FERGU neuro/incontinence

Question 1

SNS fergu

Answer 1

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

Question 2

Greater splanchnic nerve

Answer 2

T5-9

Question 3

Lesser splanchnic

Answer 3

T10-11

Question 4

Least splanchnic

Answer 4

T12

Question 5

PSNS efferent

Answer 5

CN III, VII, IX, X

sacral S2-4

Question 6

Abdominal plexuses

Answer 6

celiac
superior mesenteric
inferior mesenteric

Question 7

Intermesenteric plexus

Answer 7

btw inferior & superior mesenteric, gives rise to:
renal
testicular/ovarian
ureteric
superior hypogastric plexuses

• mostly sympathetic

Question 8

Inferior hypogastric plexus

Answer 8

formed by hypogastric nerves from superior hypogastric plexus (sym)
parasympathetic & sympathetic
parasympathetic from S2,3,4 = pelvic splanchnic nerves

majority of pelvic viscera

Question 9

Bladder innervation

Answer 9

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

Question 10

Bladder sympathetic

Answer 10

alpha - detrusor contraction

b3 - detrusor relaxation

Question 11

Normal emptying

Answer 11

Pontine micturition centre
- inhibitory from forebrain
- cerebellum - coordination
activates PSNS
inhibits SNS
inhibits pudendal nerve firing

Question 12

DDx of transient incontinence

Answer 12

Delirium
Infection
Atrophic vaginitia/urethritis
Pharmacologic
Excess urine output
Restricted mobility
Stool impaction

Question 13

Overflow incontinence

Answer 13

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)

Question 14

Stress incontinence

Answer 14

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

Question 15

Total incontinence

Answer 15

cannot store urine
damage to innervation of bladder
fistulas btw bladder &vagina, rectum
scarring of urethra - cannot constrict1

Question 16

functional incontinence

Answer 16

mentally/phyically unable

Question 17

Urgency incontinence

Answer 17

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

Question 18

Tx for increasing bladder storage

Answer 18

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

Question 19

Tx for increase storage at the outlet level

Answer 19

Biofeedback, pelvic floor exercises
electrical stimulation
pharmacologic - alpha agonist, estrogen, SSRI’s

surgery: peri-urethral bulking, pessaries (bladder neck suspension, suburethral sling, artificial sphincter

Question 20

Tx to increase emptying from bladder

Answer 20

Parasympathomimetics (urecholine)

direct stimulation of bladder & sacral roots

Question 21

Outlet - increase emptying

Answer 21

prostate obstruction: alpha blockers, 5ARis, anti-androgen
Volntary sphincter: baclofen
Catheterization

Surgical:
prostatectomy
urethrotomy
sphincterotomy
urethral stent
urinary diversion

Question 22

Anticholinergics

Answer 22

oxybutinin
tolterodine
imipramine
SE: dry mouth, dry eyes, blurred vision, constipation

Question 23

b3 agonists

Answer 23

Mirabegron

SE: HTn

Question 24

Botox

Answer 24

inject through cystoscope
failure of oral meds
SE: UTI, urinary retention

Question 25

DDx of lower urinary tract symptoms (men)

Answer 25

prostate: BPH, cancer, prostatitis
bladder: cystitis, tumour, stone
Urethra: stricture, meatal stenosis, phimosis
neurologic: Parkinson’s, stroke, Alzheimer’s, spinal cord disease
Other: DM, sleep apnea, Rx, dietary

Question 26

Evaluation of LUTS

Answer 26

Hx
PE: DRE - size does not correlate with severity of LUTS
urinanalysis

recommended:
symptoms index score - international prostate symptoms score
Serum PSA if it changes management (need life >10y)

optional:
serum creatinne
cytology - irritative
uroflow
voiding diary
post-voidal residual (no normal value)

when indicated:
urodynamics
cystoscopy
imaging