FERGU neuro/incontinence Flashcards
SNS fergu
T1 - L2/3
pre-gangiolinic exits via ventral root, enters sym trunk via white ramus communicans (myelinated)
can:
1) synapse at same spinal level, exit via gray
2) travel and synapse at cervical/sacral levels
3) pass through without synapsing, leave as:
- Greater splanchnic nerve
- Lesser splanchnic
- Least splanchnic
Greater splanchnic nerve
T5-9
Lesser splanchnic
T10-11
Least splanchnic
T12
PSNS efferent
CN III, VII, IX, X
sacral S2-4
Abdominal plexuses
celiac
superior mesenteric
inferior mesenteric
Intermesenteric plexus
btw inferior & superior mesenteric, gives rise to: renal testicular/ovarian ureteric superior hypogastric plexuses
- mostly sympathetic
Inferior hypogastric plexus
formed by hypogastric nerves from superior hypogastric plexus (sym)
parasympathetic & sympathetic
parasympathetic from S2,3,4 = pelvic splanchnic nerves
majority of pelvic viscera
Bladder innervation
hypogastric (T11-L2): detrusor relaxation and bladder neck constriction
pelvic splanchnic nerves: splanchnic from S2,3,4, detrusor contraction
Somatic: pudendal from S2, 3, 4 - external urethral sphincter
Bladder sympathetic
alpha - detrusor contraction
b3 - detrusor relaxation
Normal emptying
Pontine micturition centre - inhibitory from forebrain - cerebellum - coordination activates PSNS inhibits SNS inhibits pudendal nerve firing
DDx of transient incontinence
Delirium Infection Atrophic vaginitia/urethritis Pharmacologic Excess urine output Restricted mobility Stool impaction
Overflow incontinence
leakage from bladder that does not void properly
Urine retention –> increased P –> leakage
Causes: obs, poor bladder contraction (sacral spinal damage), medications (b3 blocker, opioids, alpha agonists)
Stress incontinence
due to abd P (sneezing etc)
common in young-middle aged women
cause: weakness of sphincter, estrogen deficiency, obesity, exacerbation due to cough from ACEi, alpha1 antagonist
anatomy: unequal movement of ant & post bladder with proximal urethra
midurethra - most important structure for incontinence
can provide backboard for midurethra surgically to improve coapt of urethra upon increase in abdominal pressure
- sling, retropubic suspension
Total incontinence
cannot store urine
damage to innervation of bladder
fistulas btw bladder &vagina, rectum
scarring of urethra - cannot constrict1
functional incontinence
mentally/phyically unable
Urgency incontinence
involuntary loss of urine following strong urge to void
bladder contractions > cerebral inhibition
overactivity
increased frequency of urination day and night
cause: constipation, diuretics, detrusor hyperreflexia due to upper motor neuron lesion
- cerebral damage
- basal ganglia disease - Parkinson’s
- suprasacral spinal damage - external sphincter dyssynergia
Tx for increasing bladder storage
Dietary
Biofeedback, pelvic floor exercises
Anticholinergic, tricyclic andidepressants, b3 agonists, botox
Surgical:
- neuromodulation - tibial nerve
- stimulation - interstim
- augment size of bladder by adding a piece of bowel
Tx for increase storage at the outlet level
Biofeedback, pelvic floor exercises
electrical stimulation
pharmacologic - alpha agonist, estrogen, SSRI’s
surgery: peri-urethral bulking, pessaries (bladder neck suspension, suburethral sling, artificial sphincter
Tx to increase emptying from bladder
Parasympathomimetics (urecholine)
direct stimulation of bladder & sacral roots
Outlet - increase emptying
prostate obstruction: alpha blockers, 5ARis, anti-androgen
Volntary sphincter: baclofen
Catheterization
Surgical: prostatectomy urethrotomy sphincterotomy urethral stent urinary diversion
Anticholinergics
oxybutinin
tolterodine
imipramine
SE: dry mouth, dry eyes, blurred vision, constipation
b3 agonists
Mirabegron
SE: HTn
Botox
inject through cystoscope
failure of oral meds
SE: UTI, urinary retention
