Bladder Disorder, Urinary Incontinence, and Penile/Urethral Disorders

Question 1

Efferent Pelvic Nerve

Answer 1

Acetylcholine to M3 receptor on bladder

PNS stimulation

Causes contraction of the detrusor muscle

Question 2

Pudendal Nerve

Answer 2

Acetylcholine to nicotinic receptor or external sphincter

SNS

Causes sphincter contraction

Under conscious control

Question 3

Hypogastric nerve

Answer 3

SNS

Releases NE to B3 receptor on bladder

-Causes relaxation of the detrusor muscle

Releases NE to alpha-1 receptor on internal sphincter

-causes contraction of internal sphincter

Question 4

Afferent pelvic nerve

Answer 4

Stimulated by bladder stretch

Question 5

Empty Bladder Physiology

Answer 5

Slow sensory impulse to sacral -> hypogastric nerve activated (B3 and alpha1)

Pons stimulates hypogastric nerve and inhibits pelvic (M3) nerve while stimulating pudendal nerve - nicotinic for contraction

SNS stimulated, PNS inhibited

Question 6

Full Bladder Physiology

Answer 6

Urine stretches detrusor muscle - signaling the pelvic afferent nerve to increase firing

-bypasses thoracic and goes straight to pons

Pons inhibits hypogastric nerve (SNS) - no detrusor relaxation, internal sphincter relaxes, pelvic efferent stimulated causing detrusor contraction

Question 7

Voiding Reflux

Answer 7

Initiation of voiding causes pelvic afferent nerve to continue signaling sacral->interneuron->PNS efferent stimulation

-This triggers detrusor contraction

Question 8

Glomerular Bleeding

Answer 8

Red cell casts

Dysmorphic rbcs

Proteinuria with large % albumin

Question 9

Interstitial Cystitis

Answer 9

Bladder Pain Syndrome (BPS)

Usually in 4th decade

Pain w/ filling that is relieved by emptying

UA to r/o cancer or infection

Tx: education, support

-Amitriptyline, Hydroxyzine, Pentosan polysulfate sodium (PPS)

Question 10

Transient Incontinence Causes

Answer 10

DIAPPERS

Delirium

Infection

Atrophic vaginitis

Pharmacology

Psychological

Excessive urine production

Restricted mobility

Stool impaction

Question 11

Causes of excessive urine production

Answer 11

Excessive urine production - diuretics

Increased ADH

Polydipsia

Hyperglysuria

Hypercalcemia

Question 12

Urge Incontinence

Answer 12

Uninhibited contractions, detrusor overactivity, idiopathic, bladder abnormalities

Sudden urge with or after leakage

More common in men and older women

Tx: anticholinergics - increase capacity; oxybutynin for detrusor antispasmodic; miragebron for bladder relaxation

Question 13

Stress Incontinence

Answer 13

Leakage with increased intraabdominal pressure w/o bladder contractions

Seconds after cough - urethral hypermobility or intrinsic sphincter deficiency

Prostate surgery most common cause

Tx: Surgical repair

Question 14

Overflow Incontinence

Answer 14

Incomplete bladder emptying - continuous leakage

Detrusor underactivity or bladder outlet obstruction (BPH)

Tx: self-catheterizing

Question 15

Immediate referral for Bladder Disorders

Answer 15

Incontinence w/ pain

UTI-free hematuria

Fistula

Complex neurological

Abnormal findings

Question 16

Anterior and Posterior Urethral Stricture

Answer 16

Anterior: begins @ bulbar urethra, ends @ meatus

-commonly caused by straddling or penetrating injuries

Posterior: involved membranous and prostatic urethra

-commonly caused by urethral disruption via pelvic fracture

Question 17

Balanitis

Answer 17

Inflammation of glans - most common in poor hygiene or uncircumcised

Pain, irritation, itching/burning, erythema, discharge, ulceration on PE

Tx: Clean, consider circumcision; bacitracin if bacterial infection; clotrimazole if fungal infection

Question 18

Phimosis

Answer 18

Inability to retract foreskin from narrowing constriction, adhesions

Caused by balanitis, poor hygiene

erythema, itching, discharge with painful excretion/intercourse

Tx: Betamethasone cream is 1st line, circumcision 2nd

Question 19

Paraphimosis

Answer 19

retracted foreskin becomes trapped proximal to glans

Emergency - leads to ischemia of glans & gangrene

Most common in elderly

Tx: Firm compression and manual reduction, circumcision

Question 20

Peyronie’s Disease

Answer 20

Curvature of penis with erection due to plaque formation in tunica albuginea

Active phase: 1st 18-24 hours; penile pain, nodule, inflammation with some curvature

Chronic phase: stable plaque, penile angulation, loss of erectile activity

Tx: 1st 6 months - Vitamin E, ibuprofen, Colchicine

-after - Collagenase clostridium histolyticum - to break up the plaque, weekly Verapamil or surgery