236. Bladder Dysfx

Question 1

Overactive Bladder

• cause
• CP
• tx

Answer 1

Cause: usually idiopathic
CP: urgency (frequency, nocturia)
LOSS OF CORTICAL INHIBITION - no warning

Tx:
1st line: behavior modification, voiding diary, pelvic floor PT, constipation tx
2nd line: meds - anticholinergics, B-adrenergics
3rd line: botox, neuromodulation, sacral nerve stim
Desperation: surgery (urinary cystoplasty/diversion)

Question 2

Stress Urinary Incontinence

• what is it
• cause
• tx

Answer 2

Leakage with physical activity (higher abd pressure)

• due to loss of bladder neck support (less urethral muscle tone, less fascia support, less pelvic floor contractions)
  tx: Kegel exercises (Pelvic floor PT), incontinence PESSARY, surgery

Question 3

Neuro Voiding Dysfx

• dx
• areflexia - what it is
• detrusor overactivity - what it is
• diminished compliance - what it is, key threshold, complication
• detrusor sphincter dyssynergia - what it is, cause

Answer 3

Dx: URODYNAMICS - catheter fills bladder, monitor pressure/urethral activity (EMG electrodes, pressure sensor)

Areflexia: absence of either voluntary/involuntary detrusor contraction w/ bladder filled to capacity (>500mL)

Detrusor Overactivity: involuntary detrusor contraction with bladder filling

Diminished compliance: abnormal increase detrusor pressure with filling; sustained bladder pressure >40cm water causes less urine delivery to bladder = HYDRONEPHROSIS; big P change, small V change

DSD: sphincter fails to relax or contracts paradoxically with detrusor contraction, loss of coordinating influence of PMC (CERVICAL/THORACIC SC injury), sustained bladder pressure >40cm H2O causes HYDRONEPHROSIS

Question 4

How do nervous system lesions affect bladder fx:

• lesion in brain
• lesion in Cervical/thoracic SC
• initial shock from SC lesion
• lesion in PNS

Answer 4

brain: detrusor overactivity (no inhibition) - URGE incontinence

Cervical/Thoracic SC: loss of PMC coordination - Detrusor Sphincter Dyssynergia

Initial spinal shock - areflexia

PNS: variable - areflexia, low compliance, stress incontinence

Question 5

Neuro Bladder Dysfx Mgmt/Tx

• mgmt
• tx of storage problems
• tx of voiding problems

Answer 5

Mgmt: utilize urodynamics and follow up with annual urodynamics and renal US (lesions may change with time)

Storage problems:

• meds: anticholinergics, B-adrenergics
• BOTOX - paralytic ACh blocker
• SURGERY: new reservoir into bladder, new urinary diversion

Voiding problems

• catheterization
• urinary diversion
• pads for women