Bladder & Micturition Flashcards
3 layers of bladder
1) outer peritoneum
2) detrusor muscle
3) inner mucosal layer
male muscles responsible for continence
1) smooth muscle fibers of prostate
2) muscle bundles around bladder neck
female muscle responsible for continence
1) bladder neck muscle fibers
2) mid-urethral complex
parasympathetic innerv of lower Urinary tract
1) innerv…
2) activ …
1) innerv detrusor muscle
2) muscle contraction and micturition
S2-S4–> pelvic nerves –> parasympathetic innerv–> bladder contract
sympathetic innerv of lower urinary tract
1) inhib…
2) incr tension in…
1) inhib detrusor contract
2) incr tension in smooth muscle of bladder and urethra preventing micturition
T10-L2 –> hypogastric nerve –> sympathetic innerv –> bladder –> inhib prevent micturition
motor innerv of lower urinary tract
1) bladder, pelvic floor, urethral sphincter arise from..
2) sensation transmitted…
1) bladder, pelvic floor, urethral sphincter arise from segments S2-S4 of psinal cord
2) sensation of fullness stretch from long neurons from spinal cord to pons
S2-S4 —> pudental nerves –> external urethral sphincter —> muscles of pelvic floor –> bladder contract
central nervous system input to lower urinary tract
choosing when to void
loss of central cortical inhibiton over sacral areas in diseases like ___ lead to incontinence
dementia, stroke, parkinson’s
dorsal root carries … signals to spinal cord
ventral root carries … signals from spinal cord
motor (bladder –> spinal cord –> DRG –> cerebral cortex
sensory
Dysfunction of storage in bladder results in ___
1) freq (small bladder)
2) urgency (bladder can’t be filled)
3) urge incontinence (OAB)
normal afferent storage reflex
1) generated by …
2) sensory fibers in pelvic nerve enter sacral cord via ___
1) generated by filling bladder
2) sensory fibers in pelvic nerve enter sacral cord via sacral DRG
dysfunction of afferent storage reflex leads to
unmyelinated C fiber –> reflex reorganization in spinal cord injury and multiple sclerosis
normal efferent storage reflex
1) efferent responses controlled at ____ by activating ___
2) inhib ___
1) controlled at supraspinal levels by activating somatic motor neurons
2) inhib detrusor motor neuron
dysfunction of efferent storage response occurs when
stroke
frontal lobe lesion
MS
SCI
–> detrusor overactivity
normal micturition reflex must ___
dysfunction of micturition reflex leads to
override storage activity
hesitancy, weak stream, incomplete bladder emptying
What is micturition cycle
KNOW!!!
1) incr wall tension in bladder
2) afferent input overcomes pontine micturition threshold –> micturition begins
3) decr pudental nerve, reflax pelvic floor, detrusor neurons are freed and fire
4) proximal urethra opens
5) bladder contracts
Dysfunction of micturtion cycle
disturbances or lack of coord from SCI or MS –> hesitancy, weak stream, incomplete emptying
urination reflex cycle
DON’T NEED TO KNOW
1) bladder fills
2) sympathetic nerves
3) closes bladder neck, relax bladder dome
4) detrusor pressure > urethral resistance –> voiding
5) symp and somatic tone decr, parasympathetic impulse cause bladder to contract
Voiding dysfunction
2 types of outflow dysfunction
1) overactive = overflow incontinence
2) underactive = stress incontinence
Voiding dysfunction
2 types of bladder dysfunction
1) overactive = urge incontinence
2) underactive = overflow incontinence
pmhx assoc with incontinence
1) diabetes
2) bowel problems/constipation
3) cva, MS, parkinson’s
shx assoc with incontinence
1) bladder outlet
2) spinal surgery
3) radical pelvic surgery (prostatectomy, APR)
Anal wink reflex
absence of anal wink suggests
touching mucocutaneous junction of perianal skin –> contraction of anal sphincter
sacral nerve disease
voluntary sphincter contraction during DRE
absence indicates
1) intact pelvic floor
2) sacral or peripheral nerve injury
bulbocavernosus reflex (S2-4)
absence indicates
squeezing glans penis –> contraction of external anal sphincter
sacral nerve damage
lab evaluation
1) UA
2) BUN, Cr, PSA
3) hematuria = cytology, cystoscopy
red flags for women
red flags for men
STRESS INCONTINENCE
1) hematuria, UTI, cancer, voding difficulty, urogenital fistula
OBSTRUCTION IF NOT NEURO OR RECENT PROSTATE SURGERY
2) hematuria without infection, urethral obstruction, prostate nodule
3 major types of incontinence
1) stress urinary incontinence
2) urge incontinence
3) mixed
approach to urge incontinence
1) rule out neuro
2) bladder outlet obstruction
3) risk factors for transitional cell carcinoma of bladder
define OAB
urgency +/- incontinence usu with freq and nocturia
most incontinent men fail to effectively contract
pelvic floor muscle
pharm treatments for OAB
1) antimuscarinic agents
2) relieved by inhib involuntary bladder contract and incr bladder capacity
afferent signals vs. efferent
afferent from bladder to spinal cord
efferents from spinal cord to bladder affected by atropine, oxybynin, tolterodine
effect of oxybutynin
smooth muscle relaxant to incr bladder storage
management of refractory OAB with intravesical botox
inhib vesicular neuronal blockade
define stress urinary incontinence
involuntary sudden loss of urine during incr intra-abd pressure
ex: laughing, sneezing, cough, exercising
Separate btwn overactive bladder and stress incontinence
overactive bladder
+ urgency + freq + large leakage with incontinence
no leaking during phys activity
causes of stress urinary incontinence
1) pelvic muscle strain and loss
2) childbirth
3) menopause
a
a
drugs to treat SUI
1) alpha agonists = possibly interact with estrogen = pseudoephedrine, ephedrine
2) estrogen
management of ISD in men
1) radical, simple prostatectomy
2) radiation
3) neurogenic = spina bifida, pelvic fracture, surgery
behavioral and phys therapy effective in ___to improve continence
early post-op phase
etiology of male lower urinary tract obstruction
bladder neck/prostate
1) BPH
2) prostate/bladder cancer
3) stricture after surgery, trauma
urethra
1) stricture
2) urethral cancer
symptoms of male lower urinary tract obstruction
storage symptoms = freq, urgency, urge incontinence and nocturia
emptying symptoms = hesitance, dribbling, dysuria
management to relieve male lower urinary tract obstruction
1) 5a-reductase inhib
2) a1-adrenergic blocker
3) surgical therapy
urethral stricture usu occurs in ___ and often due to ___
younger men due to trauma to bulbar urethra
