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Micturition Flashcards

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1
Q

What are the two parts of the autonomic nervous system?

A
  • Parasympathetic (rest and digest)

- Sympathetic (fight or flight)

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2
Q

Autonomic nervous system - voluntary or involuntary?

A
  • Involuntary
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3
Q

How many neuron systems with ANS and bladder control?

A
  • Two

- preganglionic and postganglionic

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4
Q

What does ANS innervate?

A
  • Smooth muscles, hollow organs, sweat glands
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5
Q

Somatic control of the bladder - what type of muscle?

A
  • Skeletal muscle
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6
Q

Is somatic control of the bladder voluntary or involuntary?

A
  • VOLUNTARY
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7
Q

How many neurons involved in the somatic system?

A
  • One!

- No preganglionic/postganglionic

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8
Q

Spinal cord region of the sympathetic nervous system

A
  • Thoracolumbar

- T3-L3

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9
Q

Spinal cord region of the parasympathetic nervous system

A
  • Craniosacral
  • C1-T2
  • L4-S3
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10
Q

Sympathetic preganglionic receptor and neurotransmitter type?

A
  • Nicotinic cholinergic

- NT: ACh

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11
Q

Sympathetic postganglionic receptor (effector organ) and NT type

A
  • Receptor: Adrenergic (alpha or beta)

- NT: Adrenaline derivative (epinephrine or norepinephrine)

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12
Q

Parasympathetic preganglionic receptor and neurotransmitter type?

A
  • Receptor: Nicotinic cholinergic

- NT: Acetylcholine

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13
Q

Parasympathetic postganglionic receptor (effector organ) and neurotransmitter type?

A
  • Muscarinic cholinergic

- NT: Acetylcholine

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14
Q

Somatic innervation receptor and NT type

A
  • Nicotinic cholinergic

- NT: Acetylcholine

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15
Q

Where are somatic receptor organs?

A
  • EVERYWHERE
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16
Q

Sympathetic receptor organs

A
  • bladder, smooth muscle heart
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17
Q

Parasympathetic receptor organs

A
  • Bladder, smooth muscle, heart
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18
Q

What are three components in the brain that influence bladder control?

A
  • Forebrain
  • Brainstem
  • Cerebellar
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19
Q

Forebrain influence on bladder

A
  • Learned behavior

- Voluntary control

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20
Q

Brainstem influence on bladder

A
  • Coordinate spinal reflex arcs
  • Mostly located in the pons
  • Considered UMN for normal urination
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21
Q

Cerebellar influence on bladder

A
  • Inhibitory over detrusor reflex
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22
Q

Detrusor muscle

A
  • Smooth muscle surrounding the bladder
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23
Q

What does relaxed detrusor muscle do?

A
  • fill the bladder
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24
Q

WHat does contracted detrusor muscle do?

A
  • Empty the bladder
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25
Bladder filling: Which receptor type? Which nerve? Which spinal cord segments?
- Beta adrenergic | - Sympathetic via the hypogastric nerve (L1-L4)
26
Bladder emptying: Which receptor type? Which nerve? Which spinal cord segments?
- Cholinergic (muscarinic) | - Parasympathetic (pelvic nerve) (S1-S3)
27
Where are sensory receptors for the bladder?
- Throughout the bladder wall
28
Which nerve responsible for stretch?
- Pelvic nerve (S1-S3)
29
Which nerve responsible for pain?
- Hypogastric nerve (L1-L4) >>>> pelvic nerve (S1-S3)
30
What are the two sphincters of the bladder?
- Internal and external sphincter muscle (urethralis muscle)
31
Muscle type in internal sphincter?
- Smooth muscle of the proximal urethra
32
What does contracted internal sphincter do?
- Fill the bladder
33
What does relaxed internal sphincter do?
- Bladder emptying
34
Which receptor type for internal sphincter muscle? Which nerve? Which spinal cord segments?
- Alpha adrenergic - Sympathetic via hypogastric nerve - L1-L4
35
What muscle type is external sphincter?
- skeletal muscle of urethra
36
How does the external sphincter muscle contract or not?
- Same as internal sphincter muscle
37
Innervation to the external sphincter muscle?
- Somatic or pudendal nerve (S1-S3)
38
What are the four major arms of bladder retention and filling?
1. Sensory input detecting stretch (detrusor muscle via pelvic nerve S1-S3) 2. Hypogastric nerve L1-L4 control with detrusor relaxation under beta-adrenergic and internal urethral sphincter contraction under alpha-adrenergic 3. Pudendal nerve (S1-S3) control under somatic for contraction of external urethral sphincter under the nicotinic cholinergic receptor 4. Pelvic nerve iS1-S3 inhibition (inhibition of muscarinic cholinergic pathway)
39
What are the four major arms of bladder voiding/emptying?
1. Sensory input (detrusor muscle via pelvic nerve S1-S3) 2. Pelvic nerve (S1-S3) control - detrusor contraction under muscarinic cholinergic 3. Hypogastric nerve (L1-L4) control inhibited to relax the external urethral sphincter 4. Pudendal nerve S1-S3 control (somatic) is inhibited
40
Look at the helpful charts for urination
- Just do it - it's really quite nice
41
Why do we care about the bladder with spinal cord injury?
- It can cause dysfunction of the bladder just like with the limbs downstream of hte lesion - Requires proper maangement for the type of injury - If ignored can lead to serious complications!
42
What should you NEVER EVER ASSUME?
That a dog can urinate! Even if you see a puddle of urine next to a dog
43
Four steps if you find a neurologic patient with urine in its cage?
ULTIMATELY ASSESS THE BLADDER 1. Allow patient to try and urinate - try to observe voiding or attempts to void (if they try to urinate carefully observe) 2. Try to palpate the bladder (large and firm or soft, cannot feel)? 3. Try to express the bladder? (easy or having to press forcefully) 4. Ultrasound to assess size (large? Turgid? flaccid?)
44
What can result in an UMN bladder?
- Lesion from pons to L3
45
UMN bladder signs
- Cannot urinate or complete urination, pulsations - Large, hard bladder, trying to push against an overactive internal urethral sphincter - Difficult to express
46
Why does UMN bladder happen?
- Increased tone to pelvic limbs and bladder - T3-L3 localization to the pelvic limbs? - No motor? = NO BLADDER FUNCTION
47
Lesion for LMN bladder?
- Caudal to L4
48
Signs of LMN bladdre
- Cannot urinate or complete urination - Large, either soft or non-palpable bladder - Easy to express but difficult to empty, difficult to hold on - Constantly leaking
49
Why does LMN bladder happen?
- Decreased tone to pelvic limbs, anus, and bladder - Flaccid detrusors and sphincters - L4-S3 localization to pelvic limbs? - Can lose bladder function before motor function
50
Goals of bladder management
- Keep the bladder empty | - If you cannot achieve this manually without great distress, get some help from pharmacological manipulation!
51
UMN bladder ultimate pathophys
- Lack of inhibition due to localization of lesion - Causes too much input from all the nerves controlling bladder filling TOo much tone to internal urethral sphincter (hypogastric nerve L1-L4), detrusor muscle (pelvic nerve S1-S3), external urethral sphincter (pudendal S1-S3)
52
Fundamentals behind treating the UMN bladder?
1. Use medication to decrease internal urethral sphincter tone 2. Relax external urethral sphincter 3. Release/relax body wall
53
What type of drug to counteract hypogastric nerve tone of the internal urethral sphincter with UMN bladder?
Alpha adrenergic antagonist - Sympatholytic or parasympathomimetic - Prazosin (more common; specific for alpha-1) - Phenoxybenzamine is a non-specific antagonist
54
Side effects of alpha-antagonists?
- Hypotension | - Bradycardia
55
Drugs to relax external sphincter tone and body wall (pudendal nerve)?
- We need a muscle relaxant (Diazepam) | - Sedation (Acepromazine and dexmedetomidine)
56
Diazepam side effects
- Sedation | - Fatal hepatic necrosis in cats!!!
57
LMN underlying pathophysiology
- Destroys cell bodies - Too little to no input to the pelvic and pudendal nerves - Too decreased to no tone to detrusor muscle (pelvic nerve) and external urethral sphincter (pudendal nerve)
58
How to help with LMN decreased detrusor tone and external urethral sphincter?
1. Use medication to increase detrusor tone - Do not need to treat to increase internal or external urethral sphincters to limit leakage - WOrks against trying to express
59
Drugs to increase detrusor muscle tone (pelvic nerve S1-S3)?
- Parasympathomimetic or sympatholytic | - Bethanechol (stimulates cholinergic receptors)
60
Side effects of bethanechol
- SLUD, GI hypermotility | - DO NOT USE ALONE
61
What should bethanechol be used with and why?
- Prazosin | - Need to relax the sphincters
62
Drugs to help increase internal urethral sphincter tone?
- Hypogastric nerve (L10L4) - Alpha agonist (sympathomimetic) - Phenylpropanolamine hydrochloride (mixed adrenergic agonist - Estrogen (increases alpha receptors)
63
Side effects of phenylpropanolamine and estrogen?
- Hypertension and tachycardia
64
Look at the drugs table
Just do it!
65
Modes of expressing the bladder (and which is proper)
- Manual expression - Intermittent catheterization - Indwelling catheterization***
66
Things needed for intermittent catheterization
- Difficult to do in female patients - Sterile - Red rubber catheter
67
What can a puddle of urine mean?
- Overflow from too large of a bladder that cannot be emptied - Large, distended, never fully emptied bladder - Large, distended bladder that continually leaks
68
Reflex arc with UMN bladder and overflow
1. Sensory input (detrusor muscle via pelvic nerve senses bladder stretch) 2. Pelvic control (stimulates contraction of detrusor muscle AND relaxation of external urethral sphincter to allow the bladder to empty some volume)
69
What is the consequence of the reflex arc?
- DETRUSOR ATONY!
70
What is the risk with large, distended, never fully emptied bladder?
- UTI | - Ascending pyelonephritis
71
What is risk of large, distended bladder that continually leaks?
- Urine scalding
72
WORST consequences associated with an unmanaged bladder?
- UTI - Detrusor atony - Ruptured bladder - Urine scald

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