Urology: Voiding Dysfunction

Question 1

embyrology of the bladder

Answer 1

• formed along side the lower GI tract from the endodermal tissue

Question 2

why is embryology important in urology?

Answer 2

problems in one system can be associated in problems in the other system

Question 3

what does the lower urinary tract do?

Answer 3

• storage of the adequate volumes of urine at low pressure and with no leakage
• emptying which is voluntary, efficient, complete and low pressure

Question 4

function of the bladder

Answer 4

• stores urine at low pressure

- compresses urine for voiding

Question 5

function of the urethra

Answer 5

• conveys urine from the bladder to the outside world

Question 6

function of the internal and external urethral sphincter

Answer 6

• controls urine flow & maintain continence between voidings

Question 7

how does the nervous system control the lower urinary tract

Answer 7

CNS

• Periaqueductal gray matter receives bladder filling info
• Frontal/parietal lobes & cingulate gyrus inibit lower micturition centers
• Hypothalamus center initiate voluntary voiding
• Pontine Micturition center excites Bladder & inhibits sphincter

Spinal

• Sympathetics T10-L1 via hypogastric Nerve
• S2-S4 Parasympathetic via Pelvic N Somatic via Pudental N

Question 8

why is the spinal arch used?

Answer 8

to inhibit voiding until the appropriate time arrives

Question 9

what does a voiding study do?

Answer 9

• measures the external sphincter muscle activity apart from the pressure in the bladder neck and the bladder proper

Question 10

how does voiding mature in humans?

Answer 10

• 1-2yo: they pee whenever they feel that their bladder’s full
• 2-3yo: can be able to start or stop voiding voluntarily
• 2-4yo: children have mastered voluntary control

Question 11

what is the incorrect way of voiding inhibition?

Answer 11

contraction of the external sphincter rather than stopping bladder contraction

Question 12

how can voiding dysfunction be classified?

Answer 12

• storage problem

- voiding problem

Question 13

what happens in storing problems?

Answer 13

patients fail to store normal volumes of urine at low pressure and without leaking; symptoms include a noncompliant bladder, irritable bladder and an inadequate sphincter tone during filling

Question 14

what happens in emptying problems?

Answer 14

patients fail to empty completely, on command, efficiently at low pressure; symptoms include failure of neurological control of bladder, bladder muscle failure and failure of sphincter relaxation during voiding

Question 15

clinical problems from voiding dysfunction

Answer 15

• increased bladder pressure: VUR, upper tract damage, bladder hypertrophy leading to detrusor failure
• residual urine: uTI, infected stones, CRF
• incontinence: social consequences

Question 16

presentation of voiding dysfunction

Answer 16

• infrequent voiding
• frequent voiding
• urgency
• dysuria
• holding manoeuvers
• straining
• poor stream
• intermittent stream
• incomplete emptying
• incontinence
• urinary tract infections
• VUR

Question 17

what happens in a bladder outflow problem?

Answer 17

• slow stream
• hesitancy
• post micturition dribbling
• overflow incontinence
• remember posterior urethral valves in children

Question 18

causes of secondary obstruction

Answer 18

• infective
• traumatic
• iatrogenic
• poor catheterisation technique

Question 19

what happens in detrusor disorders?

Answer 19

• extraordinary daytime urinary frequency syndrome
• giggle incontinence
• stress incontinence
• urgency/urge incontinence
• primary monosymptomatic noctural enuresis (happens in children/teenagers)

Question 20

how can elimination problems be classified?

Answer 20

• storage
• emptying
• continence
• rule out neurologic, urologic or other organic causes

Question 21

history of an elimination problem

Answer 21

• detailed voiding history
• detailed defaecation history
• past elimination/urologic history
• UTIs/constipation/age of toilet training
• intake history - fluids and diet
• family history of urologic problems
• voiding symptoms and pattern of incontinence
• check for endocrine, neurological and urological problems
• sexual abuse
• stressful occurrence

Question 22

what condition should you think of in a girl over the age of 4yo who has continued to wet herself during the day?

Answer 22

ectopic ureter

Question 23

things to look out for a physical examination?

Answer 23

• renal masses (tumour, polycystic kidney)
• distended bladder
• large stool mass suggestive of constipation
• dampness at the beginning of the exam
• signs of erythema or irritation may be indicative of vaginal voiding
• meatal stenosis in boys and presence of labial adhesions in girls
• signs of trauma suggestive of sexual abuse
• careful examination of the introitus for an ectopic ureter
• location of anus

Question 24

what to look out for in a neurological examination?

Answer 24

Lumbosacral spine for lipoma, sinus, pigmentation tufts of hair- may be clue to underlying occult myelodysplasia
Perineal sensation, anal sphincter tone, lower limb function/gait/sensation & Peripheral reflexes
The bulbocavernosus reflex: squeeze glans penis or clitoris & observe or feel reflex contraction of external anal sphincter
Checks integrity of the lower motor neuron reflex arcs
Absence suggestive of a sacral neurologic lesion

Question 25

what should the urinalysis assess?

Answer 25

1st AM pee

Question 26

investigations in voiding dysfunction

Answer 26

- post void residual urine by catheterisation or US - abdominal radiograph (KUB) - renal and bladder ultrasound (check for thickness in the walls, hydronephrosis)

Question 27

Parameters used to diagnose urodynamic dysfunction

Answer 27

Bladder capacity of <10-15 mL/kg body weight, Postvoid residual of >2 mL/kg body weight, Detrusor hyper-reflexia, (detrusor contractions during bladder filling without urine leakage and intravesical pressure of >40 cm H2 O Voiding detrusor pressure of >70 cm H2 O Dyssynergic increase or lack of suppression of sphincteric EMG with a detrusor contraction

Question 28

management of bladder outflow obstruction

Answer 28

- medical therapy (alpha blockers, 5-alpha reductase inhibitors) - phytotherapy - TURP

Question 29

complication of TURP

Answer 29

- bleeding - infection - TUR syndrome - stricture - retrograde ejaculation

Question 30

what determines the compliancy of a bladder?

Answer 30

neurological reflex activity and LPP

Question 31

what is poor bladder compliance associated with?

Answer 31

- incontinence - UTIs - upper tract damage

Question 32

alterations in lower urinary tract functions due to spinal cord injury

Answer 32

- incontinence - neurological obstruction (elevated intravesical pressure, VUR) - increased risk of UTIs - stones

Question 33

pharmacological treatment of voiding dysfunction overactivity

Answer 33

- anticholinergics (urgency, frequency, urge incontinence) - DDAVP - M3 agonists - low dose UTI prophylaxis

Question 34

what should be 2 key principles in treating voiding dysfunction

Answer 34

- preserve renal function | - continence is not an issue in the first few years of life

Question 35

treatment of neurogenic bladder

Answer 35

- clean intermittent catheterisation | - continent catheterisable stomas

Question 36

what is a Mitroffanoff procedure?

Answer 36

a conduit, made of the appendix is used to connect the bladder to the umbilicus so that catheterisation can be done easily

Question 37

indication of Mitroffanoff procedure

Answer 37

- wheelchair bound patients with severe scoliosis lordosis - poor upper extremity function - males with intact urethral sensation

Question 38

what is a bladder augmentation?

Answer 38

- done when medical therapy fails to achieve a low pressure capacity with continence - variety of substances and surgical techniques used each with problems

Question 39

types of bladder augmentation

Answer 39

- ileum and colon (hyperchloremic hypokalaemia acidosis) - stomach (less mucous, can cause hyperkalaemic metabolic alkalosis, can cause haematuria and dysuria due to acid) - dilataed ureter or non functioning kidney - detrusor myotomy (autoaugmentation)

Question 40

how can you improve continence by increasing sphincter resistance?

Answer 40

- alpha-adrenergic drugs increase sphincter tone - surgical techniques (periurethral injections, bladder neck suspension, sling procedures, artificial urinary sphincter) - stress incontinence: pelvic floor exercises to increase the tone