Neuro-Urology Flashcards
Phases of bladder Function
Filling - Detrussor muscle stretches, Sphincter Contracts (constant low pressure)
Voiding Phase- Detrussor Contracts, Sphincter Relaxes
Innervation of LUT
Autonomic:
Pelvic Parasympathetic
Lumbar (Hypogastric) Sympathetic
Somatic:
Pudendal
Micturition Pathway
Afferent Sensory Information relayed to the Pontine Micturition Centre via spinothalamic tracts - known as the M Region then to the periaquaductal grey matter
Then relayed to frontal/pre-frontal/mid-brain for modulation before going back through PAG before **sacral efferent output **
Bladder Reflexes
There are a total of 4 lumbo-sacral reflexes modulated by the pontine micturition centre:
Pro-Continence:
Pelvo-hypogastric ( - Detrussor)
Pelvo-somatic, (- Detrussor , + Sphincter)
Somato-Pelvic (- Detrussor , + Sphincter)
Pro-Voiding:
Pelvo-Pelvic (+ Detrussor , - Sphincter)
Other than bladder reflexes - what supports continence
Volitional effort from sphincters + PF muscles
Which Muscarinic Receptor mediates Cholinergic Contractions
M3 (ACh -> Phospholipase C Hydrolydis -> Ca++ release -> SM contraction)
What do catecholomines do for continence
a-adrenoreceptor stimulation - BN + Urethral SM Contraction
Noradrenaline - B-Adrenorecptor mediated detrussor relaxation
Where can neurological conditions manifest in urological symptoms.
(4)
Brain
Suprasacral
Sacral
Peripheral
Pattern in suprascral injury
Detrussor Hyperreflexia
DSD
Reflex Bowel Emptying
Pattern in Sacral Injury
Areflexic Bladder -> Overflow incontinence
Adynamic anorectum
How can you test S2-S4
Bulbocavernosus Reflex
Baseline Investigations for Suspected Neurogenic DO/ DSD
Bloods, Urinalysis
USS
FR + PVR
Bladder Diary
QOL - Qualiveen
What is Qualiveen
A 30 item assessment instrument originally designed to assess QOL in patients with urological symptoms due to multiple sclerosis
NICE - who should get VUDS in context of neuro-urology
HIGH RISK of renal complications (Spina Bifida, SCI). Don’t routinely offer to patients with low risk of renal complications.
When consider surgical intervention
Non Invasive Treatment for Neurological Bladder
Behavioural Therapy
Bladder Rehabilitation
Drugs (storage + Voiding)
Drugs Available for :
Storage
Voiding
Storage:
Anti-muscarinics
B3 Agonist
Desmopressin
Voiding:
Alpha Antagonist
Muscarinic Agonist ( Bethanecol)
Surgical Management
Stress UI due to Sphincter Inctoninence
AUS
Bladder Neck Sling
Sub Urethral Tape
Bulking Agent
Bladder Neck Closure
Surgical Management
Incontinence 2o to Detrussor Underactivity / Sphincter Overactivity
Intraurethral Stent
Transurethral Incision of Sphincter
Botox to sphincter
Surgical Management
DO
i) with DSD
ii) without DSD
i) Sacral Deafferentiation +/- CISC +/- Sacral Anterior Root Stimulation
ii) Bladder Botox / Enterocystoplasty/ Bladder autoaugmentation
Which procedures decrease bladder contractility
Botox
Cystoplasty
Autoaugmentation
What dose BOTOX do
Interacts with SNARE complex thus proventing neurotransmitter release and stopping SM contraction
Which study for BOTOX in SCI + MS Patients
DIGNITY Study ->
i) Increased cytometric bladder capacity
ii) Decreases Voiding pressure
iii) Improved QOL
iv) higher incidence of UTI (50% vs 25%)/ Urinary Retention (6% vs 2.5%)
Which procedures can enhance detrussor contractility
Sacral Anterior Root Stimulator
- Extradural/Intradural placement
Procedures to decrease outlet resistance
External Sphincterotomy (TUI)
Urethral Stent
Botox to sphincter
