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Flashcards in FERGU neuro/incontinence Deck (26):
1

SNS fergu

T1 - L2/3
pre-gangiolinic exits via ventral root, enters sym trunk via white ramus communicans (myelinated)
can:
1) synapse at same spinal level, exit via gray
2) travel and synapse at cervical/sacral levels
3) pass through without synapsing, leave as:
- Greater splanchnic nerve
- Lesser splanchnic
- Least splanchnic

2

Greater splanchnic nerve

T5-9

3

Lesser splanchnic

T10-11

4

Least splanchnic

T12

5

PSNS efferent

CN III, VII, IX, X
sacral S2-4

6

Abdominal plexuses

celiac
superior mesenteric
inferior mesenteric

7

Intermesenteric plexus

btw inferior & superior mesenteric, gives rise to:
renal
testicular/ovarian
ureteric
superior hypogastric plexuses

- mostly sympathetic

8

Inferior hypogastric plexus

formed by hypogastric nerves from superior hypogastric plexus (sym)
parasympathetic & sympathetic
parasympathetic from S2,3,4 = pelvic splanchnic nerves

majority of pelvic viscera

9

Bladder innervation

hypogastric (T11-L2): detrusor relaxation and bladder neck constriction
pelvic splanchnic nerves: splanchnic from S2,3,4, detrusor contraction
Somatic: pudendal from S2, 3, 4 - external urethral sphincter

10

Bladder sympathetic

alpha - detrusor contraction
b3 - detrusor relaxation

11

Normal emptying

Pontine micturition centre
- inhibitory from forebrain
- cerebellum - coordination
activates PSNS
inhibits SNS
inhibits pudendal nerve firing

12

DDx of transient incontinence

Delirium
Infection
Atrophic vaginitia/urethritis
Pharmacologic
Excess urine output
Restricted mobility
Stool impaction

13

Overflow incontinence

leakage from bladder that does not void properly
Urine retention --> increased P --> leakage
Causes: obs, poor bladder contraction (sacral spinal damage), medications (b3 blocker, opioids, alpha agonists)

14

Stress incontinence

due to abd P (sneezing etc)
common in young-middle aged women
cause: weakness of sphincter, estrogen deficiency, obesity, exacerbation due to cough from ACEi, alpha1 antagonist

anatomy: unequal movement of ant & post bladder with proximal urethra
midurethra - most important structure for incontinence
can provide backboard for midurethra surgically to improve coapt of urethra upon increase in abdominal pressure
- sling, retropubic suspension

15

Total incontinence

cannot store urine
damage to innervation of bladder
fistulas btw bladder &vagina, rectum
scarring of urethra - cannot constrict1

16

functional incontinence

mentally/phyically unable

17

Urgency incontinence

involuntary loss of urine following strong urge to void
bladder contractions > cerebral inhibition
overactivity
increased frequency of urination day and night
cause: constipation, diuretics, detrusor hyperreflexia due to upper motor neuron lesion
- cerebral damage
- basal ganglia disease - Parkinson's
- suprasacral spinal damage - external sphincter dyssynergia

18

Tx for increasing bladder storage

Dietary
Biofeedback, pelvic floor exercises
Anticholinergic, tricyclic andidepressants, b3 agonists, botox

Surgical:
-neuromodulation - tibial nerve
- stimulation - interstim
-augment size of bladder by adding a piece of bowel

19

Tx for increase storage at the outlet level

Biofeedback, pelvic floor exercises
electrical stimulation
pharmacologic - alpha agonist, estrogen, SSRI's

surgery: peri-urethral bulking, pessaries (bladder neck suspension, suburethral sling, artificial sphincter

20

Tx to increase emptying from bladder

Parasympathomimetics (urecholine)
direct stimulation of bladder & sacral roots

21

Outlet - increase emptying

prostate obstruction: alpha blockers, 5ARis, anti-androgen
Volntary sphincter: baclofen
Catheterization

Surgical:
prostatectomy
urethrotomy
sphincterotomy
urethral stent
urinary diversion

22

Anticholinergics

oxybutinin
tolterodine
imipramine
SE: dry mouth, dry eyes, blurred vision, constipation

23

b3 agonists

Mirabegron
SE: HTn

24

Botox

inject through cystoscope
failure of oral meds
SE: UTI, urinary retention

25

DDx of lower urinary tract symptoms (men)

prostate: BPH, cancer, prostatitis
bladder: cystitis, tumour, stone
Urethra: stricture, meatal stenosis, phimosis
neurologic: Parkinson's, stroke, Alzheimer's, spinal cord disease
Other: DM, sleep apnea, Rx, dietary

26

Evaluation of LUTS

Hx
PE: DRE - size does not correlate with severity of LUTS
urinanalysis

recommended:
symptoms index score - international prostate symptoms score
Serum PSA if it changes management (need life >10y)

optional:
serum creatinne
cytology - irritative
uroflow
voiding diary
post-voidal residual (no normal value)

when indicated:
urodynamics
cystoscopy
imaging