Urodynamic studies and Neuropathic bladder Flashcards
A muscle that forms the layer of the urinary bladder
Detrusor
The internal urethral sphincter is under involuntary control by
Sympathetic stimulation
External urethral sphincter is striated under voluntary control by the
Pudendal nerve
3 layers responsible for the contraction of the bladder wall
Outer longitudinal
Middle circular
Inner longitudinal
In the inner longitudinal layer the convergence of the muscle fibers froms a thickened bladder neck which functions as
Internal smooth-muscle sphincter
Main function of the bladder
Storage of urine
Normal capacity of bladder averages
350mL
Micturition reflex is located in
Sacral cord
When the sensation of fullness is transmitted to the sacral cord, what happens on the motor arc of the reflex
It causes a powerful and sustained detrusor contraction and urination if voluntary control is lacking
Normal residual urine volume in the bladder
0, but for clinical purposes <50 – normal
Only organ that is voluntary and at the same time under CNS control
Bladder
The door for the exit of the urine
Sphincteric unit
These 2 have to coordinate to affect the normal voiding pattern
Sphincter unit and the ureterovesical junction
2 sphincters involved in the sphincteric unit
Internal involuntary smooth muscle
External voluntary striated
Location of the internal involuntary sphincter
Near the bladder outlet
Location of the external sphincter
Proximal to the prostatic urethra
This unit prevents backflow
Ureterovesical unit
The ureterovesical unit is located at
Trigone
The superficial trigone is above the
Waldeyer’s sheath
This supplies the urinary bladder with autonomic nerves
Pelvic plexus
Parasympathetic innervation is derived from
S2-s4
Afferent innervation
Pudendal nerve
Hypogastric plexus
Parasympathetic efferent innervation
Pelvic plexus
You can control urination by trying to contract the
External sphincter
What happens in the fight or flight mechanism why there’s inhibition of urination
Sympathetic stimulation increases contraction of the internal urethral resistance of the sphincter
Micturition centers
Spinal cord (sacral) and Pons
Disorders of the bladder secondary to neuromuscular disease
Neuropathic bladder disease
This center elicits a direct reflex in infants
Sacral micturition center
Integration center for signals from bladder, cerebral cortex and hypothatlamus
Periaqueductal gray
How does the pontine micturition center initiate voiding
Distention stimulates the PMC then it will send signals for the detrusor to contract and the sphincter to relax thus voiding
End result of detrusor contraction
Sphincter relaxation
Although micturition and urine storage are primary functions of the autonomic nervous system, these are under voluntary control from
Suprapontine cerebral centers
pertains to disorders of the nerve conduction to the bladder
Neuropathic neuromuscular
Lesions above sacral micturition center
Bladder spasticity
Dementia, CVA, MS, tumors
Spinal cord injury
Lesions below sacral micturition center
Flaccid
Injury at the center, s2-s4
Involuntary contractions with coordinated sphincter function indicates a lesion where
Above the brainstem
What will happen initially if there’s a lesion above the brainstem
Detrusor areflexia
Ddx if lesion is above the brainstem
Cystitis Chronic urethritis Interstitial cystitis Cystocele Bladder outlet obstruction
Sphincter is not coordinating with the bladder
Dyssynergia
T or F: Normally if the bladder contracts the sphincter should also contract
False: if the bladder contracts the sphincter should relax
If there’s involuntary bladder contractions without sensation the lesion is where
Complete spinal cord lesions from level T6-S2
If there’s bladder spasticity/contracted bladder where’s the lesion
Above the sacral micturition center (S2-S4)
Loss of inhibition from higher centers resuls in
Overactive bladder and sphincter bhvr on the segmental lvl
Spastic neuropathic bladder is typified by
Reduced capacity Involuntary detrusor contractions High intravescial voiding pressures Marked hypertrophy of the bladder wall Spasticity of the pelvic striated muscle Autonomic dysreflexia in cervical cord lesions
If there’s frequency in urination the lesions is located in
Spinal cord
Manifestation if there’s complete spinal cord lesion
Sensation of bladder fullness becomes absent
What happens initially if there’s spinal shock
Urinary retention
One of the first indications of return of detrusor reflex activity
Strong detrusor contraction in response to filling with cold saline
Test used to differentiate upper from lower motor neuron lesions early in the recovery phase
Ice water test
If the injury is at the upper motor what would be the manifestations
Spastic – spontaneous spasms in the extremeties, leakage of urine or stool
If the injury is at the lower motor what would be the manifestations
Flaccid
Flaccid neuropathic bladder is aka
Neurogenic areflexic bladder
Direct injury to the peripheral innervations of bladder or sacral segments S2–4 results in
Flaccid paralysis of the bladder
Principal urinary symptom of flaccid neuropathic bladder
Retention with overflow incontinence
s/sx of neurogenic overactive bladder
Lack of true sensation of fullness and involuntary urination
Used to assess the integrity of the urethra and identify stricture sites
Cystourethroscopy, ureteroscopy
Abnormal bladder capacity caused by flow into the blind sacs or diverticula
Cystocoele
This is done if there’s urethral sphincter dyssynergia
Sphincterectomy
Treatmen of spastic neuropathic bladder includes
Foley catheterization Sphincterectomy Sacral rhizotomy Neurostimulation Urinary diversion
implanting a bladder pacemaker to stimulate sacral nerve roots and accomplish bladder evacuation
Neurostimulation
Treatment for spinal shock
Foley catheterization
Suprapubic cystostomy
Control of infection and calcium stone prevention
How is crede maneuver done
Manually pushing on the suprapubic area
This is indicated for hypertrophy of the bladder neck or an enlarged prostate
Transurethral resection of the bladder neck
Effect of parasympathomimetic drugs
They provide increased bladder tonus to help contract effectively
Complications of neuropathic bladder
Recurrent UTI
Hydronephrosis (d/t ureteral reflux or obstruction)
Stone formation
Techniques used to obtain graphic recording of activity in the urinary bladder, urethral sphincter and pelvic musculature
Urodynamic studies
Urodynamic studies are used to evaluate
Bladder and sphincter function and act of voiding
Study of flow of urine from urethra
Uroflowimetry
Used to measure reservoir function of lower urinary tract
Cystometry
Used to monitor urethral activity
EMG
