13 - neurogenic bladder/voiding dysfunction Flashcards
1
Q
where is voiding controlled centrally
A
pontine micturation center or barrington nucleus
2
Q
spec fxn of PMC
A
coordinates detrussor contraction and sphincter relaxation
3
Q
relay of inflow of urinary tract signals
A
afferent from lower urinary tract –> received by periaqueductal grey –> insula –> PMC
4
Q
where is micturation reflex controlled
A
anterior cingulate gyrus
5
Q
where are voluntary voiding decisions made
A
prefrontal cortex
6
Q
somatic NS controls what 2 parts of voiding
A
- striated external sphincter, 2. pelvic floor muscles
7
Q
autonomic NS controls what 2 functions
A
bladder contraction/ relaxation
8
Q
somatic NS nerves located @ what nerve root
A
S2-4
9
Q
somatic NS nerve bodies located where
A
onuf’s nucleus
10
Q
trajectory of somatic NS nerves
A
along with pudendal nerve to EUS –> sphincter control
11
Q
ganglionic relationship of somatic nerves @ nerve root
A
preganglionic
12
Q
ganglionic relationship of parasympathetic nerves @ nerve root
A
preganglionic
13
Q
parasympathetic NS nerves located @ what nerve root
A
S2-4
14
Q
trajectory of parasympathetic NS nerves
A
pelvic nerve –> pelvic plexus (adjacent to bladder)–> bladder
15
Q
sympathetic NS nerves located @ what nerve root
A
T10-L2
16
Q
trajectory of sympathetic NS nerves
A
along hypogastric nerve –> internal urethral sphincter and inhibition of parasympathetic activity
17
Q
def of guarding reflex
A
as bladder fills, increased outlet resistance
18
Q
nerve involved in guarding reflex
A
somatic
19
Q
structure involved in guarding reflex
A
striated sphincter
20
Q
def sympathetic reflex in filling - 3
A
- increases outlet resistance via smooth sphincter, 2. inhibits parasympathetic input, 3. decreases bladder/ smooth muscle tension
21
Q
continence mechanism for increased abdominal pressure
A
intrinsic competence of bladder neck and prox/mid urethra
22
Q
3 overall parts in filling
A
guarding reflex, sympathetic reflex, bladder neck/ urethral competence
23
Q
3 overall parts in storage
A
sympathetic (bladder relaxation, prox urethra and bladder base contraction), somatic EUS tone, parasympathetic inactivation
24
Q
fiber type involved in sympathetic afferent storage signal
A
a-delta
25
sympathetic ns role in storage - 2
relaxation of detrussor (parasympathetic inhibition), contraction of bladder base/ prox urethra
26
somatic NS role in storage
increased EUS tone
27
parasympathetic NS role in storage
blocked by sympathetic
28
steps in voiding
prefrontal cortex --> somatic efferents inhibited striated EUS relaxation --> sympathetic efferent inhibition --> parasympathetic efferent activation = bladder contraction/ smooth sphincter relaxation
29
2 classifications of voiding dysfuntion
1. failure to store, 2. failure to empty
30
ICS terms - nocturia
1 or greater voids during sleep
31
ics urgency -urgency
sudden or compelling desire that’s difficult to defer
32
ICS - increased bladder sensation
desire to void occurs EARLIER or is more PERSISTENT than previously experienced
33
ICS - decreased bladder sensation
desire to void occurs LATER than previously experienced
34
ICS - underactive bladder
reduced detrussor contraction resulting in PROLONGED emptying or FAILURE to empty
35
ICS - acontractile bladder
detrussor does not contract resulting in PROLONGED emptying or FAILURE to empty
36
ICS - dysfunctional voiding
intermittent flow 2ndary to INVOLUNTARY INTERMITTENT contraction of levator muscles in neurologically NORMAL pts
37
at what level does SC terminate
at cauda equina @ L2
38
rec followup in SCI
annually upto 5-10 yrs, then every other year
39
what eval is done in SCI
upper and lower tract eval, and UDS. Cysto if indwelling foley
40
def spinal shock
decreased excitability of SC at/below lesion. Absence of somatic reflex and flaccid muscle paralasys
41
status of bladder/sphincter during spinal shock
acontractile. Bladder neck closed and competent. Smooth sphincter works
42
what bladder reflex is absent
guarding (striated sphincter response @ filling
43
examples of suprapontine lesions
CVA, parkinsons, dementia
44
where do suprapontine lesions terminate
upto PMC
45
bladder in suprapontine lesions
detrussor overactivity
46
sphincter in suprapontine lesions
coordinated sphincter function
47
examples of suprasacral lesions
MS, SCI, myelomeningocele, transverse myelitis
48
level of suprasacral lesions
PMC --> S2, but divided into > T6 to < T6
49
bladder in suprasacral lesions
DO
50
sphincter in suprasacral lesion
above T6 striated/ smooth dyssynergia. Below T6 smooth synergy and striated dyssynergy
51
where are lesions with autonomic dysreflexia and caveat
above T6 with intact spinal cord below lesion
52
below S2/ peripheral lesions examples
tethered cord, myelomeningocele, diabetes, pelvic surgery'
53
below S2/ peripheral lesions - sphincter
open smooth sphincter, fixed striated
54
autonomic dysreflexia sx
HTN, bradycardia, HA, sweathing, flushing/ chills
55
tx for autonomic dysreflexia
sublingual nifedipine 10-20mg
56
pre-procedure prophylaxis for autonomic dysreflexia
nifedipine 10 mg 30 mins proir to procedure
57
what nerves are contained in cauda equina
L1-S5
58
def of cauda equina syndrome
perineal sensory loss, loss of anal/ urethal sphincter control, loss of sexual responsiveness, LE weakness
59
cauda equina tx
neurosurg decompression
60
location of lesion in cauda equina
LUMBAR pathology (posterior disc protrusion)
61
CVA bladder pathology
detrussor areflexia initially --> neurogenic DO (20-40%). Sphincters rarely affected
62
cerebral palsey findings
nl storage/emptying. Severe forms can have DO
63
parkinsons and voiding dysfunction - % and type
40-70%, urgency/ frequency
64
parkinsons and voiding dysfunction - sphincter
synergic - (bradykinesia of striated sphincter at onset of voluntary micturation or pseudodysenergia) - same urodynamic picture as DSD
65
parkinsons and voiding dysfunction - neurotransmitter role
dopamine has direct inhibitory effect
66
parkinsons and detrussor contration
can have poorly sustained contraction with obstruction - detrusor hyperreflexia and impaired contractility
67
multiple system atrophy - def
diffuse cell loss and gliosis
68
2 main sx in MSA
DO (preceds MSA dx by approx 4 yrs) with eelvated PVR and ED (95%)
69
MSA voiding progression
as MSA progresses have difficulty initiating and maintaining voiding --> elvated PVR
70
MSA and UDS
open bladder neck from striated sphincter denervation
71
eponym for uds findings in MSA
shy drager syndrome
72
meylomeningocele - % w voiding dysfunction
90% overall, 10-15% w DESD
73
myelomeningocele - UDS
areflexic bladder w open bladder neck
74
pernicious anemia def and GU def
dorsolateral SC column degeneration and loss of bladder sensation --> elevated PVR
75
most common finding in UDS for DM
25-50%
76
sacral injury and sphincter
competent with nonrelaxing sphincters
77
2 procedures with voiding dysfunction
radical hysterectomy (15-80%) and APR (20-70%)
78
% w permanent voiding dysfuntion after pelvic surg
15-30%. can take upto 6 months for apraxia to resolve.
79
pelvic surgery uds findings
acontractile or impaired contractility, possible fixed striated sphincter (closed). Open & nonfunctional smooth sphincter
80
MS voiding dysfunction
frequency/urgency and obstructive sx
81
bladder sensation and sphincter in MS
intact sensation and synergic smooth sphincter usually present
82
MS and upper tract changes
rare
83
DLPP def
lowest detrussor pressure at which urine leakage occurs in absence of detrussor or inc abd pressure
84
abdominal/ valsalva LPP
measures sphincter strength, or ability of sphincter to resist changes in abd pressure in absence of detrussor contraction
85
ISD on UDS
ALPP < 60 cm H2O
86
nl ALPP
> 90 cm H2O but urethral hypermobility
87
B3 agonist MOA
cause detrussor relaxation, inhibit firinig of bladder afferents, increase NO release --> increased bladder capacity with no change in micturation pressure
88
TCA MOA
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
what is DSD called in neurologicall normal person - 2
pelvic floor hyperactivity or dysfunctional voiding.
90
pseudodyssenergia definition
neurologically nl with external sphincter flare during filling cystometry in attempt to inhibit involuntary bladder contraction.
91
neurotransmitter shared by para/symp
acetylcholine at ganglia. also used by parasymp at effector site
92
symp effector neurotransmitter
norepi
93
spinal cord lesions between pons and S2 and detrussor, sphincter, sensation
detrussor - overactive, sphinter - dyssynergic, absent sensation
94
how to manage VUR in spinal cord injury pt
normalize lower tract as best as possible
95
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
96
sacral lesions and detrussor, sphincter, sensation
detrussor - acontractile, sphincter - open smooth, closed striated, no sensation
97
bladder pathology with nerve root compression in lumbar disc disease
reflex and sensory loss with straining to void
98
herpes zoster infection to bladder nerves
u retention
