Voiding Dysfunction

Question 1

What are the 2 functions of the bladder?

Answer 1

1. store urine
2. void urine
   * controlled by cerebral cortex, spinal cord, and bladder itself.

Question 2

What is the mechanism of bladder STORAGE?

Answer 2

• 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.

Question 3

What is the mechanism of bladder EVACUATION/VOIDING?

Answer 3

• 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.

Question 4

What should our history of voiding involve?

Answer 4

• frequency, urgency, dysuria, incontinence, nocturia (involuntary urination at night), flow etc.
• family hx, DM, enuresis (involuntary urination)

Question 5

What should a PE involve related to voiding dysfunction?

Answer 5

• 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

Question 6

*** What is the neurophysiology of VOIDING?

Answer 6

• 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.

Question 7

What symptoms can result from UTI, bladder outlet obstruction, or neurogenic bladder dysfunction?

Answer 7

• 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.

Question 8

What can cause urinary retention?

Answer 8

• 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.

Question 9

What changes occur following bladder outlet obstruction?

Answer 9

• hypertrophy of the detrusor
• trabeculation (thickened wall with reduced tone) and cellule formation of the detrusor
• vesical diverticulum
• bladder calculi
• hydronephrosis

Question 10

How can cerebral palsy lead to hyperreflexia and sphincter/detrusor dyssynergia?

Answer 10

• sphincter and proximal muscles of the urethra are constantly contracting, while the bladder is constantly contracting, leading to bladder hypertrophy.

Question 11

How many Americans are affected by urinary incontinence?

Answer 11

• 40 million (4:1 females to men)

Question 12

What are the 8 types of urinary incontinence?

Answer 12

1. 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).
2. STRESS= intra-abdominal pressure is greater than the urethral holding pressure WITHOUT sensation to void (such as when sneezing, jumping, or coughing).
3. 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).
4. MIXED= combination of urge and stress.
5. FUNCTIONAL (physical or cognitively impaired)= such as Alzheimers.
6. TRANSIENT (medication or illness)
7. URETERAL ECTOPIA= congenital anomaly where the ureter opens into the vagina.
8. FISTULA (iatrogenic or pathologic)= connection between ureter and vagina or bladder and vagina.

Question 13

What causes URGE incontinence?

Answer 13

• UTI
• over active bladder (unstable detrusor) or neurogenic dysfunction
• bladder outlet obstruction
• bladder calculus

Question 14

What causes STRESS incontinence?

Answer 14

• 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)

Question 15

What causes PARADOXICAL incontinence?

Answer 15

• bladder outlet obstruciton

- atonic detrusor dysfunction (sensory and/or motor).

Question 16

What brain conditions can affect bladder function in children?

Answer 16

• 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

Question 17

What brain conditions can affect bladder function in adults?

Answer 17

• dementia
• cerebral vascular disease
• parkinsonism
• multiple sclerosis
• tumor
• trauma

Question 18

What conditions of the spinal cord can affect bladder function?

Answer 18

• trauma
• MS
• ALS
• herniated disk
• tumors
• inflammatory disease
• myelodysplasia

Question 19

What conditions of peripheral nerve can affect bladder function?

Answer 19

• DM
• trauma
• pelvic surgery
• Guillain-Barre syndrome
• hypothyroidism
• alcoholism
• sacral agenesis

Question 20

What causes the most severe bladder dysfunction?

Answer 20

• CERVICAL or THORACIC spinal cord injuries

Question 21

Do LUMBAR or SACRAL spinal cord injuries usually affect normal striated sphincter physiology (aka voluntary muscles)?

Answer 21

NO :)

*however detrusor atonia or hyperreflexia often occur

Question 22

What affect will you see on the bladder from peripheral nerve injuries (such as from DM)?

Answer 22

• detrusor atonia= incomplete emptying leading to residual urine and paradoxical incontinence.

Question 23

What drugs affect urinary function?

Answer 23

• anticholinergic
• decongestants
• alpha and beta blockers
• alpha agonists
• antidepressants
• tranquillizers

Question 24

What parameters are measured with urodynamic exams?

Answer 24

• detrusor pressure on filling/voiding
• sphincter response to filling/voiding
• intraabdominal pressure with filling/voiding
• urine flow rate
• urethral pressure on voiding and at rest

Question 25

What is a cystometrogram (CMG)?

Answer 25

- records DETRUSOR response to filling, ability to initiate contraction, and ability to suppress contraction.

Question 26

What do we combine with a cystometrogram (CMG)?

Answer 26

- electromyelogram (EMG), which records simultaneous response of the sphincter to bladder filling. * subtracting the intraabdominal pressure gives the true intravesical pressure.

Question 27

What should we think about with voiding dysfunction?

Answer 27

- obstruction should be relieved if present. - UTI must be treated before urodynamic eval. - neurogenic voiding dysfunction should be treated with pharmacotherapy.

Question 28

*** What therapy would we use for an atonic detrusor?

Answer 28

- cholinergic medication (Bethanechol)

Question 29

*** What therapy would we use for an overactive bladder?

Answer 29

- anticholinergic (Oxybutynin, Imipramine), beta agonist, or intravesical detrusor injection of botox if other therapies fail.

Question 30

*** What therapy would we use for striated sphincter spasm or inappropriate contraction or enlarged prostate?

Answer 30

- alpha blocking (Prazosin, Tamsulosin) or muscle relaxing medicaiton.

Question 31

*** What would we use for sphincter weakness?

Answer 31

- alpha agonist (Ephedrine)

Question 32

** What are the surgical options for treating urinary retention due to OUTLET OBSTRUCTION?

Answer 32

- TURP (transurethral resection of prostate) - TUIP (transurethral incision of prostate) - DVIU

Question 33

** How do we MEDICALLY treat urinary retention due to OUTLET OBSTRUCTION?

Answer 33

- alpha blockers | - 5-alpha reductase inhibitors

Question 34

** How do we SURGICALLY treat urinary retention due to DETRUSOR ATONIA?

Answer 34

- any procedure that widens the bladder outlet. | - neuromodulation (interstem)

Question 35

** How do we MEDICALLY TREAT urinary retention due to DETRUSOR ATONIA?

Answer 35

- cholinergic medication (Bethanechol) or in combination with alpha blockers. * Intermittent catheterization is best.

Question 36

How do you treat sphincter/detrusor dyssynergia with neurogenic bladder overactivity?

Answer 36

- treat neurogenic over-activity with anticholinergic medication. - muscle relaxant for the striated muscle spasm. - can use botulinum toxin to the detrusor if those fail.

Question 37

How do you treat STRESS incontinence CONSERVATIVELY?

Answer 37

- alpha agonist (ephdrine); hardly ever used. - perineal exercises - behavior modification.

Question 38

How do you treat STRESS incontinence SURGICALLY?

Answer 38

- urethral suspension (endoscopic, laproscopic, or open) via slings. - periurethral injection of collagen or titanium oxide spheres; not very good.

Question 39

When should a permanent catheter be used?

Answer 39

- only after all else fails.

Question 40

*** Do infection, obstruction, and neurologic conditions produce similar symptoms?

Answer 40

YES and may exist simultaneously.