1. HENRY PRAKASH
CMC VELLORE

5. Mn
U
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MN
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Bladder

6.  Aim
 Reproduce symptoms
 Study pathophysiology
 Quantify appropriate measures

7.  Screening
 Diagnostic

8.  Uroflowmetry
 Cystometrogram
 Video cystometrogram

9.  Non invasive
 Inexpensive
 Relative portability
 Micturate into collecting funnel- direct calibration of flow measures

10.  ALPP Abdominal leak point pressure
 Bladder compliance
 Bladder sensations:
First sensation of bladder filling (FSF)
First desire to void (1st urge)
Strong desire to void (severe urge)
.
 DESD - Detrusor –external sphincter dys-synergia
 DLPP - Detrusor leak point pressure
 IDC - Involuntary detrusor contraction

11.  LUTS: Lower urinary tract symptoms
 Maximum cystometric capacity
 OAB: Overactive bladder.Type 1 ,2,3,4
 Pdet, Pves, Pabd
 Q: Uroflow

13.  Studies storage and voiding
 Ideally
 Normal desire
 Representative of normal voiding
 Adequate privacy
 Graph compared with patient’s micturition chart
 USG - PVR

15.  Standard measured parameters
 Maximal flow rate Qmax
 VoidedVolume
 ResidualVolume

16. •

17.  BOO - Bladder Outlet Obsturction
with Qmax cut-off 10 ml/sec to 15 ml/sec
 Sensitivity : 39 to 80%
 Specificity: 94 to 61%
Review of lit, Jour Urology, July 2006 , 29-35

18.  Pitfalls:
Doesn’t recognize BOO Vs poor detrusor
Normal flow pattern if overactive detrusor + BOO
Pressure flowmetry remains GOLD STD

19.  Bladder pressureVs Bladder volume
 Bladder filled with fluid- water/saline/gas- at fixed infusion
rate: 20-50 cc
 Pressure measured with catheter placed in bladder

24.  Vesical Pr = Detrusor pr + Abd pr
 Detrusor pr =Vesical Pr - Abd pr
 Abdominal pressure measured by catheter in rectum
 Sensation/desire to void noted
 Capacity 300-600 ml

25.  1st sensation about 50% of capacity
 Normal people can suppress detrusor contractions (>15 cm
H2O)
 Normally, bladder pressure doesn’t significantly rise till
micturition: GOOD COMPLIANCE

27.  Look for
 Pressure variation
 Bladder sensation/urgency
 Leak
 Voluntary micturition effort
ALWAYS, Correlate CLINICAL PICTURE + data

29.  Spinal shock (up to 6 months): areflexic
 Suprasacral (usually injury above L1 vertebra)
 Neurogenic Detrusor Overactivity + DSD
 Sacral/Cauda equina (usually injury below L2 vertebra)
 usually areflexic

43. NEUROGENIC DETRUSOR OVERACTIVITY
Voided with abdominal pressure

44.  “urgency, with or without urge incontinence, usually with
frequency and nocturia if there is no proven infection or other
etiology.”
 symptom complex caused by one or more of the following
detrusor over activity, sensory urgency, and low bladder
compliance.
 urinary tract infection,
 urethral obstruction, pelvic organ prolapse, neurogenic bladder,
sphincteric
 incontinence, urethral diverticulum, bladder stones/foreign body,
 Bbladder cancer

45. Idiopathic DO Neurogenic DO Non neurogenic DO
SUPRA SPINAL LESIONS Infection
Stroke,PD,MS,Tumor,TBI,Hyd.Cep, BOO
Prostatic,Urethral,stricture,UD,
Prolpase
SUPRA SACRAL SPINAL LESIONS Tumor,Stones,Age
SCI,MS,TM,Tumor,MyeloDisp Foreign Body

46.  TERMINAL –DO
 single involuntary detrusor contraction occurring
at Cystometric capacity, which cannot be
suppressed, and results in incontinence usually
resulting in bladder emptying
 PHASIC –DO
 Characteristic waveform, and may or may not lead
to urinary incontinence

51. UNSTABLE DETRUSOR- POOR COMPLIANCE

53.  Skin–CNS–bladder reflex
 Somatic motor axons can innervate bladder parasympathetic
ganglion cells and thereby transfer somatic reflex activity to
the bladder smooth muscle

54.  In true DSD, increased EMG activity correlates with an ascending
portion of the detrusor contraction curve
 Dysfunction voiding, EMG increase is random
 Sympathetic system controls the bladder neck and proximal urethra
from theT10 to L2 spinal cord segments
 A spinal cord lesion aboveT10 removes supraspinal inhibitory control
of the sympathetic vesicourethral neurons, resulting in bladder neck
functional obstruction (smooth muscle dyssynergia)

61.  Goal:
 Adequate emptying
 Social continence
 Acceptable detrusor pressures
< 40 cm H2O
2009 International ContinenceSociety guidelines.

62.  Step 1: GeneralAssessment
 Demographic data
 Family support
 Cognitive status
 Hand functions/ level of independence
↓
APPRORIATE Bladder emptying strategy
Neurogenic bladder: management guidelines

63.  Step 2: Self/refex voiding (suprasacral lesions)
 Goal: PVR < 100 or < 1/3 of prevoid volume
Max det pressure < 40 cm H2O
 Medications prn
▪ Anticholinergics low dose (Oxybutynin,Tolterodine)
▪ If leaks / high detusor pressure > 40 cm H2O
▪ Alpha1a antagonists (Tamsulosin)
▪ Poor initiation/flow- bladder neck symptoms

64. Step 3:
 If self/reflex void not possible/ not safe:
 CIC
 SPC
 IDC

65.  CIC if
 Good hand functions/ trunk balance/ cognition
 SPC if
 Poor hand functions, urethral injury/stricture
 IDC if
 Hydronephrosis, gen.condition poor, co-morbidities

66.  Supportive
▪ Diapers
▪ IDC/Condom
 Surgical
▪ Urinary Diversion
▪ Bladder Augmentation
▪ Intravesical / external sphincter Botox
Urethral suspension

67.  Non-neurogenic voiding dysfunctions- Mx:
▪ Behavior therapy
▪ Timed voiding
▪ Pharmacology-w dose