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1st Repro > Voiding Dysfunction > Flashcards

Voiding Dysfunction Flashcards

1
Q

Understand LUT antatomy

A

There are three pathways of urine

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2
Q

What is the pontine micturition centers role in normal voiding

A

to coordinate contraction of the detrusor and relaxation of the sphincters; talks to PNS and SNS from lumbar and sacral area which innervates the bladder and the urethral spincter

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3
Q

Role of CNS in the micturition

A

– Voluntary control over micturition

– Inhibition of reflex detrusor contraction

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4
Q

Parasympathetic – facilitates micturition, how?

A

– Direct motor activation of detrusor contraction (acetylcholine; muscarinic receptors)

– Indirect facilitation of detruso rcontraction via stretch receptors

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5
Q

Sympathetic – facilitates urine storage

A

– Inhibition of detrusor
» Direct (β3- adrenergic receptors)

» Indirect (via inhibition of parasympathetic stimulation)

– Contraction of “internal sphincter”/bladder neck (α adrenergic receptors)

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6
Q

– Inhibition of detrusor
» Direct (β3- adrenergic receptors)

» Indirect (via inhibition of parasympathetic stimulation)

– Contraction of “internal sphincter”/bladder neck (α adrenergic receptors)

A

Sympathetic – facilitates urine storage

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7
Q

– Direct motor activation of detrusor contraction (acetylcholine; muscarinic receptors)

– Indirect facilitation of detrusor contraction via stretch receptors

A

Parasympathetic – facilitates micturition

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8
Q

Which part of the nervous system is under voluntary control?

A

Somatic – voluntary control
• Innervation of external urethral sphincter

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9
Q

responsible for smooth muscle sphincter contraction and relaxation

A

sympathetic nervous system; alpha-adrenergic fibers

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10
Q

Responsible for detrusor contraction and relaxation

A

cholinergic fibers; Parasympathetic Nervous System

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11
Q

Striated muscle sphincter contraction and relaxation

A

Somatic nervous system

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12
Q

Autonomic reflex between bladder and spinal cord promoting bladder emptying

A

Micturition Reflex

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13
Q

Bladder fills with urine causing stretching of bladder wall

Stretch receptors activated and send signals back to spinal cord that :

Further activation of stretch receptors with :

A

promote detrusor contraction

further promotion of detrusor contraction

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14
Q

CNS (cortex) sends inhibitory signals to __________micturition reflex in cognitively intact people (otherwise we’d peeing all the time like a baby)

A

“turn off”

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15
Q

Micturition reflex can also be abolished by

A

external sphincter contraction (guarding reflex, voluntary/involuntary contraction of sphincter)

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16
Q

When decision to urinate is made,______ removes the inhibitory signals and external sphincter relaxes to allow for micturition reflex to occur

A

CNS

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17
Q

 Detrusor contraction via:

 Internal sphincter relaxation via:

A

– Parasympathetic innervation

– Sympathetic innervation

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18
Q

have the potential to cause discoordination of these phenomena

A

• Damage to the brainstem/pons or spinal cord lesions below the brainstem

Detrusor contracts simultaneously with external sphincter (detrusor-sphincter dyssynergia)

Excessively high bladder pressures and trouble emptying bladder

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19
Q

What promotes urine emptying?

A

Release of central inhibition of detrusor (brain decides “it’s time to pee”)

External sphincter relaxes

Detrusor contracts

Bladder neck/internal sphincter relaxes

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20
Q

What promotes urine storage?

A

Descending signals from CNS inhibit detrusor

Detrusor at rest

Sphincters contracted

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21
Q

= Gas pedal of car

= Brakes

A
  • Detrusor
  • Urethral sphincters
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22
Q

________ = Car moving forward
________ ≈ detrusor contraction
________ ≈ relax urethral sphincters

A

• Voiding

– Foot on gas

– Take foot off brake

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23
Q

_______ = Car stopping/stopped

_________ ≈ detrusor relaxed
_________ ≈ sphincter muscles active

A

Urine storage

– Foot off accelerator

– Foot on brake

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24
Q

Failure to store urine

– Bladder (detrusor) – overactive (OAB) vs underactive

OAB/detrusor overactivity–>_________

Underactive detrusor with chronic urinary retention and bladder

overdistension–> _________

A

urge incontinence

overflow incontinence

25
Q

– Urethral sphincter–>stress incontinence

• Incompetent/weakness

This is what type of voiding dysfunction

A

voiding dysfunction; social or anxiety with extrinsic force on the bladder from raising abdrominal pressure

26
Q

– Urethral obstruction: Anatomic causes

A

– Prostatic enlargement
– Urethral stricture
– Prior incontinence surgery

27
Q

Failure to empty urine

– Bladder (detrusor)

A
  • weak/underactive/atonic/areflexic
28
Q

Functional (hyperactive sphincter)
– Neurogenic =

– Non-neurogenic =

A

Functional (hyperactive sphincter)
– Neurogenic = detrusor-sphincter dyssynergia

– Non-neurogenic = dysfunctional voiding

29
Q

Failure to store urine (car keeps moving when you want it to stop) – Intermittent stepping on accelerator ≈

*Urge Incontinence
– Brake malfunction ≈

*Stress Incontinence

A

detrusor overactivity

urethral sphincter dysfunction

30
Q

Failure to empty urine (car won’t move forward)

– Engine malfunction/failure to step on accelerator ≈ ______

– Something blocking the front of car ≈ __________

– Intermittent/continuous stepping on brakes ≈ __________

A

bladder dysfunction

anatomic urethral obstruction

hyperactive urethral sphincter (e.g. detrusor-sphincter dyssynergia)

31
Q

Urinary Incontinence =

A

Failure to Store Urine

32
Q

Two causes of urinary incontinence

A

• Due to Detrusor – Overactive bladder/Urge urinary incontinence (UUI) • Due to sphincter – stress urinary incontinence (SUI)

33
Q

≈ Hyperactive/Irritable detrusor

 “Bladder spasms”

 Bladder decides “to go” independent of the brain’s control

Urinary Urgency (gotta go in a hurry)

Urinary Frequency (>8 voids/24 hr)

Nocturia (night time voiding)

Urge incontinence (have to go so bad that you start leaking/voiding before reaching toilet)

A

Overactive Bladder

34
Q

Causes of overactive bladders

A
  • Inflammation/infection (e.g. UTI)
  • Bladder Irritants
  • Neurologic conditions – Spinal cord injury, stroke, multiple sclerosis • Metabolic conditions – Diabetes
  • Urethral obstruction – Enlarged prostate, prior surgery for incontinence
35
Q

Etiology of overactive bladder

A
  • 16.5% of Americans met the criteria for OAB – Telephone survey of >5200 American adults
  • Estimated that 29.8 million adults aged ≥40 years in the United States have bothersome OAB symptoms

– Internet survey of 20,000 American adults

• Prevalence increases with age (not normal part of aging) – Age <70: female > male – Age >70: female ≈ male

36
Q

Behavioral therapies for OAB

A

Behavioral therapies – Fluid management – Pelvic floor exercises (Kegels)

• Inhibit detrusor contraction by contracting urinary sphincter/pelvic floor

37
Q

Why are anticholinergics such as oxybutynin and **tolterodine **recommend to tx overactive bladder?

A

• Block acetylcholine receptor in detrusor

 Inhibit overactive detrusor contractions

38
Q

Why do B-3 Adrenergic agonists work to treat OAB: Myrbetriq

A

Activates β-3 receptor in detrusor

–> Relaxation of detrusor

39
Q

Cause of stress urinary incotinence

(Incontinence with coughing, sneezing, exercise, heavy lifting (ie anything that increases intra-abdominal pressure)

A

Due to weakness of urinary sphincter and support structures of urethra and bladder neck

40
Q

– Vaginal/pevic trauma:

  • Multiple vaginal deliveries
  • Pelvic surgery (incl prior incontinence surgery)
  • External trauma (e.g. car accident)
  • Often associated with vaginal prolapse – Lack of estrogen (i.e. menopause) – Neurologic (e.g spina bifida) – Radiation therapy  scarring – Obesity
A

All can cause or risk factor for stress urinary incontinence

41
Q

How common is stress incontinence

A
  • Approx 40% of healthy females aged 30-49 have experienced some degree of incontinence with exercise
  • Up to 25% of women may experience incontinence 3 months following their first vaginal delivery
42
Q

Risk of incontinence increases with:

– Number of children (vaginally > C-section)

– Age older than 45 yrs

A 50 yr old with 3 children delivered vaginally has an almost _____risk of being incontinent

A

40%

43
Q

Behavorial therapies for Stress incontinence

A

• Behavioral therapies

– Pelvic floor exercises (Kegels)

• Learn to contract pelvic floor/sphincter prior to activity (the knack) – Weight loss

44
Q

What is duloxetine and why is it recommended for tx of stress incontinence

A

• Medication (technically no approved drug for SUI)

– Duloxetine (selective serotonin and norepinephrine reuptake inhibitor)

Increases neural output from spinal cord to external urinary sphincter

Contraction of sphincter muscle

45
Q

What are some causes of “failure to empty” that involved the detrusor

A

Due to Detrusor

– Neurogenic

– Myogenic

– Psychogenic

– Medication

46
Q

What medications can affect the detrusor muscle and prevent it from emptying

A
  • Anticholinergics
  • α-agonists
  • Narcotics
47
Q

Urinary retention; what are some anotomic causes

A

– Anatomic • Prostate enlargement

  • Urethral stricture
  • Prior incontinence surgery
48
Q

Urinary retention or failure to empty can be caused by spincter hyperactivity, what are two causes?

A

– Functional (sphincter hyperactivity)

  • Neurogenic (detrusor-sphincter dyssynergia)
  • Non-neurogenic (dysfunctional voiding)
49
Q

Post-operative state: – Anesthetics (anticholinergic activity) still on board will:

A

Inhibit detrusor thus get retention of urine

50
Q

Post Op – Increased sympathetic tone results in:

A

Inhibit detrusor

Internal sphincter/bladder neck contraction

51
Q

What are some signs and symptoms of urinary retention

A

Voiding difficulty/inability to urinate • Straining to urinate • Hesitancy • Intermittent stream • Weak urinary stream – Urinary frequency (from lack of bladder emptying) – Lower abdominal/suprapubic pain (acute) – “Overflow” urinary incontinence (chronic) – Suprapubic fullness/mass (distended bladder) – Hydronephrosis/renal failure

52
Q

Management of Urinary retention:

A

Catheter drainage of bladder – Indwelling – Intermittent (ideal)

  • Treat UTI
  • Stop aggravating meds (e.g. anticholinergics)
  • Relieve any obstruction – α-blocker medication (reduce internal sphincter tone) – Surgery on prostate
  • Neuromodulation (for non-obstructive retention)
53
Q

Parasympathetic nervous system activates the _____for micturition

A

detrusor muscle (via acetylcholine)

54
Q

inhibits the detrusor (β3 -receptor activation, inhibition of parasympathetics) and activates the bladder neck/internal sphincter for urine storage

A

Sympathetic nervous system

55
Q

Somatic nervous system controls the

A

external sphincter (voluntary control)

56
Q

CNS tonically inhibits the micturition reflex; __________ initiates micturition

A

release of this inhibition

57
Q

Failure to store (urinary incontinence)

A

 Due to hyperactive/overactive bladder

 Urge incontinence

 Due to weak overdistended bladder (ie urinary retention)  Overflow incontinence

 Due to sphincter (weak/damaged)

 Stress incontinence

58
Q

Failure to empty (urinary retention)

A

 Due to bladder (weak/underactive)

 Due to sphincter (hyperactive)

 Neurologic disorder

 Detrusor-sphincter dyssynergy

 Non-neurologic

 Dysfunctional voiding

1st Repro (16 decks)

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