Escolar Documentos
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Receptors
1. Cholinergic muscarinic receptors: M2 and M3 body of the bladder, trigone, bladder neck and urethra nicotinic receptors: striated sphincter muscle 2. Adrenergic receptors: predominately 1: trigone, bladder neck and urethra 2, 3: bladder neck, body
Braddom 3rd&4th Edition
Peripheral innervation
1. Sym: T10-L2hypogastric n. 2. Parasym: S2-4 pelvic n. 3. Somatic: S2-4 pudendal n. external urethral sphincter
Central control
Pudendal nerve Inh. Pelvic floor activity during voiding Braddom 3rd&4th Edition
Classification
Hx. taking
How to urinate? (CIC, CISC, ID, spontaneous voiding) Frequency of urination, vol. per time, PVR? Incontinence? Disturb function? Fluid input/output UTI? Previous voiding habit, changing of bladder function Satisfaction Medication Present function: transfer, toileting Underlying dis: DM Hx. of AD
Braddom 3rd&4th Edition, .
Physical exam
ASIA: neurological level Reflex: - BCR: S4-5 - Anal reflex: S4-5 VAC: S2-4 Big/Long toe flexors (S2) Sphincter tone Sensory: perianal and deep anal sensation Prostate gland hypertrophy Others: consciousness, leg spasticity, seeing function, pressure ulcer
Braddom 3rd&4th Edition, .
Investigation
U/A, U/C, urine strip BUN/Cr Cr clearance: gold standard for assess renal function Urodynamic study/ uroflowmetry PVR (Balance bladder?)
Investigation
U/S kidney: chronic obstruction, dilatation, mass, stone, cyst Plain KUB: radiopaque calculi in kidney/ureter/ bladder VCUG: detect VUR Others: CT, CT-IVP, DMSA scan, MAG-3 scan, urethral pressure profiles, bethanechol stimulation test
Braddom 3rd&4th Edition
Uroflowmetry
Normal value: - max flow rate (Q max) 25 ml/sec - mean flow rate 14 ml/sec - void vol 250 ml, time <30 sec void: Qmax/Vvoid/Vres > 150 ml Qmax < 10 ml/sec
Ref: .
Detrusor function: Normal, Overactivity/Phasic involuntary contraction/Terminal detrusor overactivity (>15 cmH2O) > 40 cm H2O upper tract Urethral function: Normal, Abnormal, incompetent, urethral relaxation incontinence, urodynamic stress incontinence
Ref: .
Ref: .
Interpretation
Bladder capacity Bladder compliance Pdet in filling and voiding phase Sphincter EMG
UMN lesion
LMN lesion
Management
Management
Detrusor: overactivity
1. Medication: anticholinergic drug ex. Oxybutynin HCl, imipramine 2. TENs: pudendal afferent stimulation for reflex inhibition (5Hz, 20-30 min, twice/d) 3. Sx: - sacral deafferentation (SDAT): posterior root rhizotomyflaccid bladder - combined with sacral anterior root stimulation (SARS): bladder
Braddom 3rd&4th Edition, .
Hyperreflexic sphincter
1. Time voiding: for incontinence person - Pt. urinate before detrusor contraction - Restrict oral fluid< 2 L/d keep urine output> 1.5 L/d - IC PVR 2. Trigger reflex voiding: suprapubic tapping if Pdet is acceptable, thigh scratching 3. Medication: - alpha blocker ex. Prazosin, phenoxybenzamine internal sphincter - Diazepam/baclofen: external sphincter 4. Sx.: sphincterotomy+bladder neck incision
Braddom 3rd&4th Edition, .
Detrusor underactivity
1. Time voiding: - Restrict oral fluid - Credes or valsavas maneuvers - IC PVR 2. Medication: cholinergic drugs (bethanechol hydrochloride )
Hyporeflexic sphincter
1. Medication: alpha agonist (ephedrine, phenylpropanolamine) 2. Kegels exercise: effective only in female with stress incontinence due to pelvic floor descent 3. Sx: urethral suspension, artificial sphincter, Teflon injection therapy
Bladder training regimen IC 4-6 /day (vol/cath < 500 ml) try voiding q 2 hr during the day and before IC Strictly follow fluid regimen (1.5-2.5 l/d) and record voiding diary Preferred urine / d = 1.5-2 L PVR vol IC frequency
> 200 ml < 200 < 150 < 100 < 50 IC 4-6 times/ day IC 3 times/day IC 2 times/day IC daily IC 2-3 times/wk until 2 wk, if < 50 ml balanced bladder off IC
Medication
Patient education
ID CISC Condom catheter