Voiding Dysfunction Flashcards
1
Q
What are the 2 functions of the bladder?
A
- store urine
- void urine
* controlled by cerebral cortex, spinal cord, and bladder itself.
2
Q
What is the mechanism of bladder STORAGE?
A
- relaxed (compliant) detrusor allows filling
- bladder neck, proximal urethra, and periurethral striated muscles contract automatically.
- cerebral cortex suppresses lower brain centers allowing compliance without urgency/need to urinate.
3
Q
What is the mechanism of bladder EVACUATION/VOIDING?
A
- sensory awareness to void occurs as filling nears detrusor capacity.
- a command to void occurs via cerebral cortex (aka you allow this to occur of your own volition).
- contraction of detrusor occurs with simultaneous relaxation of bladder neck, proximal urethra and periurethral striated muscles.
4
Q
What should our history of voiding involve?
A
- frequency, urgency, dysuria, incontinence, nocturia (involuntary urination at night), flow etc.
- family hx, DM, enuresis (involuntary urination)
5
Q
What should a PE involve related to voiding dysfunction?
A
- Head to toe PE
- Evaluate lower extremities for edema
- Deep tendon and bulbocavernosus reflexes (squeezing glans penis or clitoris causes contraction of anus).
- Palpation of abdomen including check for bladder distension
- DRE of prostate with evaluation of anal sphincter tone
6
Q
*** What is the neurophysiology of VOIDING?
A
- parasympathetic innervation causes the detrusor to contract (aka ready to pee)
- inhibition of these parasympathetics relaxes the detrusor (aka not peeing)
- ALPHA sympathetic stimulation causes contraction of the VESICAL NECK and PROXIMAL URETHRA (aka not peeing)
- ALPHA inhibition causes relaxation of the VESICAL NECK and PROXIMAL URETHRA to allow the bladder to empty (aka ready to pee)
- BETA sympathetic stimulation causes relaxation of bladder base and contraction of proximal urethra (aka not peeing)
- voluntary relaxation of striated sphincter to void.
- voluntary contraction of striated sphincter will stop stream if we want it to.
7
Q
What symptoms can result from UTI, bladder outlet obstruction, or neurogenic bladder dysfunction?
A
- urgency and increased frequency, which can result in urinary incontinence
- OR- dysuria, which can result in urinary retention (aka holding it in due to painful voiding; usually children)
- OR- chronic urinary retention may lead to the inability of the bladder to contract (from overstretched fibers), resulting in urinary incontinence when the patient puts pressure on the bladder.
8
Q
What can cause urinary retention?
A
- BLADDER OUTLET OBSTRUCTION (BOO) secondary to an enlarged prostate, stenosis of the vesicla neck or urethra, or spasm or dyssynergia (neurologic pathology) of external urinary sphincter.
- DESTRUSOR ATONIA secondary to neuropathy, over distension, sacral cord disease/injury, anticholinergics, or alpha agonist like medication.
9
Q
What changes occur following bladder outlet obstruction?
A
- hypertrophy of the detrusor
- trabeculation (thickened wall with reduced tone) and cellule formation of the detrusor
- vesical diverticulum
- bladder calculi
- hydronephrosis
10
Q
How can cerebral palsy lead to hyperreflexia and sphincter/detrusor dyssynergia?
A
- sphincter and proximal muscles of the urethra are constantly contracting, while the bladder is constantly contracting, leading to bladder hypertrophy.
11
Q
How many Americans are affected by urinary incontinence?
A
- 40 million (4:1 females to men)
12
Q
What are the 8 types of urinary incontinence?
A
- URGE= intravesicle pressure is greater than urethral closing pressure and associated WITH strong sensation to void (aka you don’t make it to the toilet in time when you feel the urge).
- STRESS= intra-abdominal pressure is greater than the urethral holding pressure WITHOUT sensation to void (such as when sneezing, jumping, or coughing).
- PARADOXICAL (overflow)= intra-abdominal pressure is greater than urethral closing pressure WITH/WITHOUT the sensation to void (aka bladder is overdistended and pressure causes involuntary loss).
- MIXED= combination of urge and stress.
- FUNCTIONAL (physical or cognitively impaired)= such as Alzheimers.
- TRANSIENT (medication or illness)
- URETERAL ECTOPIA= congenital anomaly where the ureter opens into the vagina.
- FISTULA (iatrogenic or pathologic)= connection between ureter and vagina or bladder and vagina.
13
Q
What causes URGE incontinence?
A
- UTI
- over active bladder (unstable detrusor) or neurogenic dysfunction
- bladder outlet obstruction
- bladder calculus
14
Q
What causes STRESS incontinence?
A
- hypermobility of urethra and bladder neck in females (TYPES I and II). Usually occurs post-partum.
- decrease in sphincter tone, sphincter injury, or deficiency (TYPE III).
- chronic urinary retention (PARADOXICAL)
15
Q
What causes PARADOXICAL incontinence?
A
- bladder outlet obstruciton
- atonic detrusor dysfunction (sensory and/or motor).
16
Q
What brain conditions can affect bladder function in children?
A
- maturation lag enuresis (delay in ability of the brain to learn not to wet the bed at night).
- tumor
- aneurism or A/V malfunction
- trauma
- hydrocephalus
