bladder and micturition

Question 1

3 layers of lower urinary tract

Answer 1

outer peritoneum, smooth muscle/CT layer, inner mucosal layer.

Question 2

Female vs male bladder neck

Answer 2

women: muscle fiber bundles slant downward and into urethra, maintaining continence. Males: muscle fiber bundles form complete ring around neck. Combine with muscle fibers of prostate to form urethral sphincter.

Question 3

2. Detail the parasympathetic and sympathetic innervation to the lower urinary tract

Answer 3

Parasympathetic: innervate the detrusor muscle; activation results in detrusor muscle contraction and micturition. Sympathetic: Inhibit detrusor contraction and increase tension in smooth muscle of bladder neck and proximal urethra, preventing micturition until parasympathetic stimulation.

Question 4

Describe motor (somatic) innervation to lower urinary tract

Answer 4

motor innervation of the bladder, pelvic floor, and urethral sphincter arises from segments S2-S4 of the spinal cord. Sensations of bladder fullness or stretch are conveyed through long neurons from the spinal cord to the pons.

Question 5

Functions of brain stem, cerebral cortex and cerebellum in micturition

Answer 5

Cortex: inhibitory (diseases such as dementia, stroke, parkinsons cause incontinence). Cerebellum and brain stem are facilitatory

Question 6

ventral vs dorsal root

Answer 6

ventral root carries motor signals from spinal cord. Dorsal root carries sensory signal to spinal cord

Question 7

Storage phase and result of dysfunction

Answer 7

Interrelated neural and neuromuscular responses, coordinated at a number of levels. Allows bladder to adapt to increasing volume with little change in pressure. Disturbance of this phase causes frequency, urgency and urge incontinence.

Question 8

Storage reflexes- afferent response and result of dysfunction

Answer 8

Afferent activity is generated by filling of the bladder. Sensory fibers in the pelvic nerve enters the sacral cord via the sacral DRG. Spinal cord injury and mutiple sclerosis lead to reflex reorganization (unmyelinated C fiber afferents are activated)
Afferent activity is generated by filling of the bladder. Sensory fibers in the pelvic nerve enters the sacral cord via the sacral DRG. Spinal cord injury and mutiple sclerosis lead to reflex reorganization (unmyelinated C fiber afferents are activated)

Question 9

Storage reflexes- efferent response and result of dysfunction

Answer 9

Efferent responses to bladder filling are controlled at supraspinal levels by activating somatic (pudendal) motor neurons in anterior horn of the sacral spinal cord. These responses are associated with inhibition of the detrusor motor neuron. Also, Cortical inhibition of detrusor activity. Stroke, frontal lobe lesions, MS and spinal cord injury all impair this, resulting in detrusor overactivity.
Efferent responses to bladder filling are controlled at supraspinal levels by activating somatic (pudendal) motor neurons in anterior horn of the sacral spinal cord. These responses are associated with inhibition of the detrusor motor neuron. Also, Cortical inhibition of detrusor activity. Stroke, frontal lobe lesions, MS and spinal cord injury all impair this, resulting in detrusor overactivity.

Question 10

3. Overview the micturition cycle

Answer 10

1 Increase in wall tension in the bladder. 2 Afferent input overcomes the pontine micturition center threshold and provides cortical egress micturition begins. 3 Pudendal nerve activity ceases, the external sphincter/pelvic floor relaxes, detrusor neurons are freed and discharge. 4 Proximal urethra opens . 5 Bladder immediately contracts

Question 11

Describe detrusor activity, external sphincter activity and symptoms for: cortical/brainstem lesion, spinal cord injury, overactive bladder, and sacral cord/nerve root lesion

Answer 11

cortical/brainstem lesion: hyperactive detrusor, normal sphincter, incontinence. spinal cord injury: hyperactive detrusor, hyperactive external sphincter, dyssingergia. overactive bladder: hyperactive detrusor, normal sphincter, overactive bladder symptoms. sacral cord/nerve root lesion: complete areflexia of detrusor, normal to hyperactive sphincter, inability to void.

Question 12

4. Categorize the types of urinary incontinence

Answer 12

Stress incontinence, urge (overactive bladder), overflow,

Question 13

Urodynamics

Answer 13

Urodynamics (UDS) is an interactive evaluation of the storage and evacuation of urine by the lower urinary tract. Videourodynamics is a technique using synchronously recorded UDS and cystourethrography. Cystourethrography adds an anatomical dimension to the study thereby obtaining a clearer understanding of complex voiding dysfunction

Question 14

Define overactive bladder/ urge incontinence

Answer 14

Urgency, with or without incontinence, usually with frequency and nocturia, in absence of pathologic or metabolic condtion that would explain these symptoms

Question 15

Behavioral therapy for urinary incontinence

Answer 15

fluid and dietary modification, bladder retraining, pelvic floor re-education.

Question 16

Method for pelvic floor education

Answer 16

Kegels: most incontinent men fail to effectively contract pelvic floor muscles. Stop urine flow during urination, feel vagina tighten, do not tighten glutes or ab

Question 17

Pharmacologic therapy for overactive bladder and side effects

Answer 17

antimuscarinic agents inhibit involuntary bladder contractions and increase bladder capacity, thereby relieving the symptoms of OAB, including urgency, frequency, and urge urinary incontinence. Limited by side effects: dry mouth, dry eyes, constipation, GERD, CNS effects

Question 18

Management of refractory OAB

Answer 18

Intravesicular botox will inhibit vesicular neurons for up to 9 months. Injections are done on the urethra (in striated sphincter at 4 locations) and bladder ( 30-40 sites in the detrusor. Also, interstim is a neurostimulator that can be used

Question 19

What is stress incontinence

Answer 19

·Involuntary, sudden loss of urine during increases in intra-abdominal pressure (ie. Laughing, sneezing, exercising)

Question 20

Two types of stress incontinence

Answer 20

Hypermobility (most common) poor urethral support. Intrinsic Sphincter Deficiency poor muscle tone in the wall of the urethra (continuous leaking)

Question 21

Causes of stress incontinence in women

Answer 21

Pelvic muscle strain, Childbirth, Pelvic muscle tone loss, Estrogen loss/menopause

Question 22

DeLanceys Hammock hypothesis

Answer 22

In the normal continent female, ‘increases in urethral closure pressure during a stress maneuver arise because the urethra is compressed against a hammock-like supporting layer, rather than the urethra being truly intra-abdominal’

Question 23

causes of stress incontinence in men

Answer 23

prostatectomy, radiation, neurogenic (spina bifida, pelvic fracture)

Question 24

Medical management of stress incontinence

Answer 24

Females: alpha agonists( pseudoephedrine, ephedrine) , Estrogen. Males: Kegels, biofeedback, electrical stimulation, artificial urinary sphincter

Question 25

6. Overview the common causes of lower urinary tract obstruction in men

Answer 25

Benign prostatic hypertrophy, prostate/bladder cancer, stricture after surgery, urethral cancer, diverticulum,

Question 26

male lower urinary tract obstruction symptoms

Answer 26

frequency, urgency, urge incontinence, nocturia, straining, decreased stream, dysuria, dribbling