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Surgery II > Urology: Voiding Dysfunction > Flashcards

Urology: Voiding Dysfunction Flashcards

1
Q

embyrology of the bladder

A
  • formed along side the lower GI tract from the endodermal tissue
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2
Q

why is embryology important in urology?

A

problems in one system can be associated in problems in the other system

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3
Q

what does the lower urinary tract do?

A
  • storage of the adequate volumes of urine at low pressure and with no leakage
  • emptying which is voluntary, efficient, complete and low pressure
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4
Q

function of the bladder

A
  • stores urine at low pressure

- compresses urine for voiding

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5
Q

function of the urethra

A
  • conveys urine from the bladder to the outside world
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6
Q

function of the internal and external urethral sphincter

A
  • controls urine flow & maintain continence between voidings
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7
Q

how does the nervous system control the lower urinary tract

A

CNS

  • Periaqueductal gray matter receives bladder filling info
  • Frontal/parietal lobes & cingulate gyrus inibit lower micturition centers
  • Hypothalamus center initiate voluntary voiding
  • Pontine Micturition center excites Bladder & inhibits sphincter

Spinal

  • Sympathetics T10-L1 via hypogastric Nerve
  • S2-S4 Parasympathetic via Pelvic N Somatic via Pudental N
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8
Q

why is the spinal arch used?

A

to inhibit voiding until the appropriate time arrives

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9
Q

what does a voiding study do?

A
  • measures the external sphincter muscle activity apart from the pressure in the bladder neck and the bladder proper
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10
Q

how does voiding mature in humans?

A
  • 1-2yo: they pee whenever they feel that their bladder’s full
  • 2-3yo: can be able to start or stop voiding voluntarily
  • 2-4yo: children have mastered voluntary control
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11
Q

what is the incorrect way of voiding inhibition?

A

contraction of the external sphincter rather than stopping bladder contraction

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12
Q

how can voiding dysfunction be classified?

A
  • storage problem

- voiding problem

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13
Q

what happens in storing problems?

A

patients fail to store normal volumes of urine at low pressure and without leaking; symptoms include a noncompliant bladder, irritable bladder and an inadequate sphincter tone during filling

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14
Q

what happens in emptying problems?

A

patients fail to empty completely, on command, efficiently at low pressure; symptoms include failure of neurological control of bladder, bladder muscle failure and failure of sphincter relaxation during voiding

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15
Q

clinical problems from voiding dysfunction

A
  • increased bladder pressure: VUR, upper tract damage, bladder hypertrophy leading to detrusor failure
  • residual urine: uTI, infected stones, CRF
  • incontinence: social consequences
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16
Q

presentation of voiding dysfunction

A
  • infrequent voiding
  • frequent voiding
  • urgency
  • dysuria
  • holding manoeuvers
  • straining
  • poor stream
  • intermittent stream
  • incomplete emptying
  • incontinence
  • urinary tract infections
  • VUR
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17
Q

what happens in a bladder outflow problem?

A
  • slow stream
  • hesitancy
  • post micturition dribbling
  • overflow incontinence
  • remember posterior urethral valves in children
18
Q

causes of secondary obstruction

A
  • infective
  • traumatic
  • iatrogenic
  • poor catheterisation technique
19
Q

what happens in detrusor disorders?

A
  • extraordinary daytime urinary frequency syndrome
  • giggle incontinence
  • stress incontinence
  • urgency/urge incontinence
  • primary monosymptomatic noctural enuresis (happens in children/teenagers)
20
Q

how can elimination problems be classified?

A
  • storage
  • emptying
  • continence
  • rule out neurologic, urologic or other organic causes
21
Q

history of an elimination problem

A
  • detailed voiding history
  • detailed defaecation history
  • past elimination/urologic history
  • UTIs/constipation/age of toilet training
  • intake history - fluids and diet
  • family history of urologic problems
  • voiding symptoms and pattern of incontinence
  • check for endocrine, neurological and urological problems
  • sexual abuse
  • stressful occurrence
22
Q

what condition should you think of in a girl over the age of 4yo who has continued to wet herself during the day?

A

ectopic ureter

23
Q

things to look out for a physical examination?

A
  • renal masses (tumour, polycystic kidney)
  • distended bladder
  • large stool mass suggestive of constipation
  • dampness at the beginning of the exam
  • signs of erythema or irritation may be indicative of vaginal voiding
  • meatal stenosis in boys and presence of labial adhesions in girls
  • signs of trauma suggestive of sexual abuse
  • careful examination of the introitus for an ectopic ureter
  • location of anus
24
Q

what to look out for in a neurological examination?

A

Lumbosacral spine for lipoma, sinus, pigmentation tufts of hair- may be clue to underlying occult myelodysplasia
Perineal sensation, anal sphincter tone, lower limb function/gait/sensation & Peripheral reflexes
The bulbocavernosus reflex: squeeze glans penis or clitoris & observe or feel reflex contraction of external anal sphincter
Checks integrity of the lower motor neuron reflex arcs
Absence suggestive of a sacral neurologic lesion

25
Q

what should the urinalysis assess?

A

1st AM pee

26
Q

investigations in voiding dysfunction

A
  • post void residual urine by catheterisation or US
  • abdominal radiograph (KUB)
  • renal and bladder ultrasound (check for thickness in the walls, hydronephrosis)
27
Q

Parameters used to diagnose urodynamic dysfunction

A

Bladder capacity of <10-15 mL/kg body weight,
Postvoid residual of >2 mL/kg body weight,
Detrusor hyper-reflexia, (detrusor contractions during bladder filling without urine leakage and intravesical pressure of >40 cm H2 O
Voiding detrusor pressure of >70 cm H2 O
Dyssynergic increase or lack of suppression of sphincteric EMG with a detrusor contraction

28
Q

management of bladder outflow obstruction

A
  • medical therapy (alpha blockers, 5-alpha reductase inhibitors)
  • phytotherapy
  • TURP
29
Q

complication of TURP

A
  • bleeding
  • infection
  • TUR syndrome
  • stricture
  • retrograde ejaculation
30
Q

what determines the compliancy of a bladder?

A

neurological reflex activity and LPP

31
Q

what is poor bladder compliance associated with?

A
  • incontinence
  • UTIs
  • upper tract damage
32
Q

alterations in lower urinary tract functions due to spinal cord injury

A
  • incontinence
  • neurological obstruction (elevated intravesical pressure, VUR)
  • increased risk of UTIs
  • stones
33
Q

pharmacological treatment of voiding dysfunction overactivity

A
  • anticholinergics (urgency, frequency, urge incontinence)
  • DDAVP
  • M3 agonists
  • low dose UTI prophylaxis
34
Q

what should be 2 key principles in treating voiding dysfunction

A
  • preserve renal function

- continence is not an issue in the first few years of life

35
Q

treatment of neurogenic bladder

A
  • clean intermittent catheterisation

- continent catheterisable stomas

36
Q

what is a Mitroffanoff procedure?

A

a conduit, made of the appendix is used to connect the bladder to the umbilicus so that catheterisation can be done easily

37
Q

indication of Mitroffanoff procedure

A
  • wheelchair bound patients with severe scoliosis lordosis
  • poor upper extremity function
  • males with intact urethral sensation
38
Q

what is a bladder augmentation?

A
  • done when medical therapy fails to achieve a low pressure capacity with continence
  • variety of substances and surgical techniques used each with problems
39
Q

types of bladder augmentation

A
  • ileum and colon (hyperchloremic hypokalaemia acidosis)
  • stomach (less mucous, can cause hyperkalaemic metabolic alkalosis, can cause haematuria and dysuria due to acid)
  • dilataed ureter or non functioning kidney
  • detrusor myotomy (autoaugmentation)
40
Q

how can you improve continence by increasing sphincter resistance?

A
  • alpha-adrenergic drugs increase sphincter tone
  • surgical techniques (periurethral injections, bladder neck suspension, sling procedures, artificial urinary sphincter)
  • stress incontinence: pelvic floor exercises to increase the tone

Surgery II (19 decks)

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