13 - neurogenic bladder/voiding dysfunction Flashcards
where is voiding controlled centrally
pontine micturation center or barrington nucleus
spec fxn of PMC
coordinates detrussor contraction and sphincter relaxation
relay of inflow of urinary tract signals
afferent from lower urinary tract –> received by periaqueductal grey –> insula –> PMC
where is micturation reflex controlled
anterior cingulate gyrus
where are voluntary voiding decisions made
prefrontal cortex
somatic NS controls what 2 parts of voiding
- striated external sphincter, 2. pelvic floor muscles
autonomic NS controls what 2 functions
bladder contraction/ relaxation
somatic NS nerves located @ what nerve root
S2-4
somatic NS nerve bodies located where
onuf’s nucleus
trajectory of somatic NS nerves
along with pudendal nerve to EUS –> sphincter control
ganglionic relationship of somatic nerves @ nerve root
preganglionic
ganglionic relationship of parasympathetic nerves @ nerve root
preganglionic
parasympathetic NS nerves located @ what nerve root
S2-4
trajectory of parasympathetic NS nerves
pelvic nerve –> pelvic plexus (adjacent to bladder)–> bladder
sympathetic NS nerves located @ what nerve root
T10-L2
trajectory of sympathetic NS nerves
along hypogastric nerve –> internal urethral sphincter and inhibition of parasympathetic activity
def of guarding reflex
as bladder fills, increased outlet resistance
nerve involved in guarding reflex
somatic
structure involved in guarding reflex
striated sphincter
def sympathetic reflex in filling - 3
- increases outlet resistance via smooth sphincter, 2. inhibits parasympathetic input, 3. decreases bladder/ smooth muscle tension
continence mechanism for increased abdominal pressure
intrinsic competence of bladder neck and prox/mid urethra
3 overall parts in filling
guarding reflex, sympathetic reflex, bladder neck/ urethral competence
3 overall parts in storage
sympathetic (bladder relaxation, prox urethra and bladder base contraction), somatic EUS tone, parasympathetic inactivation
fiber type involved in sympathetic afferent storage signal
a-delta
sympathetic ns role in storage - 2
relaxation of detrussor (parasympathetic inhibition), contraction of bladder base/ prox urethra
somatic NS role in storage
increased EUS tone
parasympathetic NS role in storage
blocked by sympathetic
steps in voiding
prefrontal cortex –> somatic efferents inhibited striated EUS relaxation –> sympathetic efferent inhibition –> parasympathetic efferent activation = bladder contraction/ smooth sphincter relaxation
2 classifications of voiding dysfuntion
- failure to store, 2. failure to empty
ICS terms - nocturia
1 or greater voids during sleep
ics urgency -urgency
sudden or compelling desire that’s difficult to defer
ICS - increased bladder sensation
desire to void occurs EARLIER or is more PERSISTENT than previously experienced
ICS - decreased bladder sensation
desire to void occurs LATER than previously experienced
ICS - underactive bladder
reduced detrussor contraction resulting in PROLONGED emptying or FAILURE to empty
ICS - acontractile bladder
detrussor does not contract resulting in PROLONGED emptying or FAILURE to empty
ICS - dysfunctional voiding
intermittent flow 2ndary to INVOLUNTARY INTERMITTENT contraction of levator muscles in neurologically NORMAL pts
at what level does SC terminate
at cauda equina @ L2
rec followup in SCI
annually upto 5-10 yrs, then every other year
what eval is done in SCI
upper and lower tract eval, and UDS. Cysto if indwelling foley
def spinal shock
decreased excitability of SC at/below lesion. Absence of somatic reflex and flaccid muscle paralasys
status of bladder/sphincter during spinal shock
acontractile. Bladder neck closed and competent. Smooth sphincter works
what bladder reflex is absent
guarding (striated sphincter response @ filling
examples of suprapontine lesions
CVA, parkinsons, dementia
where do suprapontine lesions terminate
upto PMC
bladder in suprapontine lesions
detrussor overactivity
sphincter in suprapontine lesions
coordinated sphincter function
examples of suprasacral lesions
MS, SCI, myelomeningocele, transverse myelitis
level of suprasacral lesions
PMC –> S2, but divided into > T6 to < T6
bladder in suprasacral lesions
DO
sphincter in suprasacral lesion
above T6 striated/ smooth dyssynergia. Below T6 smooth synergy and striated dyssynergy
where are lesions with autonomic dysreflexia and caveat
above T6 with intact spinal cord below lesion
below S2/ peripheral lesions examples
tethered cord, myelomeningocele, diabetes, pelvic surgery’
below S2/ peripheral lesions - sphincter
open smooth sphincter, fixed striated
autonomic dysreflexia sx
HTN, bradycardia, HA, sweathing, flushing/ chills
tx for autonomic dysreflexia
sublingual nifedipine 10-20mg
pre-procedure prophylaxis for autonomic dysreflexia
nifedipine 10 mg 30 mins proir to procedure
what nerves are contained in cauda equina
L1-S5
def of cauda equina syndrome
perineal sensory loss, loss of anal/ urethal sphincter control, loss of sexual responsiveness, LE weakness
cauda equina tx
neurosurg decompression
location of lesion in cauda equina
LUMBAR pathology (posterior disc protrusion)
CVA bladder pathology
detrussor areflexia initially –> neurogenic DO (20-40%). Sphincters rarely affected
cerebral palsey findings
nl storage/emptying. Severe forms can have DO
parkinsons and voiding dysfunction - % and type
40-70%, urgency/ frequency
parkinsons and voiding dysfunction - sphincter
synergic - (bradykinesia of striated sphincter at onset of voluntary micturation or pseudodysenergia) - same urodynamic picture as DSD
parkinsons and voiding dysfunction - neurotransmitter role
dopamine has direct inhibitory effect
parkinsons and detrussor contration
can have poorly sustained contraction with obstruction - detrusor hyperreflexia and impaired contractility
multiple system atrophy - def
diffuse cell loss and gliosis
2 main sx in MSA
DO (preceds MSA dx by approx 4 yrs) with eelvated PVR and ED (95%)
MSA voiding progression
as MSA progresses have difficulty initiating and maintaining voiding –> elvated PVR
MSA and UDS
open bladder neck from striated sphincter denervation
eponym for uds findings in MSA
shy drager syndrome
meylomeningocele - % w voiding dysfunction
90% overall, 10-15% w DESD
myelomeningocele - UDS
areflexic bladder w open bladder neck
pernicious anemia def and GU def
dorsolateral SC column degeneration and loss of bladder sensation –> elevated PVR
most common finding in UDS for DM
25-50%
sacral injury and sphincter
competent with nonrelaxing sphincters
2 procedures with voiding dysfunction
radical hysterectomy (15-80%) and APR (20-70%)
% w permanent voiding dysfuntion after pelvic surg
15-30%. can take upto 6 months for apraxia to resolve.
pelvic surgery uds findings
acontractile or impaired contractility, possible fixed striated sphincter (closed). Open & nonfunctional smooth sphincter
MS voiding dysfunction
frequency/urgency and obstructive sx
bladder sensation and sphincter in MS
intact sensation and synergic smooth sphincter usually present
MS and upper tract changes
rare
DLPP def
lowest detrussor pressure at which urine leakage occurs in absence of detrussor or inc abd pressure
abdominal/ valsalva LPP
measures sphincter strength, or ability of sphincter to resist changes in abd pressure in absence of detrussor contraction
ISD on UDS
ALPP < 60 cm H2O
nl ALPP
> 90 cm H2O but urethral hypermobility
B3 agonist MOA
cause detrussor relaxation, inhibit firinig of bladder afferents, increase NO release –> increased bladder capacity with no change in micturation pressure
TCA MOA
- central/ peripheral antimuscarinic effects, 2. block active transport in presynaptic nerve endings responsible for uptake of amine neurotransmitters (nor epi and seratonin), 3. centrally active sedative
what is DSD called in neurologicall normal person - 2
pelvic floor hyperactivity or dysfunctional voiding.
pseudodyssenergia definition
neurologically nl with external sphincter flare during filling cystometry in attempt to inhibit involuntary bladder contraction.
neurotransmitter shared by para/symp
acetylcholine at ganglia. also used by parasymp at effector site
symp effector neurotransmitter
norepi
spinal cord lesions between pons and S2 and detrussor, sphincter, sensation
detrussor - overactive, sphinter - dyssynergic, absent sensation
how to manage VUR in spinal cord injury pt
normalize lower tract as best as possible
followup in SCI
annual upper and lower tract eval for first 5-10 yrs, then every other year. uds at same interval. cysto anually if indwelling foley
sacral lesions and detrussor, sphincter, sensation
detrussor - acontractile, sphincter - open smooth, closed striated, no sensation
bladder pathology with nerve root compression in lumbar disc disease
reflex and sensory loss with straining to void
herpes zoster infection to bladder nerves
u retention
