Voiding Dysfunction Flashcards
Three micturition centers and their functions
- Cerebral Cortex Micturition Center (“controls when you go”)
- Inhibits bladder activation (default) - Pontine Micturition Center (“tells everyone what to do”)
- coordinates urethral sphincters and the bladder - Sacral Micturition Center (“Gets the job done”)
- parasympathetic and pudendal nerves signal allows micturition to occur.
Two main phases of voiding
Filling/Storage
Emptying
What can cause fill/storage problems with the bladder?
- Bladder overactivity (too much contraction)
- Heightened sensation by sensory/afferent receptors
- Poor compliance (due to high pressure/stiff bladder)
- Sphincter incompetence (weak or damaged sphincter muscle)
What can cause bladder overactivity by increasing contraction?
- aging
2. neurological conditions (stroke, parkinson’s)
What can cause problems with emptying the bladder?
- Dec. bladder contractility
2. Inc. outlet resistance
What can prevent bladder emptying by increasing outlet resistance?
- Overactivity of
- external sphincter muscle
- pelvic floor muscles (can’t relax) - Obstruction by
- BPH or PC
- Mass or scar causing urethral stricture
- Pelvic organ prolapse
- Female sling
A graph that plots flow rate vs. flow time to determine voided volume
Uroflow
Normal urine flow for men vs. women
Men: 15-20 mL/sec
* abnormal if <10
Women: 30 mL/sec
The bladder should be able to empty at least ____%.
75%
Ex.) Void 300 mL with PVR <100 mL
If a patient has low urine flow, or high post void residual volume, you should suspect…
Outlet obstruction (BPH, sling, mass) Poor detrusor function
Normal bladder holds roughly ____ mL to _____ mL of urine.
300-500
Continuum of care for over-active bladder (bladder overactivity/heightened sensation)
- Behavioral/lifestyle modification
- Avoid caffeine
- Scheduled toileting
- Weight loss - Medication
- M3 antagonists
- B3 agonists - Injection therapy
- botox
- sacral neuromodulation (implant) - Surgery
What are anticholinergics that can treat over-active bladder (bladder overactivity/heightened sensation)
Oxybutynin
Anticholinergics are contraindicated in patients with
- narrow angle glaucoma
2. gastroparesis
Treatment for outlet/sphincter incompetence
Female: sling or bulking agents
Male: sling or artificial sphincter
- No medications can fix this
What voiding dysfunction is NOT treatable/”fixable” at all?
Decreased/absent bladder (detrusor) contraction
No medications
- bladder needs to be emptied using catheters
Treatments for voiding dysfunction due to increased outlet resistance
- External sphincter overactivity
- bypass using catheters (best)
- botox - Pelvic Floor dysfunction
- physical therapy (relax pelvic muscles)
- electrical stimulation
Treatments for voiding dysfunction due to BPH
- Medication
- 5a-reductase inhibitor (finasteride)
- a1 antagonist (Tamsulosin) - TURP (prostate reduction surgery)
Who needs evaluation for bladder trauma
Stable patients with gross hematuria and mechanism concerning for bladder injury (pelvic fractures or penetrating injury)
How can you evaluate for bladder trauma?
retrograde cystography
- CT cystogram
- Plain Film cystography
- imaging after retrograde filling of bladder with water soluble contrast using catheter
(Intraperitoneal/extraperitoneal) injury does NOT require operative intervention and can be managed with foley catheter drainage
extraperitoneal
(Intraperitoneal/extraperitoneal) injury does require operative intervention to repair the rupture
Intraperitoneal
Who needs an evaluation for urethral (male) trauma
Presence of blood at the urethral meatus after pelvic trauma
if in doubt for a urethral trauma in male, get a retrograde urethrogram _____ placing foley
before
