Voiding Disorders Flashcards
Discuss the Bladder anatomy
- where is the base
- where is the apex
- what is the trigone
- what is the neck
- what is the detrusor muscle
Base: the posterior, inferior portion of the bladder at which the URETERS enter the bladder
Apex: at the pubic symphysis & continues at the median umbilical ligament
Trigone: the triangle created by the location of the two ureters entering, and the exit of the urethra most commong sight of where cancers can occur
Neck: most inferior portion which surrounds the urethral opening & supported by the pubovescular ligament
PB lig. is what gets stretched during pregnancy and leads to stress incontinence
Detrusor: the muscle wall layer which surrounds the entire bladder
how is the bladder innervated?
- specifically the internal urethral sphincter & the detrusor muslce
- parasymp from where?
- symp from where?
what happens with urination
the internal sphincter con stricts & the detrusor muscule relaxes with sympathetic stimulation = urinary retention
the internal sphincter relaxes & the detrusor muscle constricts (pushes) the urin out with parasympathetic stimulation = urinary release
sympathetic stimulation: L1, L2, L3, hypogastric plexus, sacral splancnic nerves
parasympathetic stimulation: S2, S3, S4, hypogastric plexus,
internal sphincter: involuntary control (autonomic)
extrenal sphincter: voluntary control
Urination
- bladder fills & distension occurrs
- stretch receptors on bladder send signal to brain (S2,S3, S4)
- stimulation of parasympatheitc causes the detrusor muscle ton contract and push the urine out while internal sphincter relaxes
- the pudenal nerve (somatic -voluntary) signals the external sphincter to relax too
types of urinary incontinence
stress incontinence: weak muscles which cannot hold in theurin during increased intra-thoracic pressure (coughing, laughing, jumping, etc.)
Urge incontinence: a strong and sudden urge to void, cannot make it to the bathroom; frequent small voids (nighttime too)
detrusor hyperactivity
overflow incontinence: an obstruction leads to the inability to enpty fully & eventually leaks out
detrusor hypoactivity
causes of urinary incontinence (without urinary pathology)
DIAPPERS
D: delirium/confusion
I: infection
A: atrophic vaginia/ureter
P: pharma (meds)
P: psychiatric stress
E: excessive urinary output
R: restritcted mobility
S: stool impaction
Drug Related Urinary Incontinence
two unique ones & others
Beta-3 agonists: used for overactive incontinence but can cause it too
antimusarinic: used for overactive incontinence but can cause it too
antidepressants, alpha blockers, ACE, antipsychotics, alcohol, caffeeine, benzos, decongestants, antihistamines, opiods, ORAL estrogen
Key Aspects of the History to take for Urinary Incontinence
- clues that there is an underlying condition
- OB (vaginal delivery), organ prolapse, surgery, hormones, obesity, UTI = give good idea baout type of incontinence’
signs there cold be underlying issues…
- a sudden onset & severe pain
- hematuria (w/o infection) = malignancy
- weakness in LE & change in walking
- cardiopulmonary symptoms
- neurologic changes/AMS
get idea about impact on life! depression, anxiety, irritation, work problems, social issues
Labs to get for Urinary Incontinence
when to refer?
Labs
- urinlyasis
- urine cx.
- urine cytology (if blood! micro or macro)
additional…
- bladder stress test
- post void residual
- urethral hypermobility test
refer when…
- need urodynamics to understand (double cath. test)
- UTI reoccurance
- hematuria without infection
- hx. of GU surgery
- peliv prolaspe
- prostate CA
- not responding to initial treatments
Stress Urinary Incontinence
- Etiology
- Signs and Symptoms
- Diagnosis
- Treatment
Etiology
- increased intraabdominal pressure –> leads to involuntary leakage of urine
- think of pregnant, post-partum, low-estrogen
- older age
- obestiy (more pressure)
- the muscles lost their tone: there is no more support
- urethral hypermobililty
- no urge to go before it happens
Signs Nd symptoms
- leaking when laughin, jumping, sneezing or exercsion
Diagnosis
-clincial based on history
Treatment
- weight loss (obese)
- fluid management/dietary changes
- bladder training
- pelvic floor exercises
- kegals: vaginal weights
NO pharm treatment recommended but can see….
- topical estrogen (short term)
- duloxetine (if depressed too)
- surgical management if none of the lifestyle factors are helpful
Urge Urinary Incontinence/Overactive Bladder
hyperactive detruser muscle
Etology
signs and symptoms
diagnosis
treatment
2 second line: Beta-3 agonists
Etiology & symptoms : sudden, frequent need to urinate + leaking because they cant make it to the bathroom on time
Diagnosis: clinical: can do urinalysis/cx. if infection suspect
Treatment
non-pharm: weight loss, fluid changes, bladder training, pelvic floor exercises
pharm:
#1: FIRST LINE: antimuscarinics
- reduce urgency to go because they block release of ACH during bladder filling
- +/- effects to cure but can help (2-4 weeks to improve)
- side effects: sympathetic : dry mouth, constipation, drowsy, tachycardia
- contraindication: angle closure glacoma, gastric retention
- NAMES: oxybutinin & tolteradine (most selective) , darifenicin, solifencinin, fesoterodine, trospium
- activate beta-3: tell detrusor muscle to relax & increases capacity
- caution use in: uncontrolled BP (incs. 1-2 mmhg) , renal/hepatic impaired, those with long QTc
- $$$
- NAME: mirabegron
botox too
Overflow Incontinence
Etiology
Symptoms and Signs
Diagnosis
Treatment
Etiology: incomplete bladder emptying (a consistent dribble of urine)
think: obstruction
- detrusor muscle hyPOactivivity
- obstruction of the urethra or bladder neck
- medications (Bblockers, relaxants)
- neurologic issues (spinal cord injury)
Treatment
- treat underlying condition (BPH, etc.)
- catheterization (intermittent > indwelling) may be needed
Acute urinary Retention
etiology
Symptoms and Signs
Diagnosis
treatment
Etiology: inability to pass urine despite producing enough; painfull and fullness feeling
- MC: BPH in men
- obstructions
- neurologic reasons (sensory or motor issue)
- detrusor muslce issue
- medications (overuse of anticholenergics or sympathomimics for urge incontinence)
- trauma
Symptoms and Signs
- palpable bladder & tender
Diagnosis
- urinalysis/cx. (cath to get)
- renal function and chemistries
- cbc (infection suspected)
- PSA NOT RECOMMENDED: it will be high
- bladder US (if highly suspicious for AUR you can cath. right away)
Treatment
- bladder decompression via catheter
- find underlying causes (if BPH: alpha blocks and send to urology)
- spasm from cath: give oxybutitin
Post-Op urinary retention
- etiology
- at risk pop.
- diagnosis
- treatment
etiology: catecholamines stimualte alpha-adernergic receptors in the bladder and the smooth muscles (leading to retention)
at risk pop
- elderyl
- excessive fluid
- anorectal surgery
- long surgery (> 2 hours)
- spinal epidural anesthesia
Diagnosis
- bladder US or cath. (> 300cc in there)
Treatment
- catheterization
- GU referal to urogloy
- antibiotics if high risk of UTI
Chronic Urinary Retention
- etiology
- treatment
etiology
- long term retention due to….
- obstruction
- neruologic disease/injury
- detrusor muscle hypoactivity
wont be painful but –> can lead to constant leak of small urine
Treatment
- intermittent or in-dwelling catheter
