Test 2: Special Considerations and Differential

Question 1

describe the filling phase associated with normal micturition

Answer 1

voluntary control over LUT ivolved complex interactions between ANS and SNS (pudendal nn) efferent pathways

empty bladder = sympathetic efferents from T11-L2 inhibit contraction of bladder wall (detrusor) and maintain contraction of internal sphincter

bladder fills = proprioceptors sense stretch = sends impulse to SC S2-S4

spinal cord relays signals:
- up cord to brain to signal fullness
- reflexive signal stimulates Sympathetic and parasympathetic branches to initiate emptying

Question 2

describe the capacity of the bladder in the filling phase

Answer 2

neuro or anatomical compromise = store quantity of 200-300 ml before signal is emitted from stretch receptors

max capacity = 500ml for females and 700 ml for males

overwhelming urge occurs at ~90% capacity (2 cups for females, 20 oz for males)

Question 3

describe the normal emptying phase

Answer 3

conditions met = frontal lobe disinhibits PMC = pontine micturition center = parasymathetic activation = detrusor contraction + relaxation of IUS

conditions not met = frontal lobe inhibits PMC = pelvic floor mm contract to keep EUS closed

as signals from pontine micturition center relax the IUS, PMC also signals SC to inhibit pelvic floor mm

Question 4

describe normal defecatory function

Answer 4

similar to the bladder

rectum has very sensitive stretch receptors that send signal to cord when the rectal cavity is full

rectum is full = signal to SC and splits with signal to brain

decision from cortex results in:
1. delay of urge through contraction of pelvic floor and EAS
2. no response from cortex = reflexive defecation

Question 5

describe LMN role in normal bowel reflexive evacuation

Answer 5

normal bowel reflexive evac involves LMN from SC transmitting signals to cord of rectal distention

parasympathetic response = increase GI activity

sympathetic response = decrease GI activity

Question 6

describe bladder development

Answer 6

begins at 4-6 weeks gestation

in infants and kids, urinary bladder is in the abdomen even when empty and enters the greater pelvis by 6 years of age but is not located entirely in the lesser pelvis until after puberty

Question 7

intermittent vs continuous urinary incontinence in children

Answer 7

intermittent = at least 5 years of age with either episodes of day or night wetting

continuous = as name indicates with the implication of either an anatomical and/or neuro deficit

Question 8

incidence of incontinence in kids

Answer 8

high

15.5% rate for enuresis in 7.5 year old kids

decreases with age but remained at 0.5-1% in adults

given close nature of GU and rectum/GI systems, children should be assessed for constipation through care for LUT dysfunction

Question 9

how long is micturition involuntary in kids

Answer 9

3-5 years

volitional control can occur as early as 1 year

hypothesis that high absorbance diapers leads to later incontinence

Question 10

what is nocturnal enuresis

Answer 10

bedwetting

genetic component

> 5 years of age

males at higher risk

other risk factors: neuropsychiatric disorders (ADD/ADHD), intellectual disorders, sleep disorders

Question 11

pediatric pelvic floor intervention examples

Answer 11

timed/schedule voiding

habit training
- limit fluid intake before bed
- pee before bed
- parent wakes child w/i 1st segment of night to trigger arousability

External pelvic floor exam (parent present + consent)

biofeedback training (external sensors)

NMES (external sensors for PFM coordination and strengthening)

pelvic girdle mm training

Question 12

etiology of tethered cord syndrome

Answer 12

vertebral column grows longer than the spinal cord

infrequent = SC attached to surrounding structures during early development

as column elongates, tethered cord becomes stretched and damages SC/causes cauda equina

red flag if symptoms have not be previously diagnosed/addressed

Question 13

causes of tethered cord syndrome

Answer 13

scar tissue
fatty mass/lipoma
abnormal development

Question 14

S&S of tethered cord

Answer 14

LBP! and LE pain
difficulty walking
excessive lordosis/scoliosis
problems with bowel/bladder control
change in LE strength
foot deformities
LMN S&S if cauda equina
UMN S&S if SC affected

abnormal integument signs (dimple, tuft of hair, hemangioma, bulge of fatty mass)

sx indicated if severe

Question 15

what is an overactive bladder (OAB)

Answer 15

includes decreases in bladder capacity, urethral compliance, maximal urethra closure pressure, and urinary flow rate

often occurs from “urinating just in case”

can lead to urge incontinence

Question 16

factors that increase likelihood of incontinence with aging (especially females)

Answer 16

anatomy, decrease in periurethral blood flow due to lack or decreased estrogen

Question 17

what happens with urinary incontinence in both men and women

Answer 17

postvoid residual volume and the prevalence of involuntary detrusor mm contraction likely increase while urethral resistance increases in men

Question 18

prevalence of UI and the 2 types

Answer 18

more than 50% nursing home residents

established = usually result of neuro damage, intrinsic bladder or urethral pathology

transient = UI caused by changes in meds, diet, hygiene (typically reversible if underlying problem is addressed)

Question 19

transient causes of UI (DIAPPERS)

Answer 19

Delirium

Infection (especially UTI)

Genitourinary Syndrome of Menopause (atrophic vaginitis)

Pharmaceuticals

Psychological Factors

Excess fluid output (i.e. dietetics)

Restricted mobility

Stool (constipation or impaction)

Question 20

types of urinary incontinence

Answer 20

stress = unopposed increases in intraabdominal pressure

urge = sudden urge to urinate without ability to hold in urine once urge sensation occurs

mixed = combo of UUI and SUI

overflow = accidental loss of urine from chronically full bladder

functional = inability to get to bathroom bc of physical limits or inability to manage clothing once individual has made it to bathroom

Question 21

what may cause overflow incontinence

Answer 21

may result due to physical alignment issues or damage to bladder nn from diabetes

loss of adequate estrogen or progesterone

herniated L/S disc

may also be due to detrusor instability; varable volume emptied but not completely emptied

Question 22

what does traditional PFT consist of

Answer 22

uptraining/progressive resistance exercise (PRE)
- independent or in conjuction with biofeedback, NMES

downtraining/relaxation
- independent or in conjunction with biofeedback

Question 22

pelvic floor intervention examples for adults

Answer 22

general mobility = gait, bed mobility, transfers, finger dexterity, strengthening

bladder/bowel logs = apply strategies based on how/when oncontinence occurs

“Knack” training = timing/coordination of pelvic floor contraction with exhale to counteract increases in intraabdominal pressure

scheduling
- fluid restriction before bed
- pee before bed
- time intervals for urination (2-3 hrs in SNF)

edu on bladder irritants
- may cause pain or increase frequency
- acidic, spicy, caffeinated, carbonated, chocolate, concentrated urine

traditional pelvic floor therapy

Question 23

causes of fecal incontinence

Answer 23

psychological (depression, anxiety, disoriented, etc)

neuro impairments (sensory/motor due to CVA, diabetes, PD, autonomic neuropathy, etc)

anal sphincter dysfunction (risk factor = 4th degree tear with labor)

hemorrhoids, rectal prolapse, or rectocele

severe diarrhea (infection, severe impaction, etc); long standing constipation = cant sense stool movement and stretch receptors are no longer stimulated

Question 24

interventions for fecal incontinence

Answer 24

team effort for why S&S are occuring - diet - med changes - function changes - voiding programs - recs on fiber/H2O consumption PFPT - biofeedback helpful in 70% people due to sensory/motor probs; rectal balloon training for over dilated rectum (attempt to regain compliance) - NMES

Question 25

2 types of neurogenic bladder

Answer 25

1. LMN alterations from T12 and below have flaccid bladder and sphincters/unable to store urine = "autonomous neurogenic bladder" 2. UMN defects; failure to empty = "reflexive neurogenic bladder"

Question 26

describe what happens with an UMN reflexive neurogenic bladder

Answer 26

defects from T12-L1 = generally reflexive bladder which may be hyperreflexive or hypertonic brain doesnt recieve signal that bladder is full and signal to delay urge to urinate is not transmitted hyperreflexive bladder reflex - spontaneous bladder emptying with occasional residual due to detrusor sphincter dyssynergia - initiating voiding is problematic due to lack of coordination between bladder contraction and sphincter relaxation

Question 27

describe a suprapubic catheter

Answer 27

implanted through lower abdominal wall PT should be aware of gait belt placement/disruption of covering may be placed for better pt management but often it is due to a wound in perineal/buttock region to keep moisture away from site

Question 28

describe intermittent catheterization

Answer 28

used when unable to initiate urination or in times of incomplete emptying acute care and IPR - initiated by nursing inpatient and outpatient - pt should bring their cath kit; therapist assesses for AD

Question 29

describe indwelling catheters

Answer 29

typically used early in recovery kinked or at capacity - may contribute to AD

Question 30

describe a condom catheter

Answer 30

option for males can be an option for episodes of incontinence in UMN but can also be used as long term strategy for those with LMN injuries typically used with leg bad can slip off if ill fitting! may or may not get dirupted during seating and mobility

Question 31

describe use of adult briefs

Answer 31

usually last resort can be used alone or in conjunction with other methods risk for skin breakdowns/excessive moisture or yeast/bacterial infections in females

Question 32

interventions for neurogenic bladder

Answer 32

ask about schedule/management methods early rehab = train with nursing lifespan = consider how pt functions in seating system; materials, wicking system, risk of AD, etc if pt has difficylty initiating = edu on tapping strategies incomplete SCI may or may not respons to traditional motor interventions - biofeedback - NMES - traditional strengthening of PFM

Question 33

describe management of UMN neurogenic bowel with SCI pts

Answer 33

reflexive bowel emptying occurs when reflex is triggered - depends on fullness of colon - can be triggered by food, movement of feces, or suppository/stimulation - UMN = T12-L1 and above continence dependent on triggering reflexes and complete bowel evac parasympathetic innervation creates sphincter tone and reduces changes of FI

Question 34

describe management of LMN areflexive bowel with SCI pts

Answer 34

LMN lesion interferes with reflexive evac - loss of motor tone and flaccidity - peristalsis may be slowed with water reabsorption and this can increase risk of constipation that leads to impaction and AD - rectal sphincter may fail to contain stool = incontinence LMN lesions = below T12-L1 continence depends on keeping rectal cavity empty and doing a full evac

Question 35

Special considerations for multiple sclerosis in regard to bowel/bladder

Answer 35

CNS lesions between pons and sacral nn = increased urge, frequency, urge incontinence, voicing dysfunction, and urinary retention demyelinating CNS lesions = slow colon transit and decrease rectal sensation/contractile response meds can lead to constipation/fecal incontinence B&B impairments are most common problems that limit those with MS; QOL, social life, and finances

Question 36

PD special considersations B&B

Answer 36

pelvic autonomic dysfunction doesn't respond well to levodopa like motor symptoms do B&B S&S have strongest correlation with QOL UI and constipation arent always addressed with these pts UPDRS has questions about bowel and bladder

Question 37

S&S of cauda equina

Answer 37

LBP and sciatica; increases with abdominal pressure and decreases with lying down decreased sensation ANS S&S = retention or incontinence motor = paresis or paralysis of nn roots involved reflexes are diminished for impaired nn roots

Question 38

prognosis for cauda equina

Answer 38

marked improvements with sx decompression greater chance of persistent problems w/o sx

Question 39

big picture/red flag for cauda equina

Answer 39

LBP and sciatica combined with NEW bowel and bladder retention or incontinence S&S requires emergency referral as it may progress to paraplegia and permanent ANS problems

Question 40

deep gluteal syndrome pain pattern (aka piriformis syndrome)

Answer 40

piriformis attaches proximally at sacrum, sacrotuberous ligament, near PSIS to greater trochanter may not just be piriformis onvolved (consider OI, SG, IG) common site for sciatic nn compression differential dx - coccyx pain - L/S radiculopathy/referred pain - deep hip ER pathology - pudendal neuralgia

Question 41

deep gluteal syndrome is compression of what and what are the subtypes

Answer 41

sciatic or pudendal nn due to non-discogenic pelvic lesions - piriformis syndrome - gemelli-obturator internus syndrome - ischiofemoral impingement syndrome - proximal hamstring syndrome

Question 42

symptoms of deep gluteal syndrome

Answer 42

deep buttock ache pain with ant pelvic tilt in quadruped (proximal HS) with or without neurologic symptoms

Question 43

diagnostic tests for deep gluteal syndrome

Answer 43

pelvic MRI and or EMG depending on S&S US guided injections (diagnostic and intervention)

Question 44

what might deep gluteal syndrome co-occur with

Answer 44

bursitis (trochanteric or ischial)

Question 45

pelvic floor referral patterns/possibilities

Answer 45

symptoms of bowel/bladder pain in groin ("golf ball in rectum") saddle anesthesia (pudendal nn compression or something else) piriformis syndrome - deep butt pain/dull ache coccydynia - pain with sitting, or possibly with defecation

Question 46

Prevalence of labral tears with hip pathology

Answer 46

prevalence of labral tears in pts with hip/groin pain = 22-55% can cooccur with pelvic floor guarding/pain may be related to childhood pathologies postpartum women = increased risk of labral tears intrapartum and at delivery (ER during delivery is recommended to reduce risk; small study though)

Question 47

S&S of femoroacetabular impingement

Answer 47

pain in hip FLX clicking/popping with activity stiffness FADIR (not used in isolation; cluster)

Question 48

explain the correlation between FAI and inguinal hernia

Answer 48

strong correlation ROM limits from FAI may contribute to formation of hernia bulge is present replication of S&S or increased bulge with increased intra abdominal pressure

Question 49

what is a stress fx

Answer 49

caused by repeated submax stress better with rest; may be painful at rest with prolonged exposure/microfx increases with activity factors influencing include: - training - biomechanics - bone health - footwear MRI is most comprehensive method to evaluate

Question 50

for pelvic or sacral stress fx individuals may exhibit what

Answer 50

inguinal, perineal, pubic rami, and/or adductor region pain sacral stress fx may elicit + FABER

Question 51

what is RED-S and the implications

Answer 51

relative energy deficiency in sport results from low energy diets and excessive exercise term encompasses both male and female populations energy reduction reduces release for gonadotropic releasing hormone (neg affect on bone health) relative risk of stress fx in athletes with menstrual disturbances is 2-4x that of eumenorrheic athletes

Question 52

what is dysuria

Answer 52

painful urination

Question 53

what is hematuria

Answer 53

blood in urine

Question 54

S&S that indicate the GU system

Answer 54

may have skin hypersensitivity (T10-L1) pelvic or genital masses abnormal discharge genital pain may or may not have fever

Question 55

how do anticholinergics/antispasmodics work and what are the adverse side effects

Answer 55

i.e. oxybutynin (for overactive bladder) may reduce spasm or smooth mm contraction adverse effects = dizziness, drowsiness, blurred vision, dry mouth, increased HR

Question 56

how do tricyclic antidepressants work and what are the adverse effects

Answer 56

i.e. amitriptyline produces strong inhibitory effect on bladder smooth mm adverse effects = weakness, fatigue, parkinsonian effect, postural hypotension, HA, irritability, abdominal stress elderly = increase risk for side effects

Question 57

what are alpha adrenergics

Answer 57

i.e. ephedrine, pseudoephedrine increases bladder outlet resistance adverse effects = tachycardia, cardiac arrhythmias, vertigo, HA

Question 58

what are beta adrenergic blocks

Answer 58

i.e. propanolol increases bladder outlet resistance adverse effects = bradycardia, lightheadedness

Question 59

how do estrogens work with bladder management

Answer 59

increases periurethral flow strengthens periurethral tissues adverse effects = HA, nausea, edema, HTN

Question 60

medications to relax striated mm

Answer 60

baclofen (oral) dantrolene sodium (skeletal mm relaxants) diazepam (benzodiazepine) relax external sphincter by inhibiting postsynaptic reflexes of strained mm adverse effects = weakness/sedation

Question 61

what is an intrathecal baclofen pump

Answer 61

intrathecal dosage instead of oral less systemic side effects