Lectures Flashcards
Normal function of LUT
Convert a continuous process of excretion (urine production) to an intermittent process of elimination.
Store urine insensibly
Void urine when convenient
Which of these are True or False:
Detrusor muscle Relaxes during Voiding
Distal sphincter contracts during storage
Detrusor = False:
Relaxes during storage (compliant)
Contracts during voiding
Distal sphincter = True:
Relaxes during voiding
What nerve roots drive detrusor contraction
Parasympathetic (cholinergic) S2-4
What nerve roots drive sphincter/urethral contraction or inhibit detrusor contraction
Sympathetic (noradrenergic) T10-L2
Types of LUTS (lower urinary tract symptoms)
Storage
Voiding
Examples of LUTS storage symptoms
Frequency
Nocturia
Urgency
Urgency Incontinence
Examples of LUTS voiding symptoms
Hesitancy Straining Poor-intermittent stream Incomplete emptying Post-micturition dribbling
Haematuria
Dysuria
What does BPH stand for
Benign Prostatic Hyperplasia
BPE stand for
Benign Prostatic Enlargement
BOO stand for
Bladder Outflow Obstruction
Epidemiology of BPH - Benign Prostatic Hyperplasia
Common in men (more with age)
- 23% of men aged 41 to 50 yrs
- 42% of men aged 51 to 60 yrs
- 71% of men aged 61 to 70 yrs
- 82% of men aged 71 to 80 yrs
What is BPH
Increase in epithelial and stromal cell numbers in the periurethral area of the prostate
Causes of BPH
Increase in cell number
Decrease apoptosis
Combination
What % of area density of hyperplastic prostate is accounted for by smooth muscle
40%
Dynamic component of benign prostatic obstruction
alpha-1 adrenoceptor mediated prostatic smooth muscle contraction
Static component of benign prostatic obstruction
volume effect of BPE
Do androgens cause BPE?
No but are a requirement for BPH:
Castration prior to puberty or genetic diseases that inhibit androgen action or production, men do not develop BPH. Androgen withdrawal leads to partial involution of established BPH.
Example of scoring system for LUTS
IPSS
International Prostate Symptom Score
Examples of categories on IPSS (scored on how much related to you):
0-7 is mild
8-19 is moderate
20-35 is severe
Frequency How often do you have sensation o needing to urinate Intermittent Urgency Weak stream Strain to start urination Nocturia Quality of Life due to symptoms
Examinations for LUTS
General examination i.e fitness for surgery Abdominal examination External genitalia Digital rectal examination (DRE) Focused neurological examination Urinalysis
LUTS investigations
Flow rates and residual volume Frequency volume chart Renal biochemistry Imaging PSA TRUSS – trans-rectal ultrasound scan (for size) Flexible cystoscopy (if infection, stones, haematuria or recent onset storage symptoms) Urodynamics
Prevalence of LUTS
25% of population
(48% above 65)
24% of >80 visits to GP/primary care due to LUTS
Variation between genders
LUT anatomy in women
Women only have urethral sphincter (along whole length of urethra) - therefore more likely to have incontinence. Support however by pelvic floor muscles (but also in men).
Why do women who have given birth undergo stress incontinence
Weakened pelvic floor muscles
LUT anatomy in men
Men have 2 sphincteric mechanisms:
Bladder neck mechanism
Distal urethral sphincter
Also have longer urethra so more resistance in male so men less likely to suffer from stress incontinence due to sphincteric deficiency - generally have opposite problem: inability to void
Why do men have 2 sphincters after bladder
For ejaculate
Role of cortex of brain for LUT
Sensation Voluntary initiation (of urination)
What part of brain is responsible for Co-ordination and Completion of voiding
Pontine Micturition Centre/Peri Aqueductal Grey
in pons
Spinal reflexes affecting LUT
Reflex bladder contraction - Sacral micturition centre
Guarding reflex (prevents you pissing yourself) - Onuf’s nucleus
Receptive relaxation - sympathetic (accept more urine without rise in pressure)
Neural control of LUT: Parasympathetic (Cholinergic) - functions and spinal roots
S3-5
Detrusor contraction
Smooth muscle sphincter relaxation
(About peeing or voiding)
Neural control of LUT: Sympathetic (Noradrenergic) - functions and spinal roots
T10-L2
Smooth muscle sphincter contraction
Inhibit detrusor contraction (allows bladder relaxation)
Neural control of LUT: Somatic
Striated sphincter contraction/relaxation (control)
Describe storage of bladder
99% of time
Sympathetic causes detrusor relaxation and sphincter contraction
Bladder fullness increases, messages to the pons and higher centres to consider voiding
Can be postponed until it is convenient
Describe voiding of bladder
1% of time
PMC co-ordinates voiding via parasympathetic causes detrusor contraction and sphincter relaxation at same time
Classification of LUTS
Storage
Voiding
Post-micturition
Classification of LUTS: Storage
Frequency
Urgency
Nocturia
Incontinence
Classification of LUTS: Voiding
Slow-stream Splitting or spraying Intermittency Hesitancy Straining Terminal dribble
Classification of LUTS: Post-micturition
Post-micturition dribble
Feeling of incomplete emptying
How would you define frequent
> 8 times per day or whenever feels more than normal
Define urinary urgency
an immediate unstoppable urge to urinate,
difficult to defer
due to a sudden involuntary contraction of the muscular wall of the bladder
Define Nocturia
Waking up with need to pee with intension of going back to sleep
Define incontinence
Inability to hold urine or involuntary loss of urine
Failure of storage
Parameters that can be measured by a Bladder Diary
Frequency/day Frequency/night Volume/day Volume/night Nocturnal volume/24h volume (should be <1/3) Functional capacity Incontinence/day
How much urine would an average 70kg male pass in 24 hours
~2.7 litres in 24 hours
Define nocturnal polyuria
Nocturnal volume/24h volume >1/3
What is functional capacity
How much bladder can hold
~400ml
Normal Frequency to urinate/day
2-8
Normal frequency to urinate/night
0-1
Normal volume to urinate/day
<2.7L (polyuria is over 2.7L)
Normal volume to urinate/night
<900ml
Normal nocturnal volume/24h volume
<1/3
Normal functional capacity
> 400ml
Normal incontinence/day
0 (abnormal finding)
Types of incontinence
Urgency Stress Mixed (U+S) Continuous Overflow Social
Urgency incontinence
Associated with an urgent desire to void which is difficult to defer
Stress incontinence
associated with coughing or straining
Cause of continuous incontinence
Fistula
Overflow incontinence
Occurs in presence of a full bladder
Social incontinence
Occurs in those with dementia
Define Over Active Bladder (OAB) syndrome
Urgency with frequency, with or without nocturia, when appearing in the absence of local pathology
Urgency is cardinal symptom
Over Active Bladder cardinal symptom
Urgency
Overactive Bladder Management in order
Behavioural therapy Anti-muscarinic agents B3 agonists Botox Sacral neuromodulation Surgery
Overactive Bladder Management: Behavioural Therapy
Frequency volume chart
Cut caffeine, alcohol
Bladder drill - slowly train bladder to hold more by progressively increasing time before can next urinate
Overactive Bladder Management: Anti-muscarinic agents
Decrease parasympathetic activity by blocking M2/3 receptors but have S/E- dry mouth, constipation, vision issues
Overactive Bladder Management: B3 agonists
Increase sympathetic activity at B3 receptor in bladder (stop bladder itself being overactive)
Overactive Bladder Management: Botox (and SEs)
Blocks neuromuscular junction for Ach release
Effects last 6-9 months
S/E Incomplete bladder emptying and need to catheterise in 15%, risk of retention
Most potent toxin to humans
Daycase procedure
Overactive Bladder Management: Sacral neuromodulation
Insertion of electrode to S3 nerve root to modulate afferent signals from bladder
Overactive Bladder Management: Surgery
Augmentation cystoplasty
Involves major surgery
Stress incontinence in females - causes
Usually secondary to birth trauma:
-Denervation of pelvic floor and urethral sphincter
-Weakening of fascial support of bladder and urethra
Neurogenic
Congenital
Management of urinary stress incontinence
*Pelvic floor physiotherapy
Duloxetine (alot of SEs)
Surgery: Sling, colposuspension, bulking agents, artificial sphincter
Causes of stress incontinence in men
Rare
Neurogenic
Iatrogenic (prostatectomy leaving only one sphincter)
Examples of disease causing obstructive voiding problems
BPE (Benign Prostatic Enlargement)
Urethral stricture
Prolapse/mass
Management of BPE (no ED) causing obstructive problems in order (men)
Alpha blockers
5 alpha reductase inhibitor
TURP
Treatment of detrusor under-activity (non-obstructive)
Long term catheterisation to empty (ISC/LTC/SPC)
Sacral neuromodulation in trial phase - works in Fowlers syndrome
Management of BPE and ED in men in order
PDE5 inhibitor
Alpha antagonist
TURP/injections/implant
Management of OAB in men and women in order
Men:
Antimuscarinic
B3 agonist, Alpha antagonist
Botox
Women:
Antimuscarinic
B3 agonist
Botox
Management of Mixed incontinence in men in order
Alpha antagonist/muscarinic
B3 agonist
TURP/Botox
Management of SUI in men in order
Physiotherapy
Surgery
Features of spastic spinal cord injury on bladder
UMN: Lost co-ordination and completion of voiding Reflex bladder contractions Detrusor sphincter dyssynergia Poorly sustained bladder contraction
Features of flaccid spinal cord injury on bladder
LMN: Loss of reflex bladder contraction, guarding reflex and receptive relaxation Areflexic bladder Stress incontinence Risk of poor compliance
Aims of management of neurogenic bladder
Bladder safety
Continence/symptom control
Prevent autonomic dysreflexia
Lesions over what spinal cord level cause autonomic dysreflexia
Lesions over T6
What is autonomic hysreflexia
Overstimulation of sympathetic nervous system below level of lesion in response to a noxious stimulus
Clinical presentation of autonomic hyperreflexia
Headache
Severe hypertension
Flushing
Treatment via reflex bladder
- Harness reflexes to empty bladder into
incontinence device (may not keep bladder
safe!) - Suppress reflexes converting bladder to
flaccid type and then empty regularly
Causes of raised bladder pressure
Prolonged detrusor contraction
Loss of compliance
Result of raised bladder pressure
Problems with drainage of urine from the kidneys and ultimately hydronephrosis and renal failure
What is an unsafe bladder
One that puts kidneys at risk of damage
Risk factors of unsafe bladder
Raised bladder pressure
Vesico-ureteric reflux
Chronic infection (residual urine or stones)
What is a paraplegic
Paralysed from the waist down
Normal upper body function
Relies on reflex bladder
Bladder management of paraplegic
Suprapubic catheter OR Suppress reflexes or poorly compliant bladder converting bladder to safe type and then empty regularly using ISC
Potential issues with catheter
Infections
Stones
Autonomic dysreflexia
What can be given to suppress bladder reflex contractions
Anticholinergics Mirabegron Intravesical botulinum toxin Posterior rhizotomy Cystoplasty
Examples of flaccid and low spinal lesions
Spina bifida Sacral fracture Transverse myelitis Ischaemic injuries Cauda equina
Features of complete loss of distal cord function
Flaccid paraplegia Areflexic bladder Stress Incontinence Areflexic bowels Loss of REFLEX erections
Treatment of Neurogenic Stress Incontinence
Ensure bladder safe before treating
Men = artificial sphincter
Women = Autologous sling, Artificial Sphincter, Synthetic Tapes TVT/TOT not
recommended by NICE
Bladder problems in MS
- Overactive bladder syndrome urinary urgency and frequency, caused by neurogenic detrusor overactivity
- Incomplete bladder emptying
