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URINARY INCONTIENCE AND NEUROPATHIC BLADDER DYSFUNCTION (Overactive…
URINARY INCONTIENCE AND NEUROPATHIC BLADDER DYSFUNCTION
Introduction to LUTS: they affect 25% of the population and 48% people aged 65 years or above
Overall storage symptoms are a lot more common
The female LUTS:
is made up of a weak bladder neck mechanism and also a urethral sphincter that runs along the whole urethra.
In comparison the Male LUTS has a much stronger bladder neck but has a shorter urethral sphincter
Most prevalent LUTS
(storage) is nocturia and voiding symptom is post micturition dribbling
SUMMARY:
40% of the population is affected and it is made up of
functional incontience
(poor mobility or
unfamiliar surroundings
). There is
stress incontience
happens when their is a
weakness of the sphincter muscle
. And finally
Urge Incontience
and this happens when you get a bit of leak that urges you to go for micturition. This is stimulated by
detrusor instability.
Storage (Not urinating):
this happens the pontine storage centre is stimulated. It sends impulses to the detrusor muscle to be relaxed and also sends impulses to
Onuf's nucleus
to excite it (guarding reflex). This is done by
T10, L1 and L2
and along the sympathetic system
LUTS symptoms
Voiding: hesitancy, stream, intermittent, straining and terminal dribbling
Post micturition: incomplete emptying feeling and post micturitional dribbling.
Storage: nocturia, frequency, urgency and incontinence
Nervous stimulation of micturition
Pontine Micturition Centre (PMC)
allows coordination and voiding
Spinal Reflex (Onuf's Nucleus) allows a guarding reflex
The cortex:
contains sensory voluntary initiation
Receptive relaxation is allowed by the sympathetic nervous system
Voiding (Urination):
in the bladder wall there are stretch receptors that respond to the changes in pressure once the bladder starts to fill. Sends afferent impulses to the
pontine micturition centre
. Where there is detrusor muscle excitation.
This is done by S3, S4, S5 and causes relaxation of the sphincter muscle and contraction of the detrusor muscle.
The whole process is inhibited by Onuf's nucleus.
Overactive Bladder
--> Urge incontience
There are two types dry or wet . Normally due to detrusor overactivity
Management
Look at a urine chart, reduce coffee and alcohol and do a bladder drill
Stage 1:
Employ the use of animuscarinic agents. These reduce parasympathetic stimulations. But a SE is a dry mouth
Stage 2:
Use B3 agonists they increase sympathetic stimulation in the bladder
Stage 3:
Botox: blocks the neuromuscular junction for Ach release. It can cause incomplete bladder emptying and also retention. So cathertisation is needed
Sacral neuromodulators: these are electrodes that are placed on the sacral spine S3. The send increased impulses to the brain and increase the guarding reflex
Stage 4: use a steroid
Definition:
this is urgency with frequency and with or without nocturia. It appears in the absence of local pathology .
Can be characterized as stress or urge incontinence
Epidemiology
Increases with age
Second most common cause of urinary incontience
Presentation
Increased frequency of micturition
Nocturia
Abdominal discomfort
Diagnosis
U&E, LFT, Blood Glucose
Urine dipstick
Stress incontienance- No.1 cause of incontience in women
Cause: i
n women this is normally a weak pelvic floor due to surgery or childbirth and in men it is normally post prostatectomy. In either case it can be neurogenic or congenital . Likely to happen once intrabdominal pressure increases i.e laughing or standing up
Management
Duloxetine (anti-depressant)
Colposuspension
Pelvic floor exercises
Surgery (sling or artificial sphincter)
Bulking agents
In males you can produce an artificial sphincter or use a sling
Sacral micturition centre:
is in the spine an dis involved in bladder reflexes once the bladder is full. When full it stimulates voiding. This can be prevented by conscious parts in the cortex and Onuf's nucleus (sacral spine). However, if there is a spinal lesion at S2, S3 or S4 it means that the bladder is bale to recognize when it's filling. There are no inhibitory systems.
Guarding reflex:
is provided by
Onuf's nucleus
in the sacral spine. It means that micturition and defecation can be controlled.