Voiding Dysfunction

Question 1

Three micturition centers and their functions

Answer 1

1. Cerebral Cortex Micturition Center (“controls when you go”)
   - Inhibits bladder activation (default)
2. Pontine Micturition Center (“tells everyone what to do”)
   - coordinates urethral sphincters and the bladder
3. Sacral Micturition Center (“Gets the job done”)
   - parasympathetic and pudendal nerves signal allows micturition to occur.

Question 2

Two main phases of voiding

Answer 2

Filling/Storage

Emptying

Question 3

What can cause fill/storage problems with the bladder?

Answer 3

1. Bladder overactivity (too much contraction)
2. Heightened sensation by sensory/afferent receptors
3. Poor compliance (due to high pressure/stiff bladder)
4. Sphincter incompetence (weak or damaged sphincter muscle)

Question 4

What can cause bladder overactivity by increasing contraction?

Answer 4

1. aging

2. neurological conditions (stroke, parkinson’s)

Question 5

What can cause problems with emptying the bladder?

Answer 5

1. Dec. bladder contractility

2. Inc. outlet resistance

Question 6

What can prevent bladder emptying by increasing outlet resistance?

Answer 6

1. Overactivity of
   - external sphincter muscle
   - pelvic floor muscles (can’t relax)
2. Obstruction by
   - BPH or PC
   - Mass or scar causing urethral stricture
   - Pelvic organ prolapse
   - Female sling

Question 7

A graph that plots flow rate vs. flow time to determine voided volume

Answer 7

Uroflow

Question 8

Normal urine flow for men vs. women

Answer 8

Men: 15-20 mL/sec
* abnormal if <10

Women: 30 mL/sec

Question 9

The bladder should be able to empty at least ____%.

Answer 9

75%

Ex.) Void 300 mL with PVR <100 mL

Question 10

If a patient has low urine flow, or high post void residual volume, you should suspect…

Answer 10

Outlet obstruction (BPH, sling, mass)
Poor detrusor function

Question 11

Normal bladder holds roughly ____ mL to _____ mL of urine.

Answer 11

300-500

Question 12

Continuum of care for over-active bladder (bladder overactivity/heightened sensation)

Answer 12

1. Behavioral/lifestyle modification
   - Avoid caffeine
   - Scheduled toileting
   - Weight loss
2. Medication
   - M3 antagonists
   - B3 agonists
3. Injection therapy
   - botox
   - sacral neuromodulation (implant)
4. Surgery

Question 13

What are anticholinergics that can treat over-active bladder (bladder overactivity/heightened sensation)

Answer 13

Oxybutynin

Question 14

Anticholinergics are contraindicated in patients with

Answer 14

1. narrow angle glaucoma

2. gastroparesis

Question 15

Treatment for outlet/sphincter incompetence

Answer 15

Female: sling or bulking agents
Male: sling or artificial sphincter

• No medications can fix this

Question 16

What voiding dysfunction is NOT treatable/”fixable” at all?

Answer 16

Decreased/absent bladder (detrusor) contraction
No medications

• bladder needs to be emptied using catheters

Question 17

Treatments for voiding dysfunction due to increased outlet resistance

Answer 17

1. External sphincter overactivity
   - bypass using catheters (best)
   - botox
2. Pelvic Floor dysfunction
   - physical therapy (relax pelvic muscles)
   - electrical stimulation

Question 18

Treatments for voiding dysfunction due to BPH

Answer 18

1. Medication
   - 5a-reductase inhibitor (finasteride)
   - a1 antagonist (Tamsulosin)
2. TURP (prostate reduction surgery)

Question 19

Who needs evaluation for bladder trauma

Answer 19

Stable patients with gross hematuria and mechanism concerning for bladder injury (pelvic fractures or penetrating injury)

Question 20

How can you evaluate for bladder trauma?

Answer 20

retrograde cystography

• CT cystogram
• Plain Film cystography
• imaging after retrograde filling of bladder with water soluble contrast using catheter

Question 21

(Intraperitoneal/extraperitoneal) injury does NOT require operative intervention and can be managed with foley catheter drainage

Answer 21

extraperitoneal

Question 22

(Intraperitoneal/extraperitoneal) injury does require operative intervention to repair the rupture

Answer 22

Intraperitoneal

Question 23

Who needs an evaluation for urethral (male) trauma

Answer 23

Presence of blood at the urethral meatus after pelvic trauma

Question 24

if in doubt for a urethral trauma in male, get a retrograde urethrogram _____ placing foley

Answer 24

before

Question 25

How to evaluate someone with potential urethral trauma

Answer 25

If male, retrograde urethrogram (contrast injected)

If female, cystourethroscopy (direct observation of urethra)

Question 26

B2 agonists are contraindicated in patients with

Answer 26

1. uncontrolled HTN

2. advanced HF