially or completely.Typically performed in women who are postmenopausal, have significant pelvic organ prolapse, and are not interested in preserving vaginal function, sex
colpectomy is the surgical removal of the entire vagina, like for cancer
What is insensible incontinence?
Insensible incontinence occurs when a woman is unaware of how or when the loss of urine happened.
This type of incontinence indicates a lack of awareness regarding urinary control.
What is coital incontinence?
Coital incontinence is the involuntary loss of urine during coitus, which can occur with penetration or orgasm.
This condition may affect sexual function and intimacy.
What is the traditional definition of increased daytime frequency?
Increased daytime frequency is traditionally considered to be more than 7 times during waking hours.
This refers to the number of times a person feels the need to urinate while awake.
What is meant by position dependent micturition?
Position dependent micturition refers to the need for specific positions, such as leaning forward, backwards, or semi-standing, to empty the bladder spontaneously.
This can indicate underlying issues with bladder function or pelvic floor stability.
Anorectal malformation relation to constipatio
Contributes to children with severe constipation and requires about management program. Enema and laxative trials during bowel management week can be considered. Other primary diagnoses for constipation can be functional constipation rectal prolapse and hirchsprungs disease
What is Hirschsprung disease in the context of pediatric bowel management?
Hirschsprung disease - nerve cells missing from large intestine
Bowel management week
Can include nutritional advice, hydration status, high-fiber diet, behavioral changes such as timed voiding, and medication’s/laxatives, stress management
What is the prevalence of idiopathic constipation in pediatrics?
As high as 30%
followign laxitive or enema tx with bowel managmeent week, What percentage of patients eventually had surgery to aid bowel management?
33%. This included sx like antegrade clonic enema (ACE), resection with ACE, and diverting stoma
How many patients on enemas underwent additional BMW for a laxative trial?
60 patients. Even after enema treatment some patients had to go for additional laxative trial
True or False: Success rates were affected by primary diagnosis or treatment regimen of those seeking care for severe constipation with bowel management week of enema versus laxative
False. There is no difference between enema versus laxative
Based off the study for reliability of PFMEMG testing what can be determined for healthy woman max volitional contraction for healthy woman and SUI woman
In healthy woman MVC had high reliability, and in woman with SUI MVC average high reliability. Weak woman values of rest average values had high reliability. The study had high standard errors of measure and min. differnces. Was attributed to a public for contraction of five seconds and pour derecruitment on test.
What is the relationship between load transfer and stress urinary incontinence?
Stress urinary incontinence may result from failed load transfer through the pelvis.
How is the ASLR test related to bladder movement?
Bladder movement occurs with a SLR test and Decreased descent of the bladder when compression is applied to the pelvis.
What are the components of the integrated model of function?
- Form closure (structure)
- Force closure (forces produced by myofascial action)
- Motor control (specific timing of muscle action/inaction during loading)
- emotions
What is the closed pack position of the SIJ?
Full nutation (posterior tilt).Notation of sacrum occurs bilaterally when lumbopelvic spine is loaded
Which muscles are considered local stabilizers for effective force closure?
- Deep fibres of multifidus
- Transversus abdominis
- Pelvic floor muscles
- Diaphragm
What systems are necessary for continence?
- Urethral support system
- Sphincteric closure system
Describe the passive system in the context of the urethra.
Includes the endopelvic fascia, anchored to the arcus tendineus fasciae.
Effective load transfer by passive and active systems work together for stability
What does the active system of the urethra consist of?
Fascial hammock or sling, primarily the levator ani muscle with Type 1 muscles
Effective load transfer by passive and active systems work together for stability
What is the role of the pudendal nerve?
Part of the “control system”. Innervates the levator ani and controls reflex function between the detrusor muscle and pelvic floor.
Fill in the blank: The garden hose analogy compares the urethra to a _______.
[garden hose].
garden hose (urethra), with water running through it (urine), lying on a trampoline bed (the pelvic floor). Stepping on the hose will block the flow of water if the bed is very stiff and provides an equal and opposite counterforce (functional pelvic floor). If however, the bed is very flexible (i.e. loss of myofascial support), the downward pressure on the hose will cause the bed to stretch and allow the hose to indent the bed. The flow of water will continue uninterrupted
What happens during a cough in healthy continent women?
Anticipatory reflex: striated muscles within the wall of the urethra (intrinsic) contract prior to any pressure received by the bladder and these muscles are also comprised of type 1 fibres Pressure in the urethra increases approximately 250 ms before any increase in bladder pressure.
What can lead to stress urinary incontinence?
- Loss of anatomical integrity
- loss of Neurophysiological dysfunction of the pelvic floor
- Single major trauma or repetitive minor trauma
- Inefficient load transfer strategies
- prolapse due to less lordosis?
What findings were observed in women with uterovaginal prolapse?
Significantly less lumbar lordosis and a less vertically oriented pelvic inlet.
True or False: Continent groups exhibited more bladder neck movement during a cough.
False.Suggest movement of urethra is not what determines continent status. Contact groups exhibited less movement during cough however stiffness value was the greatest in the Nellie Paris common group. Greater stiffness is beneficial
What is the significance of pelvic floor muscle tone for continence?
Optimal function requires constant low levels of tone with increased activation in anticipation of load.
What is a paravaginal defect?
A separation in the endopelvic fascia that can disrupt tissue stiffness.
What does the integrates treatment model suggest about compression and control?
There may be too much or too little compression, or issues with hypertonicity or poorly controlled neutral zone of motion.
What are the treatment principles when decompression is necessary?
- Correct osseous alignment
- Restore optimal force closure and motor control
- Provide external support if necessary
- Restore articular mobility/stability.
Fill in the blank: According to the integrated therory model Loads are transferred more effectively through joints that are properly _______.
[aligned].
What is the importance of joint alignment According to the integrated therory model?
Proper alignment shares compression and tension forces, preventing excessive stress and tissue breakdown.
What is the principle of exercise dosage in treatment?
Proper education on exercise perspective is crucial for the unique needs of the patient.Explain proper dosage in education and exercise. *Exercise A does not guarantee the use of muscle a therefore education is needed and need for motor control
What is Overactive Bladder (OAB)?
A symptom syndrome primarily composed of urinary urgency, usually with urinary frequency and nocturia, regardless of the existence of urgent incontinence.
OAB is associated with urinary tract infection, falls, and fractures.
What is Functional Constipation (FC)?
A condition that affects both physical and mental problems.
What embryologic origin do the bladder and intestines share?
They both arise from the embryologic hindgut.
This close relationship is important in understanding bladder and intestinal function.
How does rectal distention influence bladder sensation?
Rectal distention significantly influences the sensation of bladder filling and can cause detrusor overactivity.Detrussor over activity when rectum is distended and not when it is empty
What neural pathways are involved in the crosstalk between bladder and bowel?
Dorsal root ganglia and spinal cord are involved, along with shared neurotransmitters.
This indicates a complex interaction between bladder and bowel functions.
What co-morbidities were reported in the latent FC group?
Diabetes mellitus, hypertension, ischemic heart disease, and hyperlipidemia. these can be found with FC
14.5% had diabetes, 41.4% had hypertension, 12.4% had ischemic heart disease, and 22.8% had hyperlipidemia.
What was a significant association found in latent FC?
Antipsychotic drugs and OABSS ≥ 6 were significantly associated with latent FC.
OABSS ≥ 6 indicates a more severe symptom profile.
What were the independent indicators of moderate to severe OAB?
Diabetes, use of calcium antagonists, use of antipsychotic drugs, and latent FC.
Latent FC was a significant factor related to moderate to severe OAB symptoms.
Is latent FC associated with wet OAB?
Yes, latent FC was significantly related to wet OAB but not to dry OAB.
This indicates different underlying mechanisms for the types of OAB.
What conclusion can be drawn about OAB in patients with latent FC?
OAB is more severe in patients with latent FC, which is a significant predictor of moderate to severe OAB or wet OAB.
Assessing defecation status in OAB patients may be beneficial.
What is the difference between intermittent and continuous urinary incontinence in children?
Intermittent incontinence is more common and occurs in children at least 5 years old, classified as night (enuresis) or day wetting, while continuous indicates anatomical and/or neurological deficits.
What are the classifications of intermittent urinary incontinence in children ?
Intermittent incontinence is classified as:
* Night (enuresis)
* Day wetting
* Primary
* Secondary (after at least 6 months of dryness)
What must be diagnosed and treated before and during incontinence therapy in children?
Constipation
What are the subgroups for nocturnal enuresis?
The subgroups are:
* Monosymptomatic nocturnal enuresis (MNE)- only nocturnal enuresis is present
* Non-monosymptomatic nocturnal enuresis (NMNE) Nocturnal enuresis is accompanied by other LUT symptoms
What are some lower urinary tract (LUT) symptoms that should be documented?
- Increased/decreased voiding frequency
- Daytime incontinence
- Urgency
- Hesitancy
- Straining
- Weak stream
- Intermittency
- Holding maneuvers
- Incomplete emptying
- Post-micturition dribble
- LUT pain
- Drinking habits
- Bowel symptoms
- previosu interventions and physcological aspects
What does a physical exam for urinary incontinence include in children?
Abdominal palpation to rule out:
* Organomegaly
* Bladder distension
* Fecal masses
Inspection of the genital and sacral regions to exclude congenital malformations and cutaneous manifestations of spinal dysraphism (spina bifida).
What is the role of urinalysis in evaluating urinary incontinence in children ?
To exclude urinary tract infection (UTI).
What imaging technique is used to evaluate kidney and urinary tract abnormalities?
Ultrasonography
What can imaging of uroflow measurement identify what are invasive procedures and when should they be used?
Uroflow measurement=identifying dysfunctional voiding
invasive procedures: voiding cystourethrogram (VCUG), urodynamic investigation or spinal cord magnetic resonance imaging (MRI), should be reserved for patients with suspected organic uropathies and neurological problems, or those not responding to first-line treatment
What is urotherapy?
A basic therapeutic strategy for children with incontinence, involving nonpharmacological and nonsurgical interventions.
What are some components of standard urotherapy for children ?
- Education on normal LUT function
- Regular voiding habits
- Voiding posture
- Lifestyle advice on fluid intake and constipation prevention
- Bladder diaries or frequency-volume charts
- Pelvic floor muscle training
- Behavioral modification
- Neuromodulation
What are the two main pathophysiological causes of enuresis in children ?
- Nocturnal polyuria
- Decreased bladder storage during the night
sleep disturbances may play an important role in both
What is desmopressin used for in treating enuresis for children?
To decrease urine production during the night-nocturnal polyuria
night-time polyuria and no bladder overactivity are the best responders
Define prescense of nocturnal polyuria
[urine production exceeding 130 % of the expected bladder capacity (EBC) for a given age]
proposed optimal treatment strategy desmopressin
If decreased bladder storage at night is the pathophysiological cause for enuresis and children what is a recommended solution
choice of the alarm for children with decreased maximal voided volumes.
Combined therapy with desmopressin and the alarm may be effective in those children in whom both mechanisms are at work or overlap
What is alarm therapy in the context of enuresis for children?
A method using a moisture-triggered alarm to condition arousal and increase bladder volume.
Sensor: moisture triggers n alarm connected to device.
sensor can be placed in the child’s underwear or pad near the perineum (a personal alarm) or in a mat on which the child lies (a pad and bell alarm)
curative in 60 % of children through conditioning effects on arousal and/or increasing bladder volume
3 months tx duration
achieved at least 14 consecutive dry nights
Lots of compliance and motivation, need to void after alarm goes off and then re-set alarm
Can be re-introduced if failed with good outcomes afterwards
DAy wettign in children man occur in children due to a variety of causes which include:
OAB, voiding postponement, an underactive urinary bladder (UUB), obstruction and dysfunctional voiding
Other less likely conditions
stress incontinence (occasionally associated with obesity or chronic coughing), vesico- or urethro-vaginal reflux and giggle incontinence
What is the main symptom of an overactive bladder (OAB)?
Urgency
What is a sign of OAB in children
detrusor overactivity when confirmed by urodynamic investigation
Uninhibited detrusor contractions lead to characteristic behavior patterns
Look out for: postponing wetting, such as tiptoeing, forceful leg crossing or squatting with the heel pressed into the perineum
What are antimuscarinic agents used for and what must be ruled out?
To block acetylcholine receptors and inhibit overactive detrusor muscle.Constipation post void residual low voiding frequency dysfunctional voiding need to be excluded due to side effects
What is voiding postponement in children
Child postpones bladder emptying as long as possible and consequently wets his/her underwear due to an uninhibited reflex from an overfilled bladder.
playing computer games or with contemporaries (word used in article but I think they mean time taking tasks like doom scrolling )
May limit due to pain associated with restroom use
main aim of urotherapy is to correct the frequency of micturition, ensure reasonable fluid intake and stop or reverse bladder overdistension
What is underactive urinary bladder in children and the treatment
- decreased voiding frequency and increased bladder volume exceeding 150 % expected bladder capacity usually have UUB
- decreased ability of the detrusor muscle to contract
- confirmed by an urodynamic investigation
- introducing regular voiding and drinking regimes, correcting voiding posture and PFM relaxation. Double voiding is a useful technique when increased PVR is present (post-void residual)
Clean intermittent catheterization
may be necessary if UTI, incontinence and incomplete emptying do not respond to urotherapy.
A standard regimen:5 catheterizations daily (every 2–3 h)
Hydrophilic-coated catheters seem to be a better choice than uncoated ones, particularly in boys
what is dysfucntional voiding
- characterized by staccato uroflow pattern -irregular, fluctuating curve on a uroflowmetry test that indicates a dysfunctional urinary sphincter
- Occurs due to incomplete relaxation of the PFM and sphincters during bladder emptying, may cause overflow incontinence.
- ID if external spiner is at fault, then PFMT is 1st line
what is tx for dysfunctional voiding in children
Urotherapy and muscle retraining successful for majority of patients
normalize bladder emptying and storage
by teaching relaxed voiding techniques.
Fluid and voiding regimes
First teach bladder emptying with a relaxed pelvic floor
Correct position / posture during micturition:
Biofeedback- computer games
what is the Correct position / posture during micturition in children?
straight back with the pelvis in a proper position.
feet need to be supported, hips abducted, and buttocks well-supported.
Trousers and underpants should be pulled well down below the knees, so they do not obstruct urine flow or limit voiding position
what is stress incontinince in children
- involuntary leakage on effort, exertion, coughing or sneezing
observed during increasing intra-abdominal pressure due to inadequate urethral closure pressure - relatively rare in neurologically intact children
- Seen in chronic cough, such as that associated with cystic fibrosis or obesity.
In children, wetting during increased intra-abdominal pressure is more likely to be due to masked OAB or an over-distended bladder
what isVesico-vaginal reflux
typically occurs in prepubertal girls
urinary stream is directed towards the vagina because of urethral opening position, entrapment of urine by the labia or poor toilet posture and compression by the thighs
* Leakage happens later, frequently during physical activities when urine, entrapped in the vagina, leaks out
* Hallmark sign: post-void wetting
* possible risk factor for UTI
Posture: Instructed on how to spread the labia, adjust thighs, sit backwards on toilet
* TX Treatment of labial adhesions, meatal anomalies and attention to diet (if overweight) may also be helpful
What is giggle incontinence?
Involuntary, complete bladder emptying during laughing.
Fill in the blank: The main aim of urotherapy is to correct the frequency of micturition, ensure reasonable fluid intake, and stop or reverse _______.
bladder overdistension
True or False: Stress incontinence is common in neurologically intact children.
False
What is dysfunctional voiding characterized by?
A staccato uroflow pattern.
What is the recommended treatment for dysfunctional voiding?
Urotherapy and muscle retraining.
What is the first line pharmacological treatment for enuresis?
Desmopressin
What can be a risk factor for urinary tract infections (UTI) in children?
Vesico-vaginal reflux
What is the proposed treatment for extraordinary daytime frequency in children?
Fluid monitoring of type and amount, including caffeine.
void at least once hourly, and average voided volumes are <50 % of EBC
Managed with fluid monitoring of type and amount (caffeine)
What is interstitial cystitis (IC)?
A chronic pain syndrome and chronic inflammatory condition predominant in females that leads to pain, discomfort, and tenderness in the bladder and neighboring pelvic region.
What are the two types of interstitial cystitis?
Ulcerative and non-ulcerative types.
What are common symptoms of interstitial cystitis?
- Urinary urgency and frequency
- Sleep disruption
- Nocturia
- Pelvic pain (vulvar, suprapubic, pubic, vaginal)
- IBS
- Fibromyalgia
- chronic Fatigue
What factors can exacerbate IC symptoms?
- Bladder filling
- Bleeding
- Presence of ulcers
- Menstruation
- Intercourse
What is the prevalence ratio of interstitial cystitis in men to women?
1:4.
What are some comorbid diseases associated with interstitial cystitis?
- IBS
- Vulvodynia
- Chronic pelvic pain
- Endometriosis
- Fibromyalgia
- Chronic fatigue syndrome
- Overactive bladder
- Bladder cancer
2x more likely to develop neurological diseases, rheumatological diseases and mental illnesses
True or False: Interstitial cystitis is likely overdiagnosed.
False.
What is the glycosaminoglycan theory in relation to IC?
Impairment of the glycosaminoglycan molecule layer leading to an imbalance in urine storage, resulting in frequent urination, reduced capacity, and pelvic pain.
What does the microbial/infection theory state about IC?
Experts have excluded infection of the lower urinary tract as a symptom or diagnostic criterion of IC/PBS.
What role do mast cells play in interstitial cystitis?
Damaged or dysfunctional urothelium activates mast cells, which may induce inflammation, pain, vasodilation, fibrosis, and smooth muscle contractions.
What is neural upregulation in the context of IC/PBS?
Dysfunctional or disrupted signaling pathways between organs and the nervous system, which may change the inflammatory response.
Neural upregulation affects: sympathetic nervous system and hypothalamo-pituitary-adrenal axis, sensory innervation,Increased nerve growth factor in bladder tissue, C fiber over expression
What is a potential genetic factor in interstitial cystitis?
More research is needed to determine if any biomarkers can be used in diagnosis.
How might sex hormones influence interstitial cystitis?
Low estrogen levels may impair barrier function, leading to inflammatory and immune activation.
What is a potential link between IC/PBS and women’s health?
IC/PBS could be considered a menopause symptom.
What demographic is interstitial cystitis more severe and common in? How does the progression of ICS change as a woman changes:
Women over 40 years old.
Potential link between IC/PBS and pelvic surgeries prior to symptoms
Premenstrual IC/PBS worsens with progression on menstrual cycle
Pregnancy may postpone onset of IC/PBS
For children with OAB, what can be used as an intervention
Diagnostic for dysfunctional voiding : Increased EMG activity during voiding with staccato voiding pattern on UF-EMG
* Biofeedback can improve strength and endurance
* Increased tonic activity of the external urethral sphincter and PFMs. May lead to chronic tightening and fibrosis of external sphincter and result in turbulent urine flow, urethral instability, and urethritis
What is intermittent incontinence, continuous incontinence and secondary incontinence ?
intermittent incontinence: Incontinence in kids at 5+ years old
continuous incontinence: Constant leakage in even infants or young children
secondary incontinence: Child becomes incontinent after a period of urinary control
What does enuresis refer to?
Nighttime incontinence
Often associated with bedwetting in children.
What is monosymptomatic nocturnal enuresis (MNE)?
No LUTS, enuresis only
Indicates that there are no lower urinary tract symptoms present.
Define non-monosymptomatic nocturnal enuresis (NMNE).
Enuresis with LUTS
This includes symptoms such as urgency, frequency, or pain.
What is giggle incontinence?
Nearly complete voiding occurs during or immediately after laughing, usually in girls
A rare type of incontinence that is often triggered by laughter.
What is the Pediatric Incontinence Questionnaire (PIN-Q)?
A tool used for evaluating pediatric incontinence
Bristol stoll scale may also be used
Helps in assessing the severity and impact of incontinence on children.
What dietary changes are recommended for managing daytime incontinence in children?
Fiber and fluid intake
Important for maintaining bowel health and reducing constipation.
What is the maximum dose of Miralax for daytime management?
if diet changes are not succesful, use 17g/day.
* 34-51g (2-3 capfuls) 1x daily with sennosides oral laxative once a week can be used for several months
* Down titration begins at 6 months after consistent soft stools, regular BMs and improved radiographs
Miralax is used to treat constipation as part of bowel management.
What is the role of bladder therapy in managing incontinence in children ?
To begin after bowel management
Bladder therapy consits of: Avoid bladder irritants
Voiding schedule
Bladder diary
Education
Biofeedback
Focuses on improving bladder function and control.
What medication is commonly used for oral anticholinergic therapy?
Oxybutynin
Helps to manage overactive bladder by blocking certain muscarinic receptors.
What are the side effects of oxybutynin?
- Dry mouth
- Blurred vision
- Facial flushing
- Headache
- Tiredness
- TI discomfort
- Constipation
- swellign and heat intolerance
anticholinergic
Side effects can vary by individual and dosage.
What is the purpose of Botox in managing incontinence?
Blocks the release of acetylcholine, preventing bladder contraction
Used for detrusor overactivity.
What conditions contribute to nocturnal incontinence?
- Impaired sleep arousal threshold
- Nocturnal polyuria
- Detrusor overactivity
These factors can lead to bedwetting episodes.
What is desmopressin used for?
Antidiuretic effect
Helps reduce urine production at night.
What is the effect of imipramine in managing nocturnal enuresis?
Increases vasopressin release and modifies sleep arousal pattern
A tricyclic antidepressant that also has anticholinergic effects.
What is neurogenic incontinence?
Leakage due to detrusor overactivity or incompetent external urethral sphincter
Often associated with neurological conditions affecting bladder control.
What management strategies are used for anatomic incontinence?
- Surgery to fix ectopic ureter
- Surgery to reconstruct urethra and bladder neck
Aimed at correcting structural abnormalities.
“shorten the penis.” is best effective for which effect on EMG for males
Greatest dorsal displacement of the mid-urethra and SUS activity was achieved with the instruction
“Elevate the bladder” is best effective for which effect on EMG for males
induced the greatest increase in abdominal EMG and IAP.
“Tighten around the anus” is best effective for which effect on EMG for males
induced greatest anal sphincter activity
What was the significant finding regarding self-monitoring of urinary symptoms in parkinsons disease?
It resulted in fewer urinary symptoms in both treatment and control groups
However, only multi-component behavioral training was associated with reduced bother and improved quality of life.
What is hypothesized to cause urinary symptoms in Parkinson’s Disease?
Loss of dopaminergic balance in the basal ganglia and cortical alpha-synuclein pathology
This leads to increased involuntary bladder contractions and loss of recognition of bladder fullness.
What non-motor symptoms of Parkinson’s Disease are closely associated with well-being?
Overactive bladder (OAB), urgency, frequency, nocturia, and urinary incontinence (UI). Urgency, frequency, nocturia are associated with falls which are a cause of increased mortality in pts with PD
These symptoms can impact the quality of life and increase the risk of falls.
What are the potential negative side effects of anticholinergic drugs in Parkinson’s Disease patients?
Cognitive effects, constipation, and dry mouth
Patients with PD are more susceptible to these side effects.
What types of medications were noted for having anticholinergic effects?
Amantadine, trihexyphenidyl, and ethopropazine
These medications can exacerbate urinary symptoms in PD patients.
Did both the treatment and control groups report a difference in weekly urinary incontinence episodes for patients with PD?
No, both groups reported a reduction in episodes with no difference between them. Interventions= PFMT with urge supression fluid management (decrease caffeine, drink 6-8 8oz glasses of fluid daily) and education regarding constipation management
However, the intervention group reported a greater reduction in symptom bother and improved quality of life.
What was the conclusion regarding the effectiveness of self-monitoring for urinary symptoms in PD?
Self-monitoring may lead to clinically significant improvement in urinary incontinence and overactive bladder symptoms
The study suggests the importance of self-monitoring in managing urinary symptoms in PD.
What is unknown regarding cognitive dysfunction (perhaps in those with PD) in relation to behavioral therapy?
The level of cognitive dysfunction that precludes the ability to learn and implement exercise-based behavioral therapy
This remains an area for further research.
What is double incontinence?
Complaint of both anal incontinence and urinary incontinence
This term is newly defined in the context of anorectal dysfunction.
What is coital fecal incontinence?
Fecal (flatal) incontinence occurring with vaginal intercourse
Related to the term ‘Coital fecal urgency’.
Define passive fecal leakage.
Involuntary soiling of liquid or solid stool without sensation or warning or difficulty wiping clean
What is overflow fecal incontinence?
Seepage of stool due to fecal impaction
What does increased daytime defecation refer to?
Complaint that defecation occurs more frequently during waking hours than previously deemed normal by the woman
What is nocturnal defecation?
Complaint of interruption of sleep one or more times because of the need to defecate
Define tenesmus.
A desire to evacuate the bowel, often accompanied by pain, cramping, and straining, in the absence of feces in the rectum
What is coital fecal urgency?
Feeling of impending bowel action during vaginal intercourse
List the Rome III Criteria for functional constipation.
- 1 at least 2 of the following * Straining during at least 25% of defecations
- Lumpy or hard stools in at least 25% of defecations
- Sensation of incomplete evacuation for at least 25% of defecations
- Sensation of anorectal obstruction/blockage for at least 25% of defecations
- Manual maneuvers to facilitate at least 25% of defecations
- Fewer than three defecations per week
- Loose stools are rarely present without the use of laxatives.
- Insufficient criteria for irritable bowel syndrome.
Criteria fulfilled for the last 3 months with symptom onset at least
- Insufficient criteria for irritable bowel syndrome.
What is splinting?
Support perineum or buttocks manually to assist in evacuation of stool content
What is post defecatory soiling?
Soiling occurring after defecation
What are the two types of anorectal pain?
- Inflammatory anorectal pain
- Non-inflammatory anorectal pain
Define anodyspareunia.
Complaint of pain or discomfort associated with attempted or complete anal penetration
What is anal laxity?
Complaint of the feeling of a reduction in anal tone
what are considerations with Anal laxity
Receptive anal intercourse is associated with increased risk of
female sexual dysfunction, female sexual arousal disorder with distress. Repeteted anal intercourse with sexual dysfunction might be due to physiological and/or psychological processes. Physiologic factors could include that: (1) mechanical stimulation of the anus and rectum during anal intercourse increases hemorrhoid risk; (2) women with hemorrhoidectomy have impaired sexual function; and (3) persons with hemorrhoids and not yet had hemorrhoidectomy “are more likely to have abnormal perineal descent with pudendal neuropathy.”
* pudendal nerve dysfunction - could be one mechanism leading to sexual dysfunction, might be the case even without diagnosed haemorrhoids.
* A history of receptive anal intercourse has been shown to increase risk of anal incontinence, rectal bleeding, and anal fissure.
* Unlike dyspareunia (from coitus), it might be normal to experience pain or discomfort during receptive anal intercourse.
What are the grades of hemorrhoids?
- Grade I: bleeding without prolapse
- Grade II: prolapse with spontaneous reduction
- Grade III: prolapse with manual reduction
- Grade IV: incarcerated, irreducible prolapse
What is a perineocele?
Bulge in the perineum associated with herniation of the anterior wall of the rectum
What position is recommended for anorectal examination?
Left lateral decubitus position with hips flexed or dorsal lithotomy position
what should be included in anorectal exam ?
- Perianal sensation: assess S2-4, anal reflex, and perianal sensation
- Digital rectal examination: Gently press into anal canal towards posterior wall and sling of puborectalis- this can overcome the tone of the anal sphincter and allows the finger to straighten and slip into the rectum.
- Palpate hemorrhoids grade II and III; painful assessment may indicate fistula in ano, fissure in ano, infection or pilonidal abscess
- Palpable anal sphincter gap may indicate previous obstetric or surgical damage
- Assess for rectal contents: texture of residual feces, collapsed or ballooned out, impaction?
- Assess for rectal lesions- carcinoma, intussusception or recto vaginal fistua- if a mass is felt, it will often descend with valsalva
What does the digital rectal examination assess?
Resting anal tone, voluntary squeeze of anal sphincter, and palpation for hemorrhoids, voluntary squeeze of anal sphincter and LA muscles- sustained squeeze for 5 sec and involuntary contraction elicited during cough
What is pelvic floor muscle assessment?
Evaluation of tone at rest, strength of voluntary contraction and relaxation, endurance, repeatability, duration, coordination, displacement
Define pelvic floor muscle spasm.
Persistent contraction of striated pelvic floor muscles that cannot be released voluntarily
What is the Bristol stool chart used for?
Assessing stool consistency
little validation. Change in consistency may not represent sufficient sufficient degree of precision for use as a trial/tx end point. May be use outcomes
What is the purpose of a bowel diary?
To track urgency, fecal incontinence, straining, and other bowel habits
best validated and and most widely used tools for IDIOPATHIC CONSTIPATION
Patient assessment of constipation QoL (PAC-QOL) and PAC-SYM-
Outcomes for fecal incontinence grade B
Fecal incontinence QoL scale: GRADE B
Fecal incontinence Severity Index FISI: GRADE B
Cleveland clinic score = wexner score, and the St. Marks score is an adaptation of wexner. These all get 3s.
What does anal manometry assess?
The mechanical strength of the anal sphincters
What is the significance of the IAS
IAS has continuous tonic activity and is responsible for 55-85% of resting anal canal pressure
What is the significance of the EAS
EAS can be assessed during the squeeze and cough manuever. The pressure increment above resting pressure represented EAS function - normal range approximately 60 cmH2O
What is the rectoanal inhibitory reflex (RAIR)?
Relaxation response in the internal anal sphincter following rectal distension
* Drop of at least 25% resting pressure. This is absent in hirschsprungs disease. This reflex underlies the sampling response.
RAIR is elicited by:
During manometry RAIR is elicited by rapid insufflation and disinflation of 50mLs of air into a balloon in the distal rectum
What are sensory measurements in anorectal physiology?
Assessment of distension thresholds and rectal compliance
* Distension is generally assessed by manually inflating an intrarectal balloon at a rate of 5ml/s. Distension threshholds
During ballon rectal testing what is normal range of volume that typically elicits the first sensation of rectal fullness? defecate? max tolerated volume?
12-25ml: normal range of volume that typically elicits the first sensation of rectal fullness
35-65ml: normal range to get the urge to defecate
120-300ml: maximal tolerated volume
When and why would BF be used in constipation of FI
Distension sensitivity testing has been shown to be beneficial for FI to help with biofeedback training to normalize sensory thresholds; identifying poor rectal compliance or rectal irritability
There is no evidence to support use of sensory thresholds for diagnosis and biofeedback training for constipation
What do Pudendal nerve terminal motor latencies (PNTMLs) indicate?
Pudendal N is stimulate at the ischial spine- DOES NOT RELIABLY REFLECT PUDENDAL NERVE DAMAGE. Latencies are normal is they are below 2.2msec
What is defecatory proctology?
Real-time morphology of the rectum and anal canal by injection of a thick barium paste
Describe the algorithm for treatment for fecal incontinence and constipation
Refer to article 11.20 for photos on page 9
What are colonic transit studies used for?
Assessing segmental and total colonic transit time
What can treatment of chronic constipation with dyssynergic defecation in children include?
Focus of pelvic floor physical therapy (PFPT) in pediatric patients
PFPT is a novel intervention aimed at addressing specific functional issues related to defecation.
How can children be diagnosed with constipation and dyssynergic defecation?
Anorectal manometry and balloon expulsion testing
These diagnostic tools assess anal canal function and rectal pressure during defecation.
What is the conclusion regarding pediatric PFPT?
It is a safe and effective intervention for children with dyssynergic defecation causing chronic constipation
Particularly beneficial for children with comorbidities like anxiety and low muscle tone.
What are the current management strategies for childhood constipation?
Laxatives, stimulants, dietary and behavioral interventions, scheduled toileting, valsalva technique
Valsalva technique includes actions like blowing up a balloon while defecating.
How has biofeedback and PFPT been viewed in the adult population with constipation?
Efficacious in treating adults; older studies in children showed no benefit over laxatives alone
Recent advancements include external vs internal sensors to reduce psychological impact.
What age group can benefit from PFMT for chronic constipation?
Children aged 5-18 with chronic constipation not responsive to traditional treatment
Diagnosis of dyssynergia should be confirmed via anorectal manometry.
Define dyssynergia in children.
No relaxation of the anal canal during bear down, insufficient increase in rectal pressure, or failure to expel balloon
These criteria determine the presence of dyssynergia.
How are patients with dyssynergia classified (hypo/hyper sensitive) based on balloon inflation sensitivity?
Hypersensitive (<25 mL) and hyposensitive (>80 mL)
This classification is based on initial sensing of balloon inflation during testing.
What is the recommended PFMT regime for children with dyssynergic defecation?
- at least 3 sessions of PT
- meds as Rx’d
- evaluation of PFM, TrA, and diaphragm
- use of biofeedback via surface electrodes,
- trained in toileting mechanics including engaging TrA and elongating PFM
- encouraged to complete between 3-8 sessions of PF PT weekly or biweekly
What outcomes are reported from PFPT in children?
Decreased straining, decreased fecal incontinence, reduction in medication needed
Control group showed hospitalizations for stool clean-out and surgical interventions.
What is the association between pediatric diastasis recti abdominal (DRA) and muscle tone?
Peds DRA is often associated with low muscle tone
Low muscle tone can complicate functional coordination during defecation.
What emphasis should be placed on muscle coordination in children with constipation?
Dissociation between abdominal muscles and pelvic floor muscles
Focus on abdominal wall strengthening, pelvic floor muscle lengthening, and functional coordination.
What psychological factors can contribute to withholding behavior in children?
Fear and stress of using the toilet
These emotions can perpetuate constipation and avoidance behaviors.
dyssynergic defecation in children can be addressed with
PFMT
This condition is a key focus for alleviating chronic constipation.
