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08. Piso pelvico y Funcional (1403) > 13 - neurogenic bladder/voiding dysfunction > Flashcards

13 - neurogenic bladder/voiding dysfunction Flashcards

1
Q

where is voiding controlled centrally

A

pontine micturation center or barrington nucleus

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2
Q

spec fxn of PMC

A

coordinates detrussor contraction and sphincter relaxation

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3
Q

relay of inflow of urinary tract signals

A

afferent from lower urinary tract –> received by periaqueductal grey –> insula –> PMC

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4
Q

where is micturation reflex controlled

A

anterior cingulate gyrus

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5
Q

where are voluntary voiding decisions made

A

prefrontal cortex

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6
Q

somatic NS controls what 2 parts of voiding

A
  1. striated external sphincter, 2. pelvic floor muscles
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7
Q

autonomic NS controls what 2 functions

A

bladder contraction/ relaxation

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8
Q

somatic NS nerves located @ what nerve root

A

S2-4

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9
Q

somatic NS nerve bodies located where

A

onuf’s nucleus

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10
Q

trajectory of somatic NS nerves

A

along with pudendal nerve to EUS –> sphincter control

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11
Q

ganglionic relationship of somatic nerves @ nerve root

A

preganglionic

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12
Q

ganglionic relationship of parasympathetic nerves @ nerve root

A

preganglionic

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13
Q

parasympathetic NS nerves located @ what nerve root

A

S2-4

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14
Q

trajectory of parasympathetic NS nerves

A

pelvic nerve –> pelvic plexus (adjacent to bladder)–> bladder

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15
Q

sympathetic NS nerves located @ what nerve root

A

T10-L2

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16
Q

trajectory of sympathetic NS nerves

A

along hypogastric nerve –> internal urethral sphincter and inhibition of parasympathetic activity

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17
Q

def of guarding reflex

A

as bladder fills, increased outlet resistance

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18
Q

nerve involved in guarding reflex

A

somatic

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19
Q

structure involved in guarding reflex

A

striated sphincter

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20
Q

def sympathetic reflex in filling - 3

A
  1. increases outlet resistance via smooth sphincter, 2. inhibits parasympathetic input, 3. decreases bladder/ smooth muscle tension
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21
Q

continence mechanism for increased abdominal pressure

A

intrinsic competence of bladder neck and prox/mid urethra

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22
Q

3 overall parts in filling

A

guarding reflex, sympathetic reflex, bladder neck/ urethral competence

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23
Q

3 overall parts in storage

A

sympathetic (bladder relaxation, prox urethra and bladder base contraction), somatic EUS tone, parasympathetic inactivation

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24
Q

fiber type involved in sympathetic afferent storage signal

A

a-delta

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25
Q

sympathetic ns role in storage - 2

A

relaxation of detrussor (parasympathetic inhibition), contraction of bladder base/ prox urethra

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26
Q

somatic NS role in storage

A

increased EUS tone

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27
Q

parasympathetic NS role in storage

A

blocked by sympathetic

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28
Q

steps in voiding

A

prefrontal cortex –> somatic efferents inhibited striated EUS relaxation –> sympathetic efferent inhibition –> parasympathetic efferent activation = bladder contraction/ smooth sphincter relaxation

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29
Q

2 classifications of voiding dysfuntion

A
  1. failure to store, 2. failure to empty
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30
Q

ICS terms - nocturia

A

1 or greater voids during sleep

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31
Q

ics urgency -urgency

A

sudden or compelling desire that’s difficult to defer

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32
Q

ICS - increased bladder sensation

A

desire to void occurs EARLIER or is more PERSISTENT than previously experienced

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33
Q

ICS - decreased bladder sensation

A

desire to void occurs LATER than previously experienced

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34
Q

ICS - underactive bladder

A

reduced detrussor contraction resulting in PROLONGED emptying or FAILURE to empty

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35
Q

ICS - acontractile bladder

A

detrussor does not contract resulting in PROLONGED emptying or FAILURE to empty

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36
Q

ICS - dysfunctional voiding

A

intermittent flow 2ndary to INVOLUNTARY INTERMITTENT contraction of levator muscles in neurologically NORMAL pts

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37
Q

at what level does SC terminate

A

at cauda equina @ L2

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38
Q

rec followup in SCI

A

annually upto 5-10 yrs, then every other year

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39
Q

what eval is done in SCI

A

upper and lower tract eval, and UDS. Cysto if indwelling foley

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40
Q

def spinal shock

A

decreased excitability of SC at/below lesion. Absence of somatic reflex and flaccid muscle paralasys

41
Q

status of bladder/sphincter during spinal shock

A

acontractile. Bladder neck closed and competent. Smooth sphincter works

42
Q

what bladder reflex is absent

A

guarding (striated sphincter response @ filling

43
Q

examples of suprapontine lesions

A

CVA, parkinsons, dementia

44
Q

where do suprapontine lesions terminate

A

upto PMC

45
Q

bladder in suprapontine lesions

A

detrussor overactivity

46
Q

sphincter in suprapontine lesions

A

coordinated sphincter function

47
Q

examples of suprasacral lesions

A

MS, SCI, myelomeningocele, transverse myelitis

48
Q

level of suprasacral lesions

A

PMC –> S2, but divided into > T6 to < T6

49
Q

bladder in suprasacral lesions

A

DO

50
Q

sphincter in suprasacral lesion

A

above T6 striated/ smooth dyssynergia. Below T6 smooth synergy and striated dyssynergy

51
Q

where are lesions with autonomic dysreflexia and caveat

A

above T6 with intact spinal cord below lesion

52
Q

below S2/ peripheral lesions examples

A

tethered cord, myelomeningocele, diabetes, pelvic surgery’

53
Q

below S2/ peripheral lesions - sphincter

A

open smooth sphincter, fixed striated

54
Q

autonomic dysreflexia sx

A

HTN, bradycardia, HA, sweathing, flushing/ chills

55
Q

tx for autonomic dysreflexia

A

sublingual nifedipine 10-20mg

56
Q

pre-procedure prophylaxis for autonomic dysreflexia

A

nifedipine 10 mg 30 mins proir to procedure

57
Q

what nerves are contained in cauda equina

A

L1-S5

58
Q

def of cauda equina syndrome

A

perineal sensory loss, loss of anal/ urethal sphincter control, loss of sexual responsiveness, LE weakness

59
Q

cauda equina tx

A

neurosurg decompression

60
Q

location of lesion in cauda equina

A

LUMBAR pathology (posterior disc protrusion)

61
Q

CVA bladder pathology

A

detrussor areflexia initially –> neurogenic DO (20-40%). Sphincters rarely affected

62
Q

cerebral palsey findings

A

nl storage/emptying. Severe forms can have DO

63
Q

parkinsons and voiding dysfunction - % and type

A

40-70%, urgency/ frequency

64
Q

parkinsons and voiding dysfunction - sphincter

A

synergic - (bradykinesia of striated sphincter at onset of voluntary micturation or pseudodysenergia) - same urodynamic picture as DSD

65
Q

parkinsons and voiding dysfunction - neurotransmitter role

A

dopamine has direct inhibitory effect

66
Q

parkinsons and detrussor contration

A

can have poorly sustained contraction with obstruction - detrusor hyperreflexia and impaired contractility

67
Q

multiple system atrophy - def

A

diffuse cell loss and gliosis

68
Q

2 main sx in MSA

A

DO (preceds MSA dx by approx 4 yrs) with eelvated PVR and ED (95%)

69
Q

MSA voiding progression

A

as MSA progresses have difficulty initiating and maintaining voiding –> elvated PVR

70
Q

MSA and UDS

A

open bladder neck from striated sphincter denervation

71
Q

eponym for uds findings in MSA

A

shy drager syndrome

72
Q

meylomeningocele - % w voiding dysfunction

A

90% overall, 10-15% w DESD

73
Q

myelomeningocele - UDS

A

areflexic bladder w open bladder neck

74
Q

pernicious anemia def and GU def

A

dorsolateral SC column degeneration and loss of bladder sensation –> elevated PVR

75
Q

most common finding in UDS for DM

A

25-50%

76
Q

sacral injury and sphincter

A

competent with nonrelaxing sphincters

77
Q

2 procedures with voiding dysfunction

A

radical hysterectomy (15-80%) and APR (20-70%)

78
Q

% w permanent voiding dysfuntion after pelvic surg

A

15-30%. can take upto 6 months for apraxia to resolve.

79
Q

pelvic surgery uds findings

A

acontractile or impaired contractility, possible fixed striated sphincter (closed). Open & nonfunctional smooth sphincter

80
Q

MS voiding dysfunction

A

frequency/urgency and obstructive sx

81
Q

bladder sensation and sphincter in MS

A

intact sensation and synergic smooth sphincter usually present

82
Q

MS and upper tract changes

A

rare

83
Q

DLPP def

A

lowest detrussor pressure at which urine leakage occurs in absence of detrussor or inc abd pressure

84
Q

abdominal/ valsalva LPP

A

measures sphincter strength, or ability of sphincter to resist changes in abd pressure in absence of detrussor contraction

85
Q

ISD on UDS

A

ALPP < 60 cm H2O

86
Q

nl ALPP

A

> 90 cm H2O but urethral hypermobility

87
Q

B3 agonist MOA

A

cause detrussor relaxation, inhibit firinig of bladder afferents, increase NO release –> increased bladder capacity with no change in micturation pressure

88
Q

TCA MOA

A
  1. 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
89
Q

what is DSD called in neurologicall normal person - 2

A

pelvic floor hyperactivity or dysfunctional voiding.

90
Q

pseudodyssenergia definition

A

neurologically nl with external sphincter flare during filling cystometry in attempt to inhibit involuntary bladder contraction.

91
Q

neurotransmitter shared by para/symp

A

acetylcholine at ganglia. also used by parasymp at effector site

92
Q

symp effector neurotransmitter

A

norepi

93
Q

spinal cord lesions between pons and S2 and detrussor, sphincter, sensation

A

detrussor - overactive, sphinter - dyssynergic, absent sensation

94
Q

how to manage VUR in spinal cord injury pt

A

normalize lower tract as best as possible

95
Q

followup in SCI

A

annual upper and lower tract eval for first 5-10 yrs, then every other year. uds at same interval. cysto anually if indwelling foley

96
Q

sacral lesions and detrussor, sphincter, sensation

A

detrussor - acontractile, sphincter - open smooth, closed striated, no sensation

97
Q

bladder pathology with nerve root compression in lumbar disc disease

A

reflex and sensory loss with straining to void

98
Q

herpes zoster infection to bladder nerves

A

u retention

08. Piso pelvico y Funcional (1403) (11 decks)

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