8- Neuro control of micturition and incontinence Flashcards
What centre helps support contience
Lateral centre
Where do the sympathetic neurons go to
Detrusor muscles and internal urinary sphincter
What effect do sympathetic branches have on bladder msucle
Inhibitory
What receptor does the sympathetics work on at the detrusor muscle
B3
What receptor does the parasmpathetic branch work on at the bladder muscle and what is the effect
M3 and excitatory
What receptors and neurotransmitter does the sympathetics use
Adrenoceptors - noradrenaline
What leads to the M centre stimulation
High stretch
What is the effect of M centre stimulation
Stimulates parasympathetics= detrusor excited
Inhibits M centre= inhibition of excitation of EUS by pudendal nerve
What nerve works on the external urinary sphincter
Pudendal nerve.
Where does the sensory neurons synapse with para
S2-S4
Where does the sensory neurons synapse with symp
Enter at sacral region but synapse in lower thoracic region T10-L2
What is the conscious control of the M centre
Paracentral lobules send excitatory and inhibitory influences to M centre.
Two effects of sympathetics
Inhibit detrusor
Excite IUS
What receptor at IUS
A1
What happens to the pressure in bladder and urine fills
Bladder stretches so very little increase in pressure until over 500.
What level is pudendal nerves
S2,3,4
What level are pelvic (parasymp) nerves
S2,3,4
What examination findings would a lower motor neuron lesion cause (i.e. cauda equina)
Low detrusor pressure, large residual volume, overflow incontinence.
Reduced perianal sensation
Relaxed PR exam.
What would a upper motor neuron lesion cause (i.e. transection)
High pressure detrusor contractions not coordinated with sphincters.
Back pressure to kidneys- dilated ureters
Lower urinary tract symptoms
Storage: frequency, nocturia, urgency
Voiding: splitting, hesitancy, straining
Post: dribble, incomplete emptying
4 types of incontinence
Stress, urgency, mixed, overflow
Overflow
When high residual
Chronic retention
Chronic obstruction
Lower motor neuron lesion
Stress
Involuntary leakage on effort or exertion
Sneezing or coughing
Urgency
Involuntary leakage accompanied by or immediately preceded by urgency
Mixed
Involuntary leakage associated with urgency and also exertion, effort, sneezing, coughing
What is more common Overactive bladder or Stress UI
OAB- urgency, nocturia, increased frequency
Risk factors for UI
Pregnancy, childbirth (less compliant) Age Obesity Drugs UTI Race Family predisposition Anatomical abnormalities
What examination should be performed
BMI, abdo (exclude palpable bladder)
Rectal exam- bladder and anal tone
Females- stress test, vaginal exam
Investigations- mandatory
Dipstick
UTI, haematuria, protein, glucose
Tumour, infection, diabetic
Non invasive investigation
Frequency volume chart
Bladder diary
Residual volumes
Optional investigations
Pad test
Invasive urodynamics- pressure flow studies +/- videos
Cystoscopy
Mangagement
Fluid intake modify Weight loss Stop smoking Decrease caffeine Timed voiding Avoid constipation
Contained incontinence
Indwelling catheter
Sheath
Pads
Managing SUI
Exercise + drug
Pelvic floor training
8 contractions x 3 day
for 3 months
Duloxetine: norad and serotonin uptake inhibitor to increase activity in striated (EUS) sphincter during filling phase
Surgery for SUI
Female
Male
Sling procedures
Low tension vaginal tapes- supports mid urethra
Intramural bulking- botox - 6 months
Retropubic suspension- increase support by tightening pelvic floor
Artificial sphincters
Male sling
Management UUI
Bladder training schedule - 6 weeks
Pharmacological UUI
Anticholinergics- act on M3/M2 to block
also work on other areas of body ie heart, smooth muscle, eye, salivary glands (Oxybutynin)
B3 adrenoceptor agonist- increases bladder capacity to store urine
Botox- inhibits Ach release causing targeted flaccid paralysis- 6 months
Surgery UUI
Sacral nerve neuromodulation
Autoaugmentation
Urinary diversion
Bedwetting
Enuresis- involuntary 2xweek over age of 5 with no CNS defects
Secondary enuresis
Restarted after dry for 6 months
Causes of primary enuresis
Lower urinary tract disorders
Causes of secondary enuresis
UTI, constipation, diabetes, family problems, psychological problems, physical, neurological problems
