The document discusses neurogenic bladder and its anatomy, innervation, and types. It provides details on:
1) The urinary bladder is innervated by the parasympathetic, sympathetic, and somatic nervous systems which control storage and voiding functions.
2) There are several types of neurogenic bladder depending on the location of lesions in the central or peripheral nervous system, including loss of supraspinal control, spinal cord lesions above or at the sacral level.
3) Evaluating the type of neurogenic bladder helps determine the symptoms, cystometric findings, and appropriate management.
Approach to bladder symptoms, Innervation of Bladder, Control of Micturition, Bladder Functions, Funtions and synergy of Sphincters and Detrusor, UMN Bladder, LMN Bladder, Pathological Basis of symptoms, Clinical signs in different types of Bladder, Investigations of Bladder disorder, Approach to Treatment of bladder disorders,Clean Intermittent Self Catherterisation, Surgical Treatment of bladder dysfunction
Follow up and Complications
Approach to bladder symptoms, Innervation of Bladder, Control of Micturition, Bladder Functions, Funtions and synergy of Sphincters and Detrusor, UMN Bladder, LMN Bladder, Pathological Basis of symptoms, Clinical signs in different types of Bladder, Investigations of Bladder disorder, Approach to Treatment of bladder disorders,Clean Intermittent Self Catherterisation, Surgical Treatment of bladder dysfunction
Follow up and Complications
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
2. • Neurogenic bladder refers to dysfunction of the
urinary bladder due to disease of the central
nervous system or peripheral nerves involved in
the control of micturition .
• Non Neurogenic bladder refers to dysfunction of
the urinary bladder due to dynamic disturbance
of genitourinary system.
• Complaints about bladder function are >common
in patients with neurological disease
• 98% of lifetime bladder is in storage phase.
INTRODUCTION
3. ANATOMY
• The UB is a smooth muscle chamber
• Composed of two main parts: (1) BODY (2) NECK
• Bladder Muscle is Detrusor muscle- Smooth muscle.
• Trigone : Small triangular area ,Immediately above the bladder
neck.
• The bladder neck is 2 to 3 cm long, and its wall is
composed of detrusor muscle interlaced with a large
amount of elastic tissue. Muscle in this area is called
Internal sphincter. Its natural tone normally keeps
the bladder neck and posterior urethra empty of urine
• Posterior urethra- lower part of the bladder neck ( because of its
relation to the urethra)
• External urethral sphincter :- Voluntary skeletal muscle ( Other
entirely smooth muscle). The external sphincter muscle is under
voluntary control of the nervous system and can be used to
consciously prevent urination even when involuntary controls are
attempting to empty the bladder.
• Capacity:- Is about 300 ml with a maximum capacity of 500 ml
6. RECEPTORS & INNERVATION
• Detrusor - intermediolateral
gray column of S2,3,4
parasympathetic – pelvic n (M2
receptors)
• External urethral sphincter -
Innervated by somatomotor
S2,3,4 nucleus (Onuf’s
Nucleus)-pudendal n
(Nicotinic receptor)
• Trigone and internal sphincter
innervated by Sympathetic
T10,11,12 (less important)
• SNS acts through B2 and A1
receptors
• A-delta fibers – Micturition reflex,
stretch and fullness sensation
• C-fibers – Noxious sensation
7. • Frontal lobe- Sends inhibitory signals
• Pons (Pontine Micturition Center=PMC)
– Major relay/excitatory center
– Coordinates urinary sphincters and the bladder
– Affected by emotions
• Spinal cord (S2-4)-Intermediary between upper and lower control
• Peripheral nervous system-
Parasympathetic (S2-S4)-Pelvic nerves
Excitatory to bladder, relaxes sphincter
Somatic (S2-S4)-Pudendal nerves -Excitatory to external
sphincter Sympathetic (T10-L2)
– Hypogastric nerves to pelvic ganglia
– Inhibitory to bladder body, excitatory to bladder base/urethra
NEURAXIS
8. 1.CORTEX – increased blood flow
• During storage During micturition
Mid cingulate gyrus Rt Inferior frontal gyrus
Lat bilateral frontal lobes Rt. Anterior cingulate gyrus
Periaqueductal gray matter (PAG)
2.PONS
• Micturition is being controlled by pontine micturition center (PMC)
which is situated in mediodorsal Pons called as M region
• During storage phase PMC is inhibited by higher cortical control
unless socially appropriate
• Blok et al asked to void the volunteers under scanner In successful
voiders activity was shown in mediopost pons (M region)
• In subjects unable to void and storing urine a distinct region in the
ventrolateral pontine tegmentum was activated (L region)
Central neural control
PET studies Blok et al . Brain 1998
10. Central neural control
• Successful voiders –Rt Inferior frontal gyrus
Rt Ant cingulate gyrus
• Pontine micturition center- M region
• Unable to void – Mid cingulate gyrus Lat bilateral frontal
lobes
• Pontine storage center - L region PAG
11. Peripheral Nervous System
• Parasympathetic (S2-S4)
– Pelvic nerves
• Excitatory to bladder,relaxes sphincter
• Somatic (S2-S4)
– Pudendal nerves
Excitatory to external sphincter
• Sympathetic (T10-L2)
– Hypogastric nerves to pelvic
ganglia
– Inhibitory to bladder body,
excitatory to bladder base/urethra
• Afferents through Pelvic, pudendal,
hypogastric by A-delta fibers
Micturition reflex,stretch and
fullness sensation C-fibers – Noxious
sensation
12. FUNCTION OF BLADDER
Function
Balance between suprasacral
modulating pathways, sacral
cord and the pelvic floor
Emptying phase: “Voiding
Reflex”
Series of coordinated events
involving outlet relaxation,
detrusor contraction
Storage phase: “Guarding
reflexes” constant afferent
input to maintain continence
13. Normal Voiding
• SNS primarily controls bladder and the IUS
– Bladder increases capacity but not pressure
– Internal urinary sphincter to remain tightly closed
– Parasympathetic stimulation inhibited
• PNS:-Immediately prior to PNS stimulation,
SNS is suppressed
Stimulates detrusor to contract
Pudendal nerve is inhibitedexternal sphincter openfacilitation of voluntary
urination
• Somatics (pudendal N) regulate EUS,Pelvic diaphragm
Delaying voiding or voluntary voiding:
• When an individual cannot find a bathroom nearby, the brain inhibit PMC to
prevent detrusor contractions & actively contract the levator muscles to
keep the external sphincter closed
• Thus , voiding process requires coordination of both the ANS and somatic nervous
system, which are in turn controlled by the PMC located in the brainstem.
Normal Voiding
14. • In child Controlled by it is controlled by Sacral spinal cord reflex
• Newborns void 20 x/day with only a slight decrease during the 1st year of life
• Bladder capacity increases & voiding frequency decrease with growth
Bladder capacity in Ounces (30ml) = Age (yrs) +2
• 1-2 yrs: conscious sensation of bladder fullness develops
• 2-3 yrs: Ability to initiate or inhibit voiding voluntarily develops
• 2-4 yrs: Voiding comes under reliable voluntary control
• By age 4 Micturition spinal reflex fully modulated by CNS micturition center
via a spinobulbospinal tact
• Initially child has better control over external sphincter than bladder
DEVELOPMENT IN CHILD
17. Storage - At low pressure until such time as it is convenient and socially acceptable
to void
Voiding - Initiated by inhibition of the striated sphincter and pelvic floor,followed
some
seconds later by a contraction of the detrusor muscle.
• Storage Problem: Failure to Store normal volumes of urine at low pressure & without
leakage
– Non compliant bladder -Irritable bladder
– Inadequate sphincter tone during filling
• Emptying Problem: Failure to empty completely, on command, efficiently at low pressures
– Failure of neurological control of bladder -Bladder muscle failure
– Failure of sphincter relaxation during voiding
• Voiding symptoms; Storage symptoms;
Hesitency Frequency
Slow stream Urgency
Straining to void Urge incontinence
Terminal dribbling Nocturia
Feeling of incomplete emptying.
Description of Terminology
18. 1. LOSS OF SUPRASPINAL CONTROL (UNINHIBITED
BLADDER)
2. SPINAL CORD LESION ABOVE SACRAL LEVEL
REFLEX NEUROGENIC BLADDER (AUTOMATIC)
3. SPINAL CORD LESION INVOLVING SACRAL
LEVEL AUTONOMOUS BLADDER
4. LESION INVOLVING AFFERENT SENSORY
NEURONS SENSORY NEUROGENIC BLADDER
5. LESION INVOLVING EFFERENT MOTOR
NEURONS MOTOR PARALYTIC BLADDER
6.OTHERS: Stroke/Dementia/NPH/PD/MSA/MS Diabetic
cystopathy/Spinal shock
TYPE AND LOCALIZATION
OF BLADDER
20. Type of Urinary Incontinence
1. Stress-Urine loss during activities such
as coughing, sneezing,
laughing or lifting.
2.Urge-A sudden need to urinate,
occasionally with large volume
urine loss. Can also exist
without incontinence (Urgency).
3.Overflow- A frequent dribble of urine
as a result of inefficient bladder
emptying symptoms are similar
to stress incontinence.
4.Mixed- stress + urge forms.
5.Functional-Urine loss not associated
with any pathology or problem
in the urinary system.
22. • Lesions of CNS involving area above pons
• Micturition is usually precipitous and complete
• Frequency, urgency & urge incontinence
• Low or absent residual volume as there is no DSD
• Normal sensation of bladder filling
• Causes: CVA, frontal tumors, parasagittal
meningioma, ACA aneurysm,NPH, PD,
Demyelinating disease
LOSS OF SUPRASPINAL CONTROL
(UNINHIBITED BLADDER):
23. • Detrusor- sphincter dyssynergia is a rule
• Bladder sensation variably interrupted
• Bladder tone increased, capacity reduced
• Small residual urine
• Urgency, frequency and urge incontinence
• In incomplete lesions Inability to initiate voluntary micturition
• Cystometrogram shows uninhibited contractions
of detrusor in response to small volume of fluid
• Causes: spine cord trauma, compressive myelopathy, myeilitis,
syringomyelia
SPINAL CORD LESION ABOVE SACRAL LEVEL
REFLEX NEUROGENIC BLADDER (AUTOMATIC)
24. • Denervation of both afferent and efferent supply to bladder
• Bladder tone flaccid, sensation absent, Inability to initiate
micturition
• Increased bladder capacity and residual urine
• Overflow incontinence, no urgency
• No bladder reflex activity, Infection risk high
• Voiding is possible only by maneuver
• Cystometrogram shows low pressure and no emptying
contraction
• Causes: Cauda equina syndrome,Conus medullaris Spinal shock
SPINAL CORD LESION INVOLVING SACRAL LEVEL
AUTONOMOUS BLADDER:
25. • Impaired bladder sensation
• Initiation of micturition is possible
• c/o urinary retention or overflow incontinence
• Infection risk high
• If bladder not voided at timely basis over distension of
bladder
• Bulbocavernosus & anal reflexes absent
• Causes: Tabes dorsalis Neuropathies mainly small fibers:
DM, Amyloidosis
LESION INVOLVING AFFERENT SENSORY NEURONS
SENSORY NEUROGENIC BLADDER
26. • Bladder tone flaccid, sensation intact
• c/o Painful retention of urine or impaired bladder emptying
• Inability to initiate or maintain micturition
• Bladder capacity and residual urine markedly increased,
infection risk high
• Bulbocavernosus & anal reflexes absent
• Causes: Lumbosacral meningomyelocele,tethered cord
syndrome Extensive pelvic surgery or trauma Lumber
spinal stenosis
LESION INVOLVING EFFERENT MOTOR NEURONS
MOTOR PARALYTIC BLADDER:
27. • Intracranial tumors, damage after rupture of an aneurysm,
penetrating brain wounds, and prefrontal lobotomy subjects
(Andrew and nathan 1964). Patients with right frontal lobe
disorders who had urinary retention and in whom there was
restoration of voiding when the frontal lobe disorder was
treated successfully (Fowler 1999).
• DH with coordinated urethral sphincter is MC
• c/ o urinary frequency, urgency, and urge incontinence
• First-line treatment for detrusor hyperreflexia includes
anticholinergic medication
CORTICAL LESION
28. 1. STROKE ;
• Mechanisms: decreased sensation or awareness of bladder
filling and inability to suppress bladder contraction.
> Incontinence after stroke is frequently transitory and
upto 80% recover and being continent at 6 months.
2. DEMENTIA ;
• The cause of urinary incontinence in dementia probably is
multifactorial.
• Functional incontinence is major cause. It refers to incontinence
that is not derived from an abnormality in the lower urinary tract
or its innervation, but from immobility, gait disorder, cognitive
disability,and decreased motivation,
• Overactive bladder (OAB) is a also major cause.
29. • In NPH, Incontinence is late feature.
• Failure of CSF to flow into the parasagittal subarachnoid space
(where most fluid resorption occurs) as the most likely mechanism
• Distortion of central portion of corona radiata and Periventricular
white matter by distended ventricles which anatomically includes
sacral motor fibers that innervate legs and bladder, thus explaining
abnormal gait and incontinence
• Urodynamic parameters consistent with detrusor overactivity in 95%
pts.(Sakakibara et al 1996)
• Improvement in urodynamic function has been demonstrated within
hours of lumbar puncture in patients with NPH.
Normal pressure hydrocephalus:
30. 3. Spinal Cord Lesions: • Detrusor areflexia ( spinal shock) at
initial insult but progress to hyperreflexic and DSD over few
weeks
• C fiber emerge as major afferent mediate mechano
sensitivity forming abnormal sacral segmental reflex
resulting in automatic voiding
• c/o urgency frequency incomplete bladder emptying,
interrupted stream, difficulty in initiating micturition.
4. Multiple sclerosis: • Interruption of the reticulospinal
pathways between the pontine and sacral micturition centers
may cause DSD
• Plaques located in the spinal afferents and efferents of
the sacral reflex arc may inhibit bladder contraction and
therefore result in impaired emptying or urinary retention
• Intracranial plaques may result in loss of voluntary control of
initiation or prevention of voiding
31. 5. Herpes zoster ; • Herpes virus lies dormant in the dorsal
root ganglia or the sacral nerves
• Sacral nerve involvement leads to impairment of
detrusor function
• Early stages of herpes infection are a/w frequency,
urgency, and urge incontinence
• Later stages include decreased bladder sensation,
increased residual urine, and urinary retention
32. 1.Onset: Etiology help
2.Sense of bladder filling: Motor/Sensory/Cortical
3.Can they feel urine passing: Afferent Neuraxis
4.Can they stop urine passing in midstream at will: Efferent Neuraxis
5.Does bladder leak continually or suddenly pass large volume:OI/DSD/Sensory
6.Frequency: NON NEUROGENIC/NEUROGENIC
7.Stream: NON NEUROGENIC/NEUROGENIC
8.Initiation: CORTEX/OUTLET
9.Termination : CORTEX/OUTLET
10.Ablity to stop on command : CORTEX
11.Volume of urine passed : LMN/UMN
12.H/O of spinal injury or surgery and meningomyelocele, Low backache, lower
limb paresis, sensory sympt. PD, CVA, MS Drugs: anticholinergics and α
adrenergics Sexual and bowel dysfunction &
Other autonomic symptoms Genitourinary symp: UTI, reflux, stones,surgery
Obstetric history: no. of deliveries, prolapse uterus
Clinical evaluation - History:
33. • Urinalysis and urine culture- UTI can cause irritative voiding
symptoms and urge incontinence.
• Urine cytology- carcinoma-in-situ of the urinary bladder causes
symptoms of urinary frequency and urgency BUN and
creatinine are checked if compromised renal function is
suspected.
• MRI spine and brain
• Radiological evaluation of upper urinary tract
Laboratory Studies
Laboratory Studies
34. • Urodynamic studies are necessary to document type of
bladder dysfunction
• Measurement of urine flow rate
• Measurement of post-void residual(PVR) volume
• Cystometry during filling and voiding
• Video-cystometry
• Urethral pressure profile measurement
• Assessment of pelvic floor neurophysiology
ASSESMENT OF LOWER URINARY
TRACT
35. • Noninvasive bladder investigations
– Post void residual volume – In out catheterization,
– Ultrasound ( N is <100ml)
– Uroflowmetry : Voided volume ( >100ml)
Maximal flow, maximal and average flow rate (M > 20ml/sec F >
15ml/sec)
• Cystometry
* Measure detrusor pressure (Intravesical presure – Rectal pressure)
* Bladder infused till 400 to 600ml – Pressure should not rise to >15cm
water (Stable bladder)
* Neurogenic detrusor overactivity – Involutary detrusor contraction
during filling phase
* Voiding phase – Detrusor pressure M < 50cm water F < 30cm water
• Sphincter EMG – Reinnervation with prolonged duration of MUAPs
• Neuroimaging – Cauda equina & conus lesions, spinal, supra pontine and
pontine lesions
INVESTIGATIONS
36. • Cystoscopy Indicated for people complaining of persistent irritative
voiding symptoms or hematuria
It can diagnose obvious causes of bladder overactivity, such as
cystitis, stone, and tumor, easily
• Determine etiology of the incontinence and may influence treatment
decisions
• Videourodynamics When cystometry is carried out using a contrast
filling medium and the procedure is visualized radiographically
• Useful to see Reflux into the ureters
• Thickening of the bladder wall and bladder diverticula.
• In detecting sphincter or bladder neck incompetence in genuine
stress incontinence.
• Inspect the outflow tract during voiding in patients with suspected
obstruction
INVESTIGATIONS
38. • Electrical stimulation:
Stimulation of levator ani muscles using painless electric
shocks
> Electrical stimulation of pelvic floor muscles produces a
contraction of the levator ani muscles and EUS while
inhibiting bladder contraction.
• Depends on a preserved reflex arc through the intact sacral
micturition center Can be used in conjunction with
biofeedback or pelvic floor muscle exercises.
• Effective in : Stress incontinence, as well as urge and mixed
incontinence
• Stimulation for a minimum of 4 weeks Decreasing bladder outlet
resistance
• Alpha-blockers (non-selective and selective) have been partially
successful for decreasing bladder outlet resistance,
residual urine and autonomic dysreflexia.
Non-invasive conservative treatment
39. • Anticholinergic are the most useful medications available for
neurogenic
detrusor overactivity.
• Muscarinic receptor antagonists. Reduce DO and improve bladder
compliance
• Propiverine has both anticholinergic and calcium channel blocking
properties & it is better tolerated than oxybutynin.
• Recently, darifenacin and solifenacin have been introduced , but no
clinical experience with these drugs in neurogenic bladder
overactivity has been published
• Additional treatment with desmopressin might improve the efficacy
of the treatment
Generic Name-Oxybutynin,Tolterodine,Trospium chloride,propiverin.
Drugs for detrusor overactivity
40. • Cholinergic drugs, such as bethanechol chloride and
distigmine bromide , have been considered to enhance
detrusor contractility and promote bladder emptying.
• The available studies do not support the use of
parasympathomimetics because of possible serious
possible side effects
• Combination therapy with a cholinergic drug and an
alpha-blocker appears to be more useful than
monotherapy
• There is no drug with evidence of efficacy for underactive
detrusor(LOE 2a, Gr of recom B).
Drugs for detrusor underactivity
41. • 3 types of Catheters ;
– Indwelling urethral catheters
– Suprapubic catheters
– Intermittent catheterization
Catheterization usually used for
• Atonic bladder with overflow incontinence
• Overactive bladder with detrusor sphincter dyssynergia.
Catheters:
42. • Intermittent self- or third-party catheterization is the gold
standard for the Mx of neurogenic bladder, Performed
using a short, rigid, plastic catheter
• Drain the bladder at timed Intervals (e-g awakening,
every 3-6 hours during the day, and before bed) or based
on bladder vol
• The average adult empties the bladder 4-5 times a day.
Thus, catheterization should occur 4-5 times a day
Patients should wash their hands with soap and water.
Sterile gloves are not necessary Intermittent
catheterization
Intermittent catheterization
43. • Botulinum toxin injections in the bladder most effective
minimally invasive treatment to reduce neurogenic
detrusor overactivity
• Repeated injections seem to be possible without loss of
efficacy
• Sphincterotomy is the standard treatment for DSD (level
of evidence: 2, grade of recommendation A ) Bladder
outlet resistance can be reduced without completely
losing the closure function of the urethra
• The laser technique is advantageous Sphincterotomy
TREATMENT