Neuropathic Bladder Dysfunction Flashcards
Name some storage and voiding LUTS
Storage
- frequency
- urgency
- nocturia
- incontinence
Voiding
- slow stream
- splitting or spraying
- intermittency
- hesistancy
- straining
- terminal dribble
What things would we look for in a bladder diary?
- If patient has symptoms, a patient should full out a bladder diary to see how much their urinating and when.
What do we look for in the diary?
- Time that they are going
- Frequency per day
- Frequency per night
- Volume per night
- Nocturnal volume
- Functional capacity
- Incontinence
What is a normal amount of times to urinate a day?
2-8 times
Risk factors for urinary incontinence
- female (pregnancy, vaginal delivery, DM, oral oestrogen. therapy, high BMI), hysterectomy, childbirth damaging pelvic floor muscles, more common in women with UTIs
- Older age
Main cause of incontinence in men
Enlargement of the prostate is the major cause
TURP surgery may also weaken. the bladder sphincter and cause incontinence
What is functional incontinence?
Physiological factors unimportant, patient is ‘caught short’ and too slow finding toilet due to immobility, unfamiliar surroundings etc.
What is stress incontinence?
Who is more at risk?
Treatment?
- Urine leakage from incompetent sphincter when the bladder is under pressure due to increased intra-abdominal pressure (eg. after coughing, sneezing or laughing)
- Increasing age, pregnancy and obesity are risk factors
- Key to diagnosis is small but often frequent amount of urine when coughing etc.
- Common in pregnancy and following birth - occurs in about 50% of post menopausal women
- Treatment
- Pelvic floor exercises are 1st line (8 contractions 3x a day for 3 months).
- Avoid caffeine, diuretics, overfilling bladder etc.
- Weight loss if appropriate
- Medical option: duloxetine (SNRI antidepressant) - increases contraction of urethral sphincter
- Surgical options: intravaginal electrical stimulation, tension free vaginal tape to stabilise the mid-urethra.
- Male with stress incontinence - prostatectomy, neurogenic - treat with artificial sphincter.
What is urge incontinence?
Who is more at risk?
Treatment?
Sudden and very intense urge to pass urine, where unable to delay going to the toilet and uncontrollable contraction of the detrusor muscle. Detrusor muscle overactivity.
Precipitated: arriving home, cold, caffeine, obesity, secondary to stroke, spinal cord injury etc. Other causes: UTI, diuretics, diabetes.
Affects females more than males
Treatment
- Bladder training
- Kegel exercises
- Aids (absorbent pads, condom catheters for males)
- Antimuscarinics to decrease detrusor muscle activity (tolderodine)
- Botox
- Topical oestrogens for post menopausal with urgency and frequency
- Surgery last resort, bladder augmentation, botox, percutaneous sacral. nerve stimulation.
What is mixed incontinence?
- Mixture of urine leakage with coughing/sneezing and also experience very intense urges to pass urine. Mixed stress and urgency
- Eg. Pregnant woman with UTI
What is continuous incontinence?
- Constant stream as the bladder fills
- Due to fistulas for example
What is overflow incontinence?
- Usually due to chronic bladder outflow obstruction
- Often due to prostatic disease in men
- Can lead to obstructive nephropathy due to back pressure.
What are some causes of obstructive voiding problems?
BPE, urethral stricture, prolapse, masses.
What treatment can we offer for those with voiding problems?
Obstructive
- If BPE = give alpha blockers (release smooth muscle) and or 5alpha reductase inhibitors (reduces side of prostate, stops conversion of testosterone to dihydrotestosterone)
- PDE5i = viagra - helps empty bladder and relaxes bladder neck & can treat erectile dysfunction too.
- TRUP - shaving inside of prostate, bigger hole to urinate through
Non-obstructive - destrusor underactivity
→ Long term catheter
Describe what happens in a suprasacral / spastic spinal cord injury. What is a complication which can occur?
- Spinal injury anywhere above the sacral spinal cord
- Sacral part controls bladder reflex so if it is supra-sacral the micturition reflex will not be affected
- What is disrupted is the brain’s ability to control the reflex and inhibition of the reflex
- We lose co-ordination and completion of voiding
- Features: reflex bladder contractions, signal blocked from going to brain, bladder becomes autonomous and will squeeze to empty bladder, guarding reflex comes into play.
- This leads to poorly sustained bladder contraction leading to incontinence and overtime, the bladder muscle thickens.
- Thickened bladder wall means there is an increased pressure in the bladder leading to either incontinence or urine can reflux into the kidneys
- Effect: potentially unsafe
Describe what happens in a conus/sacral spinal cord injury
- Damage to sacral micturition centre - S2,3,4 so no sensation or contraction can occur
- This leads to bladder filling until it can no longer fill & it will not contract.
- Sacral spinal cord injury causes a weak sphincter so any increase in pressure in the bladder will cause incontinence.
- Lost: reflex bladder contraction, guarding reflex, receptive relaxation
- Areflexic bladder, stress incontinence as sphincter is open, risk of poor compliance
