Brown sequard syndrome or transverse hemisection syndrome
Causes symptoms and treatment of brown sequard syndrome
Background about the disease
Neural tracts
Ascending and descending pathways of the spinal cord (motor and sensory pathways)
Pathophysiology of brown sequard syndrome
Brown sequard syndrome or transverse hemisection syndrome
Causes symptoms and treatment of brown sequard syndrome
Background about the disease
Neural tracts
Ascending and descending pathways of the spinal cord (motor and sensory pathways)
Pathophysiology of brown sequard syndrome
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
CONCEPT OF NODOPATHIES AND PARANODOPATHIES.pptxNeurologyKota
emergence of autoimmune neuropathies and role of nodal and paranodal regions in their pathophysiology.
Peripheral neuropathies are traditionally categorized into demyelinating or axonal.
dysfunction at nodal/paranodal region key for better understanding of patients with immune mediated neuropathies.
antibodies targeting node and paranode of myelinated nerves have been increasingly detected in patients with immune mediated neuropathies.
have clinical phenotype similar common inflammatory neuropathies like Guillain Barre syndrome and chronic inflammatory demyelinating polyradiculoneuropathy
they respond poorly to conventional first line immunotherapies like IVIG
This presentation briefs out the approach of dementia assessment in line with consideration of recent advances. Now the pattern of assessment has evolved towards examining each individual domain rather than lobar assessment.
This presentation contains information about Dementia in Young onset. Also it describes the etiologies, clinical feature of common YOD & their management.
Entrapment Syndromes of Lower Limb.pptxNeurologyKota
This presentation contains information about the various Entrapment syndromes of Lower limb in descending order of topography. It also contains information about etiology, clinical features and management of each of these entrapment syndromes with special emphasis on electrodiagnostic confirmation.
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
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
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.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- 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
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Neurological control of Micturition order and disorder
1. Dr Ashwin Lathiya
SR neurology
GMC Kota
Neurological control of Micturition Order
and Disorder
2. OUTLINE OF THE PRESENTATION
Anatomy & Physiology of micturition
Terminology
Classification of neurogenic bladder
Various disease and bladder
Diagnosis
Management
Take home
3. ANATOMY OF URINARY BLADDER
Bladder divides into two parts:
[1] body and [2] base
Body of the bladder is composed of
smooth muscle k/a detrusor muscle
Base of the bladder is comprised of
Trigone, a triangular area at posterior
wall of bladder
Bladder neck ,which opens into
urethra.
4. Internal sphincter:
• Involuntary smooth muscle at bladder neck
• Absent in females
External sphincter:
• Skeletal muscle, voluntary control
• In urogenital diaphragm
Superior and Inferior vesical artieries branches of ant. trunk of internal
iliac
Internal iliac veincommon iliacIVC
External iliac nodes
5.
6. Nerve Detrusor Internal
sphincter
External
sphincter
Final effect
Parasympathetic
(Pelvic n= Nervi
Erigentis)
Contraction Relaxation Not supplied Emptying of
bladder
Sympathetic
(Hypogastric n)
Relaxation Contraction Not supplied Filling of bladder
Somatic
(Pudendal n)
Not supplied Not supplied Contraction Voluntary
control
of micturition
7. Sensations of pain, temp, urgency follows the anterolateral white
columns.
Conscious sensations (bladder distention, ongoing micturition, tactile
pressure) follow the posterior columns
• A-delta fibers – Micturition reflex, stretch and fullness sensation
C-fibers – Noxious sensation
8. Block et al. --PET studies
1. PMC/Berrington’s nucleus/M region--in rostral pontine tegmentum;
voiding of urine.
2. Pontine storage centre/L region--located ventrolateral to PMC;
inhibits micturition.
3. PAG
4.Anterior and caudal hypothalamus
5.Insula
6.Anterior cingulate cortex
7.Locus ceruleus
8.Medial frontal cortex(right inferior frontal gyrus)-seat of attention and
response selection; selects socially appropriate place for micturition.
9.
10.
11. PHYSIOLOGY
Function --to store and expel urine in a coordinated, controlled
fashion, regulated by the central and peripheral nervous systems.
Bladder capacity changes throughout person's life.
In children, bladder volume: (years of age + 2) x 30mL
Wall pressure of 5 to 15 mmHg--sensation of bladder fullness
>30 mmHg-- painful
12. Amount of Urine
<50 ml Residual volume
250 ml First desire
>400 ml Urgency
>600 ml Painful urgency
800-900 ml Physiological capacity
1000 ml Anatomical capacity
13. 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.
14. STORAGE SYMPTOMS
Increased daytime frequency--if he voids too often by day. =Pollakisuria
Nocturia--if has to wake at night one or more times to void.
Urgency--sudden compelling desire to pass urine which is difficult to defer.
Urinary incontinence--any involuntary leakage of urine.
Stress urinary incontinence--involuntary leakage on effort or exertion, or
on sneezing or coughing.
Urge urinary incontinence--involuntary leakage accompanied by or
immediately preceded by urgency.
Mixed urinary incontinence--involuntary leakage associated with urgency
and also with exertion, effort, sneezing or coughing.
15. VOIDING SYMPTOMS
Slow stream--perception of reduced urine flow, usually compared to
previous performance.
Intermittent stream (Intermittency)--when flow stops and starts, on one or
more occasions, during micturition.
Hesitancy--difficulty in initiating micturition resulting in delay in the onset
of voiding after pt is ready to pass urine.
Straining to void--muscular effort used to either initiate, maintain or improve
the urinary stream.
Terminal dribble--prolonged final part of micturition, when the flow has
slowed to a trickle/ dribble.
16. POST MICTURITION SYMPTOMS
Feeling of incomplete emptying
Post micturition dribble--involuntary loss of urine immediately after he
has finished passing urine, usually after leaving the toilet.
17. Detrusor hypereflexia=OAB: Involuntary detrusor contraction
symptoms due to a suprapontine neurologic disorder. The
detrusor & sphincter function in coordination.
• Detrusor sphincter dyssynergia: is defined as detrusor
contraction concurrent with involuntary contraction of the
urethral and/or periurethral striated muscle.
• Detrusor areflexia:Is complete inability of the detrusor to
empty due to lower motor neuron lesion ( eg , sacral cord or
peripheral nerves injury)
20. UNINHIBITED BLADDER
LOSS OF SUPRASPINAL CONTROL
Results from injury to corticoregulatory tract exerting
inhibitory control on PMC
Lesions above pons.
Frequency, urgency & urge incontinence.
Micturition is usually precipitous and complete.
Low or absent residual volume
Bladder behaves like infants urine voided anytime
anywhere without control
Causes: CVA, frontal tumors, parasagittal meningioma, ACA
aneurysm, NPH, PD, Demyelinating disease
21. REFLEX NEUROGENIC BLADDER(AUTOMATIC)
SPINAL CORD LESION ABOVE SACRAL LEVEL
Post–spinal shock second stage of recovery.
Hyperactive micturition reflex with loss of voluntary
control small amount of urine collected in the bladder
elicits the micturition reflex
Bladder tone increased, capacity reduced
No residual urine
Causes: spine cord injury, compressive myelopathy,
myeilitis, syringomyelia
22. AUTONOMOUS BLADDER
SPINAL CORD LESION INVOLVING SACRAL LEVEL
Spinal cord injury that causes complete motor and sensory
impairment of the bladder from the sacral cord.
Bladder tone flaccid, sensation absent.
Inability to initiate micturition.
bladder capacity and residual urine.
Overflow incontinence, no urgency.
Voiding possible only by maneuver.
Causes: Cauda equina syndrome,Conus medullaris.
23. SENSORY NEUROGENIC BLADDER
LESION INVOLVING AFFERENT SENSORY NEURONS
Selectively interrupt the sensory fibers from the bladder to
spinal cord or from the afferent tract to the brain
Impaired bladder sensation painless distention
Initiation of micturition is possible.
If bladder not voided at timely basis l/t over distension of
bladder
Bulbocavernosus & anal reflexes absent
Causes: Tabes dorsalis
Neuropathies mainly small fibers: DM, Amyloidosis
24. MOTOR PARALYTIC BLADDER
LESION INVOLVING EFFERENT MOTOR NEURONS
Disease processes that affect parasympathetic motor
innervation of the bladder.
Inability to initiate or maintain micturition.
Bladder sensations intact.
c/o Painful retention of urine or impaired bladder
emptying.
Bladder capacity, residual urine, infection.
Bulbocavernosus & anal reflexes absent
Causes: Lumbosacral meningomyelocele,
Extensive pelvic surgery or trauma ,
Lumber spinal stenosis
Herpes zoster
25. STROKE
Acute presentation: Urinary retention; mecha. not clear but pheno
termed “cerebral shock’’
Chronic presentation: Freq, Urg, Incontinence
Incontinence after stroke is frequently transitory and upto 80%
recover and being continent at 6 months
Frontal lobe and internal capsule lesion: Detrusor overactivity and
increased rate of uninhibited sphincter relaxation
Brainstem stroke: Obstructive voiding symptom and retention.
Urodynamics: Detrusor overactivity (MC). Detrusor areflexia can
also be seen, esp in cerebellar lesion or in acute phase related to
cerebral shock.
26. DEMENTIA
Cause of incontinence is multifactorial.
Functional incontinence not derived from abnormality in the
lower urinary tract or its innervation, but from immobility, gait
disorder, cognitive disability, decreased motivation, rigidity,
spasticity.
Onset of urinary incontinence significantly earlier in DLB (3.2
years after dementia onset) than in AD (6.5 years after dementia
onset ) Del-Ser et al (1996)
Detrussor overactivity found in 58% (AD), 90% (VAD) (Mori et al 1999)
27. NORMAL PRESSURE HYDROCEPHALUS
Incontinence is late feature.
Mechanism: Failure of CSF to flow into the parasagittal
subarachnoid space (where most fluid resorption occurs).
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: detrusor overactivity in 95% pts.
Improvement in urodynamic function has been demonstrated
within hours of lumbar puncture in patients with NPH.
28. PARKINSON DISEASE
Prevalence -38% and 71%
LUTS- most common nonmotor symptom (Martinez et al 2007)
Urinary symptoms began approximately 5 years after onset of motor
symptoms (wing et al 2006).
MC Hypothesis is basal ganglia have inhibitory effect on the
micturition reflex, and with neuronal loss in the substantia nigra,
detrusor hyper-reflexia develops
MC symptoms freq, nocturia, urgency, and urge incontinence
Urodynamics: detrusor overactivity in filling phase.
Bladder symptoms are correlated with extent of dopamine depletion,
neurologic disability and with stage of disease.
DBS of the subthalamic nucleus improved voiding dysfunction.
29. MSA
Urinary dysfunction is a prominent autonomic feature (more than
90%)and may precede overt neurological involvement by 4-5 years
Difficulty voiding (79%)
Nocturnal urinary frequency (74%),
Urgency, Urg incontinence(63%),
Nocturnal enuresis (19%)
Urinary retention (8%)
Pathophysiology : Affects several location in CNS-
1. BO--by neuronal loss in pons
2. Incomplete bladder emptying--by loss of parasympathetic innervation
due to neuronal degeneration in the intermediolateral column of spinal
cord
3. AHC loss in onuf’s nucleus results in denervation of the EUS
4.Sympathetic nerve atrophy causes non-functional bladder and open
bladder neck
30. SPINAL CORD LESIONS
Detrusor areflexia ( spinal shock) at initial insult but progress to
hyperreflexic and DSD over few weeks
c/o urgency, frequency, incomplete bladder emptying , difficulty
in initiating micturition.
In neurologic mid thoracic (above T6 or higher) lesion--
autonomic dysreflexia occur secondary to loss of supraspinal
inhibitory control of thoracolumbar sympathetic outflow l/t
massive discharge of the sympathetic system.
Autonomic dysreflexia is exaggerated sympathetic response to
any stimuli below the level of the lesion.
31. MULTIPLE SCLEROSIS
32% to 96%
Interruption of the reticulospinal pathways between the pontine
and sacral micturition centers cause DSD
Plaques located in the spinal afferents and efferents of the sacral
reflex arc inhibit bladder contraction and result in impaired
emptying or urinary retention
Intracranial plaques result in loss of voluntary control of
initiation or prevention of voiding
Urodynamics :
1.MC is DH ( 50-90% of patients with MS).
2.Upto 50% of patients have DSD-DH
3.Detrusor areflexia in 20-30% of cases
32. DIABETIC CYSTOPATHY
10 or more years after the onset of DM
D/t autonomic and peripheral neuropathy
Most patients have other long-term diabetic complications.
C/f –Initially loss of sensation of bladder filling followed by loss
of motor function
• Urodynamics-- bladder sensation, residual urine, impaired
detrusor contractility, and later detrusor areflexia
• Rx-CIC.
33. HERNIATED DISC
Slow and progressive herniation of the lumbar disc-- nerve
irritation and DH
Acute compression of the sacral roots d/t deceleration trauma --
prevent nerve conduction and result in detrusor areflexia
Displaced disc material have direct neurotoxic and vascular
effects on spinal nerve roots, which is unrelated to compressive
effects.
Unilateral and less severe sensory loss--more favorable
prognosis, while persistent sensory deficits suggest that bladder
contractility may not completely recover.
34. MICTURITION SYNCOPE
Reflex syncope (neurally mediated syncope)
Cardiovascular reflexes become intermittently inappropriate, in
response to trigger, resulting in vasodilatation and bradycardia
l/t fall in BP and global cerebral hypoperfusion.
Middle-aged man using vasodilators or after drinking alcohol;
absent prodrome.
Tilt table test.
Recognition and avoidance of trigger.
35. HISTORY
Do you feel to pass urine urgently? With passing of
few drops en route to bathroom?
Urgency and urge
Incontinence
Do you feel to pass urine more frequently than
before?
Increased frequency
Do you wake up frequently in night to pass urine? Nocturia
Do you have problem in initiating urine? Hesitancy
Do you feel few drops of urine keep passing without
your knowledge?
Urinary dribbling
Do you feel you have not passed urine completely? Incomplete bladder
emptying
Have you started wearing pads? Incontinence
Is there a burning sensation while initiating
micturition?
Burning micturition
Is there small amount of passage of urine during
laughing, coughing, sneezing or any other physical
Stress incontinence
36. H/o spinal injury or surgery or meningiomyelocele
H/o Low back ache, lower limb paresis
H/o CVA, PD, MS
Sexual and bowel dysfunction & Other autonomic symptoms
Obstetric history: No. of deliveries, Prolapse uterus
Medicine H/o: antidepressants, diuretics, bronchodilators, and
antihistamines a/w LUTS
37. EXAMINATION
Neurological exam-- mental status, bulk, tone, power, reflexes and
sensation (including sacral dermatomes)
Spinal cord injury-- motor level of spinal lesion, extremity tone and
bulbocavernosus reflex
Rectal exam to assess prostate size and consistency for a gross estimate
of the degree of BPH
Abdominal exam after voiding to:
•Assess for palpable bladder- present with incomplete emptying
•Assess for abdominal mass- that cause pressure on the bladder
38. INVESTIGATIONS
Urine- UTI can cause irritative voiding symptoms and urge
incontinence.
Urine cytology- carcinoma-in-situ of the urinary bladder cause
frequency and urgency
voiding diary-daily record of the patient's bladder activity; objective
documentation of the patient's voiding pattern, incontinent episodes,
and inciting events a/w incontinence.
MRI spine and brain
Radiological evaluation of upper urinary tract
46. ANTIMUSCARINIC AGENTS:
first-line management for overactive bladder, including urge
incontinence.
MOA: Competitive antagonist at muscarinic receptors l/t
detrusor relaxation and lower intravesical pressures.
S/E:Dry mouth, blurred vision for near objects, constipation, and
tachycardia, alterations in cognition and consciousness
Caution: Elderly, risk of fall (trospium chloride or darifenacin-
less impact on cognition)
47.
48. β3-RECEPTOR AGONISTS--Mirabegron
FDA approved in 2012 for OAB
25-50 mg daily
S/E: Palpitations, raised blood pressure rarely, atrial fibrillation.
Devoid of anticholinergic s/e
49. DESMOPRESSIN
MOA: synthetic analogue of arginine vasopressin, temporarily
reduces urine production by promoting fluid reabsorption at the
time of renal excretion.
For the treatment of nocturia in MS, providing symptom relief
for up to 6 hours, as well as for managing nocturnal polyuria.
S/E: hyponatremia or fluid overload.
Caution: Older age, dependent leg edema.
C/I:CrCl<50ml/min
50. BOTULINUM TOXIN
2nd line for neurogenic detrusor overactivity–related incontinence
Approved dose: 200 units of onabotulinumtoxinA via flexible or rigid
cystoscopy as 20 to 30 injections into the bladder wall
Effect lasts 8 to 11 months
Caution: Risk of urinary retention; before undergoing treatment,
patients should be counseled about the possibility of requiring to use a
catheter.
Age>65, dependent leg edema
Contraindications:
Absolute: active urinary tract infection and hypersensitivity to the
toxin or its components.
Relative: Pregnancy, and concomitant use of drugs that affect the
neuromuscular junction (i.e.,aminoglycosides).
51.
52. TIBIAL NEUROMODULATION.
Safe and effective treatment for mild-moderate OAB symptoms
Percutaneous vs Transcutaneous
Fixed-frequency electrical signal(200 msec pulses with a pulse
rate of 20 Hz) for 30-min outpatient treatment sessions once a
week for a period of 12 weeks.
Advantage: Does not worsen voiding difficulties or increase the
postvoid residual, unlike other treatments such as antimuscarinic
agents or botulinum toxin.
Effects are relatively short-lived
53. MANAGING VOIDING DYSFUNCTION
PVR exacerbate overactive bladder symptoms and render
antimuscarinics and botulinum toxin less effective, Predispose to UTI
Clean Intermittent self catheterization- 4 to 6 times per day
Incidence of symptomatic UTI is low when intermittent catheterization
is performed regularly.
Reflex voiding using trigger techniques and the Crede maneuver not
recommended
Supra pubic vibration using a mechanical “buzzer” -MS with
incomplete bladder emptying and detrusor overactivity –effect is
limited
Alpha-blockers relax internal urethral sphincter in men improve bladder
emptying and reduce PVR.
Botulinum into the external urethral sphincter may improve bladder
emptying in patients with spinal cord injury who have significant
voiding dysfunction.
54. DRUGS FOR DETRUSOR UNDERACTIVITY
CHOLINERGIC DRUGS: Bethanechol chloride and
Distigmine bromide; detrusor contractility and promote
bladder emptying.
Usual dose: 10 to 50 mg 3 to 4 times daily PO.
Available studies do not support use because of possible serious
possible s/e
Combination with cholinergic drug and alpha-blocker more
useful than monotherapy
No drug with evidence of efficacy for underactive detrusor
55. DECREASING BLADDER OUTLET RESISTANCE
ALPHA-BLOCKERS:for decreasing bladder outlet resistance,
residual urine and autonomic dysreflexia.
MOA: Prostate smooth muscle relaxation l/t increased flow
Used in men with retention d/t BPH
DOXAZOSIN (1): average PVR from 65 mL to 8 mL
Dose:1 mg OD; titrate by doubling daily dose at 1- to 2-wk
intervals up to 8 mg OD based on response and tolerability (max:
8 mg/day)
TAMSULOSIN: incontinence episodes, urine flow rate and
post void residual volume
Initial and Maintenance dose: 0.4 mg once daily.
56.
57. SURGICAL TREATMENT
Overactive Detrusor:
Detrusor myectomy if conservative approaches failed
Sacral rhizotomy with Sacral ant root stimulation in complete lesions
and sacral neuromodulation in incomplete lesions are effective Rx
Bladder augmentation for severely thick or fibrotic bladder wall
Underactive Detrusor
SARS with rhizotomy and sacral neuromodulation are effective in
selected patients
Overactive Urethra (DSD)
Sphincterotomy is standard treatment for DSD
Underactive urethra
Placement of a urethral sling is established procedure.
58.
59.
60. TAKE HOME
Complaints about bladder function are common in patients with
neurological disease
Neurological evaluation is important to diagnose type of
neurogenic bladder
Urodynamic studies are important to diagnose detrusor
hyperreflexia (DH), detrusor sphincter dyssynergia (DSD),
detrusor areflexia and organic outlet obstruction
For DH, anticholinergics are primary T/t.
For DSD, anticholinergics with α - blocker may be tried along
with CIC
For detrusor areflexia best therapy is CIC.
61. REFERENCES
Panicker J, DasGupta R. Bradly’s Neurology in clinical
practice.7th Ed. Elsevier 2016.Chapter 47: Neurourology. p 605-
621.
Corcos J, Ginsberg V, Karsenty G. Textbook of Neurogenic
bladder (3rd Ed).
Continuum (minneap minn) 2020;26(1, autonomic
disorders):178–199.
International continence society guidlines.
Abrams P, Cardozo L, Fall M, et al: The Standardisation of
Terminology of Lower Urinary Tract Function: Report from the
Standardisation Sub-committee of the International Continence
Society. Neurourol Urodyn 21: 167-178, 2002
P2x purinergic receptor mediated by ATP
Internal sphincter has both sympathetic and parasympathetic supply
Storage of urine. Low-level bladder afferent firing, secondary to bladder distension, increases sympathetic outflow to the bladder outlet and external urethral sphincter (‘guarding reflex’). Sympathetic signaling also acts to inhibit detrusor-muscle contractions. B. Voiding. At bladder capacity, highlevel bladder afferent activity activates the pontine-micturition center. This, in turn, inhibits the guarding reflex. The activated pontine-micturition center, under appropriate conditions, will lead to parasympathetic outflow to the bladder and internal-sphincter smooth muscle. Urinary sphincter relaxation is soon followed by a large, coordinated detrusor contraction leading to expulsion of urine from the bladder.
Hinman syndrome: functional baldder outlet obstruction in absence of neurologic deficit.
Abrams P, Cardozo L, Fall M, et al: The Standardisation of Terminology of Lower Urinary Tract Function: Report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 21: 167-178, 2002
Increased frq is >7 times/d and >1/night . Goldberg et al 2003.
are experienced immediately after micturition
Neurogenic causes of OAB include cerebrovascular accident, Parkinson disease, multiple sclerosis, and spinal cord injury.
Non-neurogenic, or idiopathic, causes of OAB include BOO (usually secondary to BPH), postoperative pelvic surgery, and bladder stones or other foreign bodies.
OAB symptoms are thought to be related to decreased suprapontine inhibition of the micturition reflex, leading to enhanced excitatory neurotransmission in the micturition reflex pathway
Since the PMC is intact, the normal opposition of detrusor and internal/external sphincter tonus is maintained so there are no high bladder pressures developed that can lead to upper urinary tract damage.
Bladder behaves like infants urine voided anytime anywhere without control
Automatic bladder is the urinary bladder characterized by hyperactive micturition reflex with loss of voluntary control. So, even a small amount of urine collected
in the bladder elicits the micturition reflex resulting in emptying of bladder.
This occurs during the second stage (stage of recovery) after complete transection of spinal cord above the sacral segments.
During the first stage (stage of spinal shock) after complete transection of spinal cord above sacral segments, the urinary bladder loses the tone and
becomes atonic resulting in overflow incontinence.
During the second stage after shock period, the micturition reflex returns. However, the voluntary control is lacking because of absence of inhibition or facilitation
of micturition by higher centers. There is hypertrophy of detrusor muscles so that the capacity of bladder reduces.
A/k/a ATONIC BLADDER: Due to the destruction of sensory nerve fibers, the bladder is filled without any stretch signals to spinal cord.
Due to the absence of stretch signals, detrusor muscle loses the tone and becomes flaccid- distention f/b overflow inconti
flaccid neurogenic bladder or hypoactive neurogenic bladder
2 Mechanisms of pathophysiology of micturition disturbance:
1. Decreased sensation or awareness of bladder filling and
2. Damage to higher cortical centres, specially in fronal lobe that lead to an inability to suppress bladder contraction l/t incomplete emptying, bladder overflow or detrusor overactivity.
Detrusor hyperreflexia can be treated with scheduled voiding, tailored fluid restriction, and anticholinergic drugs.
More common in right sided stroke
(Burney et al: 85% incidence of urinary retention in H’gic CVA of frontal lobe & retention resolved in 96% pt within 2 months after discharge)
Presence of post stroke incontinence within first wk is an indicator of a more severe CVA and independent risk factor for poor outcome at 3 months
AD mcc dementia; VacD 2ndmcc DLB 3rd Mcc
Bladder sensation preserved.
Pseudodysnergia may occur d/t delay in ext sphinter relaxation.
Moderate doses of levodopa alleviated detrusor overactivity but high doses aggravated it.
Medical emergency- hypertension, headache, sweating, blurred vision
Make pt sit upright, BP mx, Removal of trigger- constipation, UTI
Detrusor overactivity is the most common urologic abnormality affecting patients with MS, and is typically caused by cortical demyelinating lesions that impair the detrusor reflex at the level of the frontal cortex.
Detrusor sphincter dyssynergia, the term used to describe detrusor contraction without urethral sphincter relaxation, leading to functional bladder outlet obstruction and failure to empty, typically caused by lesions involving the pontine micturition center or spinal cord lesions above the sacral parasympathetic centers. Associated symptoms include hesitancy, interrupted stream, and incomplete voiding.
most frequent urinary complaint is urgency, which is usually the result of uninhibited detrusor contraction due to a suprasegmental lesion.
Inefficient bladder contractility, leading to failure of the bladder to empty, and attributed to lesions spinal cord lesions that disrupt coordination with the pontine micturition center. Related symptoms include incomplete emptying, residual urine, and frequency.
Abnormal sensation and bladder hypoactivity due to involvement of sacral segments of the spinal cord, leading to failure to empty (ie, an atonic dilated bladder that empties by overflow); this condition results from loss of perception of bladder fullness, and it is usually associated with urethral, anal, and genital hypesthesia, and sensory deficits in the sacral dermatomes. Symptoms include urinary retention, interrupted micturition, and incomplete bladder emptying.
Bladder dysfunction appears to be related to the severity of diabetes, not to its duration.
because normal bladder function requires an intact sensory sacral visceral reflex arc
Avoid excessive drinking of alcohol
Don't get out of bed suddenly — first, sit on the edge of the bed and move your legs, making sure you aren't dizzy or lightheaded
Urinate sitting down
Ask your doctor whether any medications you're taking may be causing your condition
T-LOC d/t transient global cerebral hypoperfusion charact by rapid onset, short duration and spontaneous complete recovery
>50% pt do not report bladder problems so have to ask
Bulbocavernous reflex:in cauda equina and LMN lesion. tests integrity of large myelinated nerve fibers in S2-S4 segmments. Minimum latency measured. if>45ms-abnormal
Pad test-objective test that documents and can quantify urine loss. helfpul to assess severity of incontinence.
detrusor pressure at maximum flow rate (pdetQmax):reduced in the obstructed group
Healthy children have a typical, bell-shaped voiding pattern, whereas those with sphincter overactivity have interrupted, staccato flow, and those with bladder outlet obstruction have a plateau pattern to their voiding.
staccato shape: indicative of either abnormal sphincter relaxation in dysfunctional voiding of non-neurogenic neurogenic bladder (hinman Allen syn), or unsustained bladder contraction and abdominal straining.
tower-shaped curve: associated with high maximal flow rate and is believed to reflect dysfunctional voiding.
Fluid restriction 1-2l/d
Caffiene control
Rehabilitation: Kegel exercise, Biofeedback
Minimally invasive: Catheterisation, Botox, Sphincterotomy for DSD
Intravesical antimuscarinics
most common agent used is oxybutynin, crushed or dissolved in solution and applied at a daily dosage of 0.2–0.3 mg/kg
neurogenic bladder patients who do not respond to or do not tolerate oral antimuscarinic agents.
lower incidence of systemic side effects
b Side effects include dry mouth, blurred vision for near objects, constipation, and tachycardia.c In patients taking potent cytochrome P-450 3A4 inhibitors, the dosage of fesoterodine should not exceed 4 mg/d.d Propiverine is not available in the United States.e In patients taking potent cytochrome P-450 3A4 inhibitors, the dosage of solifenacin should not exceed 5 mg/d.f In patients taking potent cytochrome P-450 3A4 inhibitors, the dosage of tolterodine immediate release should not exceed 4 mg/d
Adipocyes:insulin resistance
Endothelial cell: Improve endothelial function
Cardiac myocyte:relaxation,hypertrophy
120ug/d PO bedtime
MOA: Blocks synaptic release of acetylcholine from the parasympathetic nerve endings and produces a paralysis of detrusor muscle
Injections to the trigone have traditionally been spared out of concern for producing vesicoureteral reflux(VUR).
Despite this, several studies have shown trigonal injections to be safe and effective without evidence of VUR(Del Popolo G, et al. Eur Urol 2008)
stimulating the nerve near the medial malleolus using a fine-gauge needle vs cutaneous electrode0-10 mA intensity
PTNS delivers neuromodulation to the pelvic floor through the sacral nerve plexus via the less invasive route of the posterior tibial nerve.
Sacral nerve roots, pudendal nerve and dorsal penile or clitoral nerves studied-modulation of sacral afferent nerves and spinal cord mediated relexes through inhibitoryinterneurons.
postvoid residual should be routinely measured during the workup of every patient with neurologic disease reporting LUTS crede method result in high detrusor pressure and incomplete bladder emptying during voiding
S?E: headache, dizziness, blurred vision
Doxazocin –structural analogue of prazocin. FDA aproved
Sars: sacral anterior root stimulation to allow voiding but sacral posterior root rhizotomy often required to supress detrusor and sphincter overactivity. s/e loss of reflex sexual function and defecation