Incontinence: Voiding Function

Question 1

lower urinary tract has two basic functions:

Answer 1

1. storage of adequate volume of urine at low pressure; ensures contienence and protects kidneys
2. voluntary and complete emptying

Question 2

medications for SUI

Answer 2

Question 3

innervation of the detrusor muscle

Answer 3

parasympathetic (motor efferent) innervation: Ach-receptors

Question 4

the mucosa of the bladder sends ___ ___ to the SC and the brain

Answer 4

afferent sensation to the spinal cord and brain. allows us to detect stretch or pain

Question 5

bladder outlet:

the internal __ muscle sphincter is innervated ___ via __- receptors.

the external __ muscle spincter is innervated __ via ___ receptors

Answer 5

the internal smooth muscle sphincter is innervated sympatehtically via ALPHA- receptors.

the external striated muscle spincter is innervated somatically via NIC receptors

Question 6

Answer 6

Question 7

what type of muscle is the pelvic floor composed of

Answer 7

striated muscle

Question 8

the bladder and outlet has different innervation depending on the location. Outline this diagram in terms of which nerve and which transmitter is involved at each site.

Answer 8

Question 9

Normal Voiding (micturition Cycle):

Bladder filling: the detrusor __, the urethra is _, and the pelvic floor is __.

First sensation to void: the detrusor is __, the urethra __ __, and the pelvic flood __.

the normal desire to void: the destrusor __, the urethra __, and the pelvic floor relaxes, allowing for __/urination.

Answer 9

Bladder filling: the detrusor relaxes, the urethra is contracted, and the pelvic floor is contracted.

First sensation to void: the detrusor is relaxed, the urethra contraction increases, and the pelvic flood contracts.

the normal desire to void: the destrusor contracts, the urethra relaxes, and the pelvic floor relaxes, allowing for micturition/urination.

the bladder then fills again.

Question 10

Neurological steps of voiding:

1. brain removes inhibition
2. PMC (__ __ __) facilitates voiding:
   - inhibits the sphincter/pelvic floor contraction via __ innervation
   - removes inhibition to bladder muscle (__ innervation)
   - stimulates contraction of bladder muscle via __ innervation
3. outlet __
4. bladder __
5. bladder empties
6. outlet __
7. bladder contraction ends
8. inhibitory stimuli returns

Answer 10

1. brain removes inhibition
2. PMC PONTINE MUCTURITION CENTER facilitates voiding:
   - inhibits the sphincter/pelvic fllor contraction via somatic innervation
   - removes inhibition to bladder muscle (sympathetic innervation)
   - stimulates contraction of bladder muscle via parasympathetic innervation
3. outlet relaxes
4. bladder contracts
5. bladder empties
6. outlet contracts
7. bladder contraction ends
8. inhibitory stimuli returns

Question 11

Question 13

key symptoms of an overactive bladder (OAB)

Answer 13

frequecy, noctuia, urgency, +/- urge incontinence

Question 14

2 forms of OAB and their causes

Answer 14

1. sensory nervous bladder. due to increased firing from bladder or CNS is over-aware of bladder filling. these people usually sleep through the night
2. motor nervous bladder. Day adn night-time frequency and urgency. May have urge incontinece

Question 15

conservative management of overactive bladder

Answer 15

Question 16

2 calasses of medications that can help with medical treatment of OAB. What is their MOA?

Answer 16

mainstay therapy are either antimuscarinics or beta 3 agonists

• they both work by inhibiting the detrusor overactivity and may block sensory signals

Question 17

two first line antimuscarinics

Answer 17

Question 18

side effects and contra-indications of antimuscarinics

Answer 18

side effects; dry mouth, dry eyes, constipation, confusion and drowsiness

contraindications; untreated narrow angle glaucoma, gastric retention (will make this worse), hypersensitivity

Question 19

if a person with overactive bladder is refractory to conservative measures and to medications, which three surgical procedures may help things?

Answer 19

botox therapy

neuromodulation

bladder augmentation

Question 20

T/F Dysfunctionally voiding involves the impaired relaxation of the sphincter in someone with a non=neurologically intact patient

Answer 20

false. the person IS neurologically intact. • Impaired relaxation of sphincter and/or
pelvic floor during voiding in neurologically intact patient

Question 21

two key populations affected by dysfunctional voiding

Answer 21

1. those who develop in childhood. happens during toilet training, with over-bearing parents, abuse. common cause of secondary reflux d/t high voiding pressures. at worst, can present with renal failure and bilateral hydronephropathy.
2. devlops as an adult- following UTIs, surgery, abuse, high anxiety individials. commonly associated with pelvic pain, sensory urgency (OAB)

Question 22

complications of pediatric dysfunctional voiding

Answer 22

renal failure and bilateral hydronephropathy.

Question 23

treatment of dysfunctional voiding (DFV)

Answer 23

1. proper diagnosis and education
2. self cath program when necessary at least initially to avoid renal failure and bilateral hydronephropathy.
3. pelvic floor rehab/
4. neuromodulation
5. renal monitoring when necessary

Question 24

T/F; isolated nocturia is uaully a bladder issue involving irritation

Answer 24

false. not usually a bladder problem. usually its polyuria– caused by DI, DM, edema, sleep apnea.

Question 25

6 broad types of incontinence

Answer 25

1. stress
2. urge
3. mixed
4. overflow
5. total
6. functional

should be able to differentiate by history

Question 26

stress versus urge incontence region affected

Answer 26

stress– causes contraction or stimulation of the bladder muscles

urge; usually due to issues below the bladder- of the urethra or pelvic floor

Question 27

Question 28

3 main causes of total incontinence

Answer 28

1. really really bad stress incontinence
2. ectopic ureter
3. fistula

Question 29

most common cause of urinary incontinence

Answer 29

stress incontinence

Question 30

MOA and causes of stress incontinence

Answer 30

develops due to relaxation of supportive structures under bladdder neck and urethra (pelvic floor), or impaired inward coaptation or urethra (AGE)
causes:

• childbirth
• hysterectomy and other surgery
• age and urogenital atrohpy, congenital weak tissues
• chronic pressure (cough, constipation)

Question 31

evaluation of stress incontinence

Answer 31

Question 32

conservatie management of stress incontinence

Answer 32

Question 33

how does pelvic muscle training help with incontinence? what modalities are frequently used?

Answer 33

rationale: strengthens the pelvic musculature, improves voluntary activation and regain normal unconscious activation. imrpves sexual function
modalities: hegels, biofeedback, electrical stimulation, weighted cone devices.

Question 34

medications for SUI

Answer 34

alpha agonists

estrogen

Question 35

t/f for stress incontinence, the mainstay treatment is pelvic floor exercises

Answer 35

false. the mainstay of treatment is srurgery.

SLINGS ARE THE NEW GOLD STANDARD: either the tension free vaginal tape, or the transobturator tape.

Question 36

Outline the gender differences in overactie bladder based on age.

Answer 36

in younger and middle age, women are often the ones to suffer more from overactive bladder. in the elderly, men more often have overactive bladder