Urology: Voiding Dysfunction Flashcards
embyrology of the bladder
- formed along side the lower GI tract from the endodermal tissue
why is embryology important in urology?
problems in one system can be associated in problems in the other system
what does the lower urinary tract do?
- storage of the adequate volumes of urine at low pressure and with no leakage
- emptying which is voluntary, efficient, complete and low pressure
function of the bladder
- stores urine at low pressure
- compresses urine for voiding
function of the urethra
- conveys urine from the bladder to the outside world
function of the internal and external urethral sphincter
- controls urine flow & maintain continence between voidings
how does the nervous system control the lower urinary tract
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
why is the spinal arch used?
to inhibit voiding until the appropriate time arrives
what does a voiding study do?
- measures the external sphincter muscle activity apart from the pressure in the bladder neck and the bladder proper
how does voiding mature in humans?
- 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
what is the incorrect way of voiding inhibition?
contraction of the external sphincter rather than stopping bladder contraction
how can voiding dysfunction be classified?
- storage problem
- voiding problem
what happens in storing problems?
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
what happens in emptying problems?
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
clinical problems from voiding dysfunction
- increased bladder pressure: VUR, upper tract damage, bladder hypertrophy leading to detrusor failure
- residual urine: uTI, infected stones, CRF
- incontinence: social consequences
presentation of voiding dysfunction
- infrequent voiding
- frequent voiding
- urgency
- dysuria
- holding manoeuvers
- straining
- poor stream
- intermittent stream
- incomplete emptying
- incontinence
- urinary tract infections
- VUR
what happens in a bladder outflow problem?
- slow stream
- hesitancy
- post micturition dribbling
- overflow incontinence
- remember posterior urethral valves in children
causes of secondary obstruction
- infective
- traumatic
- iatrogenic
- poor catheterisation technique
what happens in detrusor disorders?
- extraordinary daytime urinary frequency syndrome
- giggle incontinence
- stress incontinence
- urgency/urge incontinence
- primary monosymptomatic noctural enuresis (happens in children/teenagers)
how can elimination problems be classified?
- storage
- emptying
- continence
- rule out neurologic, urologic or other organic causes
history of an elimination problem
- 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
what condition should you think of in a girl over the age of 4yo who has continued to wet herself during the day?
ectopic ureter
things to look out for a physical examination?
- 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
what to look out for in a neurological examination?
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
what should the urinalysis assess?
1st AM pee
investigations in voiding dysfunction
- post void residual urine by catheterisation or US
- abdominal radiograph (KUB)
- renal and bladder ultrasound (check for thickness in the walls, hydronephrosis)
Parameters used to diagnose urodynamic dysfunction
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
management of bladder outflow obstruction
- medical therapy (alpha blockers, 5-alpha reductase inhibitors)
- phytotherapy
- TURP
complication of TURP
- bleeding
- infection
- TUR syndrome
- stricture
- retrograde ejaculation
what determines the compliancy of a bladder?
neurological reflex activity and LPP
what is poor bladder compliance associated with?
- incontinence
- UTIs
- upper tract damage
alterations in lower urinary tract functions due to spinal cord injury
- incontinence
- neurological obstruction (elevated intravesical pressure, VUR)
- increased risk of UTIs
- stones
pharmacological treatment of voiding dysfunction overactivity
- anticholinergics (urgency, frequency, urge incontinence)
- DDAVP
- M3 agonists
- low dose UTI prophylaxis
what should be 2 key principles in treating voiding dysfunction
- preserve renal function
- continence is not an issue in the first few years of life
treatment of neurogenic bladder
- clean intermittent catheterisation
- continent catheterisable stomas
what is a Mitroffanoff procedure?
a conduit, made of the appendix is used to connect the bladder to the umbilicus so that catheterisation can be done easily
indication of Mitroffanoff procedure
- wheelchair bound patients with severe scoliosis lordosis
- poor upper extremity function
- males with intact urethral sensation
what is a bladder augmentation?
- done when medical therapy fails to achieve a low pressure capacity with continence
- variety of substances and surgical techniques used each with problems
types of bladder augmentation
- 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)
how can you improve continence by increasing sphincter resistance?
- 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
