Normal micturition involves complex
|
|
- Junior Chapman
- 6 years ago
- Views:
Transcription
1 NEW TARGET FOR INTERVENTION: THE NEUROUROLOGY CONNECTION * Donald R. Ostergard, MD, FACOG ABSTRACT Urine storage and release are under the control of the parasympathetic, sympathetic, and somatic nervous systems. Coordinated interaction of multiple reflexes is required for normal bladder filling and voiding. Several neurotransmitters play a role in micturition. Urinary continence is preserved by maintaining lower pressure within the bladder and proximal urethra. During increases in intraabdominal pressure, this balance depends on equal pressure being exerted on the bladder and proximal urethra. Excessive movement of the urethra outside the abdominal cavity disturbs the balance and can result in urine leakage. Potential causes of urine loss can be evaluated effectively in the clinic, and basic urodynamic testing can confirm a clinical diagnosis of stress urinary incontinence. Clinicians might soon be able to treat stress incontinence with a drug therapy that augments urethral resistance by inhibiting the reuptake of neurotransmitters thought to make key contributions to micturition. (Adv Stud Med. 2004;4(3C):S220-S224) *Based on a presentation given by Dr Ostergard at a symposium held in conjunction with the American Urogynecologic Society 2003 Scientific Meeting. Professor of Obstetrics and Gynecology, University of California, Irvine; Director, Division of Urogynecology, Department of Obstetrics and Gynecology, and Associate Medical Director for Gynecology, Women s Hospital, Long Beach Memorial Medical Center, Long Beach, California. Address correspondence to: Donald R. Ostergard, MD, FACOG, Women s Hospital, Long Beach Memorial Medical Center, Female Uro-General Gyn, 701 East 28th St, Suite 212, Long Beach, CA cmcgowan@memorialcare.org. Normal micturition involves complex interaction and coordination among a multitude of reflexes and neurotransmitters. Growing recognition of the many physiologic contributors to normal urine storage and voiding has given rise to new concepts about the management of bladder and urethral dysfunction. Stress urinary incontinence (SUI) is a common presenting clinical problem in urology, obstetrics and gynecology, and primary care practices. In most cases, the problem can be diagnosed by means of a careful and targeted office evaluation that includes basic urodynamic testing. A type of therapy based on recent advances in understanding the neurophysiology of micturition will soon be available, providing physicians with a new tool to help patients manage SUI without the need for surgical intervention. PHYSIOLOGY OF NORMAL MICTURITION The normal micturition cycle involves 2 distinct phases: storage and emptying (Figure). The process involves complex coordination and interaction among almost 3 dozen different reflexes. As urine accumulates and the bladder expands, action potentials generated by stretch receptors in the bladder wall are transmitted through the pelvic nerve. Reflex activation of the sympathetic nucleus causes release of norepinephrine via the hypogastric nerve and subsequent relaxation of the bladder via activation of beta-adrenergic receptors. At the same time, norepinephrine activation of alpha-1 adrenergic receptors causes urethral smooth muscle to contract. Sympathetic activation and concomitant suppression of parasympathetic activity allow the bladder to fill with little if any increase in pressure. 1 S220 Vol. 4 (3C) March 2004
2 With any sudden external pressure on the bladder, such as that caused by coughing or sneezing, a rapid somatic response (sometimes called the guarding reflex) occurs to prevent urine leakage. Action potentials are transmitted to pudendal motor neurons in Onuf s nucleus in the sacral spinal cord, and activation of these motor neurons causes the pudendal nerve to release acetylcholine. Rapid activation of nicotinic cholinergic receptors induces rhabdosphincter contraction to help avoid accidental leakage. As bladder storage approaches capacity, impulse transmission in the pelvic nerve increases substantially and activates the pontine micturition center. Descending impulses from the center stimulate the sacral parasympathetic nucleus to cause acetylcholine release. Muscarinic receptors in the bladder are activated, and bladder contraction ensues. In coordination with bladder contraction, the sympathetic and somatic reflexes associated with urine storage are inhibited to allow the urethra and rhabdosphincter to relax, resulting in efficient emptying of the bladder. In addition to the contributions of reflex pathways to normal micturition, conscious control over reflex activity can be exerted by cortical inhibition of bladder contraction and cortical stimulation of rhabdosphincter contraction. The cortical influence permits conscious postponement of micturition until voiding can occur at an appropriate time and place. 2 Several different neurotransmitters are involved in normal bladder function including acetylcholine, norepinephrine, serotonin, glutamate, gammaaminobutyric acid, and dopamine. 1 Norepinephrine is involved in several key functions in micturition, including control of urethral smooth muscle, central urine storage, and micturition centers in the brain and spinal cord, particularly in Onuf s nucleus. Serotonin exerts a controlling influence in the same centers. Glutamate plays a key role in bladder storage and is inhibited during the transition from storage to urge to voiding. A final requisite for micturition is normal urethral mobility, which typically is associated with good urethral tone and the ability to induce urethral contraction on command. Normal urethral mobility can be defined as a straining angle of less than 30 degrees from horizontal on a cotton-swab test. The proximal urethra remains in the abdominal cavity, and the proximal urethra and bladder are subject to the same pressure. Under those conditions, no urine leakage occurs. 3 PATHOPHYSIOLOGY OF SUI Urethral hypermobility is a key contributor to the pathophysiology of SUI. Hypermobility occurs when the proximal urethra moves outside the abdominal cavity and is no longer subject to the pressure forces that prevent urine leakage. As previously suggested, hypermobility can be defined by a cotton-swab test that reveals a straining angle of more than 30 degrees from horizontal. Because SUI is a multifactorial condition, hypermobility does not immediately cause SUI in every patient. The body has the ability to compensate to some extent for hypermobility to prevent urine loss. However, with repeated episodes of hypermobility over time, such as those caused by coughing or sneezing, patients lose the ability to compensate, and urethral hypermobility assumes a major role in the pathophysiology of SUI. 4 Figure. Normal Micturition Cycle Advanced Studies in Medicine S221
3 In some cases, urethral hypermobility coexists with intrinsic sphincter deficiency, which is defined by low urethral closure pressure or low leak-point pressure. Urine leakage from a relatively empty bladder in the supine position indicates a high probability of intrinsic sphincter deficiency. With the combination of urethral hypermobility and intrinsic sphincter deficiency, intra-abdominal pressure on the bladder easily overrides urethral resistance, causing urine loss. To put the pathophysiology into a practical perspective, consider that under normal circumstances the proximal urethra and bladder rest above the pelvic floor and share a common abdominal cavity. Water pressure of 100 cm impinging on the bladder creates an equal and opposite 100 cm of pressure on the proximal urethra. The equal and opposing pressures prevent urine loss. In response to a sudden increase in intra-abdominal pressure from a sneeze or cough, the striated urethral sphincter will contract as part of the guarding reflex to prevent urine leakage. In the SUI patient, the proximal urethra is outside the confines of the abdominal cavity, and the hypothetical 100 cm of water pressure on the bladder no longer transmits to the proximal urethra. Without the pressure transmission from the bladder, resisting forces in the urethra are easily overcome, and urine is lost. CLINICAL EVALUATION OF SUI Office evaluation of SUI should cover several key diagnostic possibilities, including urinary tract infection, overactive bladder, urinary retention, extraurethral causes of incontinence, and urethral diverticulum, as well as urethral hypermobility (see sidebar). The most common cause of urinary tract infection is Escherichia coli, which produces an endotoxin that can produce symptoms that mimic SUI or overactive bladder. A cystometrogram can accurately determine whether the patient has an unstable bladder. Urinary retention must be ruled out because of its potential to cause overflow incontinence. Postvoid of residual is the key measurement to diagnose or rule out urinary retention. Consideration of extraurethral causes of incontinence is of particular importance in patients who have had recent surgery involving the pelvic floor, such as a hysterectomy, which has a well documented incidence of fistulae. Ectopic ureter, though uncommon, also can cause symptoms similar to those observed in SUI and should be ruled out. Urethral diverticulum can be detected by palpation of the anterior vaginal wall. A diverticulum can fill with urine during voiding and then empty during subsequent exposure to stress to give the appearance of SUI. URODYNAMIC EVALUATION Accurate urodynamic assessment requires a combination of appropriate equipment and technique. 5 Multichannel urodynamic testing employs a microtransducer catheter that comprises a double catheter for the urethra and bladder and a single catheter for evaluation of intra-abdominal pressure in the vagina. Appropriate technique begins with patient positioning for the test. Urethral closure pressure differs substantially when a patient is in a supine position with an empty bladder versus upright with a full bladder. These differences should be taken into account during the evaluation. Accurate testing requires an upright patient who has a comfortably full bladder. Stress for the test can be created by continuous coughing or Valsalva maneuver. Regardless of how the stress is created, the technique should strive for equivalent intensity throughout the test. During the test, the microtransducer catheter should be withdrawn slowly through the urethra. Pressure profiles differ markedly between patients who have normal urethral function and those who have SUI. In a patient who has normal urethral clo- Office Evaluation for Stress Urinary Incontinence Evaluate for: Urinary tract infection Overactive bladder Retention Urethral hypermobility Extraurethral incontinence Vesicovaginal fistula Ureterovaginal fistula Ectopic ureter Urethral diverticulum S222 Vol. 4 (3C) March 2004
4 sure pressure, the supine position is associated with a pressure of about 80 cm H 2 0. Upon sitting upright, pressure increases to about 100 cm H 2 0. During a cough stress test, the pressure spikes and then falls back toward the point of normalization, perhaps resulting in a total difference of 75 cm in maximal water pressure; however, the pressure does not fall below the point of normalization, the point at which urine leakage could occur. In contrast, a patient with SUI and intrinsic sphincter deficiency might have a water pressure of 20 cm in the supine position, declining to 10 cm in the upright position. Looking across the functional length of the urethra, the difference might decrease from 24 cm in the supine position to 8 cm in the upright position. The differences emphasize the loss of continence defense mechanisms in the upright position. Similar changes occur with bladder filling. The cough profile demonstrates pressure equalization and urine loss. Continuous coughing results in continuous pressure equalization, and blips in the tracings associated with flow rate indicate urine loss, providing the basis for a definitive diagnosis of stress incontinence. Calculation of the pressure-transmission ratio (PTR) is not required to diagnosis SUI but is useful for anyone involved in SUI research. PTR represents urethral pressure with acutely increased abdominal pressure as a percentage of the simultaneously measured intravesical pressure. To calculate the PTR, divide the height of the pressure spike in the urethra by the height of the spike associated with the pressure transmitted to the bladder. In the normal setting, the PTR would be 100% in the proximal urethra, declining gradually across distal areas. In a patient with SUI, the PTR will be much lower in the proximal urethra and decline more rapidly along the length of the urethra. 6 NEUROLOGY OF MICTURITION Recent studies have suggested that the release and uptake of the neurotransmitters serotonin and norepinephrine play a key role in normal micturition. 7 Conceptually, norepinephrine and serotonin are thought to be released into the synaptic cleft in response to action potentials that reach the nerve terminal. The neurotransmitters continue from the synaptic cleft onto motor neurons in Onuf s nucleus, where serotonin and norepinephrine bind to postsynaptic receptor sites, increase motor neuron output, and induce contraction of the rhabdosphincter. Upon activation of the postsynaptic receptors, serotonin and norepinephrine are released and reabsorbed into the presynaptic nerve terminal by means of reuptake pumps. The end result is decreased output from the pudendal motor neuron. 8 Three primary mechanisms are involved in modulating the effects of norepinephrine and serotonin, as well as acetylcholine: Administration of a receptor agonist to mimic the effect of the neurotransmitter. When endogenous neurotransmitter is released from the nerve terminal, it binds to the muscle receptor, causing contraction. A circulating receptor agonist can induce the same effect, including muscle contraction, by binding to the muscle receptor. In contrast to the neurotransmitter, a circulating agonist is not reabsorbed into the nerve terminal by reuptake mechanisms, so that receptor stimulation continues until the agonist is metabolized or excreted. Use of a receptor antagonist to block the effect of the neurotransmitter. By blocking neurotransmitter binding to its receptor, the antagonist inhibits the neurotransmitter s effect on muscle. The inhibitory effect continues until the receptor antagonist is metabolized or excreted. Prolonging the effect of the neurotransmitter by inhibiting reuptake. Blocking reuptake causes the endogenous neurotransmitter to remain in the synaptic cleft longer and allows it to bind repeatedly to the post-synaptic receptor. Each of these strategies suggests possibilities for development of SUI therapies based on modulation of neurotransmitter activity. The first such therapy will likely become commercially available in the near future. The drug is duloxetine, which inhibits the reuptake of both serotonin and norepinephrine. SUMMARY Normal micturition is under the control of a number of reflexes that ensure normal urine storage Advanced Studies in Medicine S223
5 and release. Urethral hypermobility and intrinsic sphincter deficiency have key roles in the pathophysiology of SUI. An office evaluation, including basic urodynamic testing, can identify most patients with SUI. Recent advances in the understanding of the neurourologic components of micturition have raised the possibility that modulation of key neurotransmitters might have a role in the treatment of SUI. The first of these neuromodulatory agents should be available in the near future, giving physicians and patients the first approved pharmacologic therapy for SUI. REFERENCES 1. degroat WC. Basic neurophysiology and neuropharmacology. In: Abrams P, Khoury S, Wien A, eds. Incontinence. Plymouth, UK: Health Publications, Ltd; Fraser MO, Chancellor MB. Neural control of the urethra and development of pharmacotherapy for stress urinary incontinence. BJU Int. 2003;91(8): Walters MD, Shields LE. The diagnostic value of the history, physical examination, and the Q-tip cotton swab test in women with urinary incontinence. Am J Obstet Gynecol. 1988;159(1): Bump RC, Norton PA. Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin North Am. 1998;25(4): 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. 2002; 21(2): Bump RC, Copeland WE Jr, Hurt WG, Fantl JA. Dynamic urethral pressure/profilometry pressure transmission ratio determinations in stress-incontinent and stress-continent subjects. Am J Obstet Gynecol. 1988;159(3): Thor KB, Katofiasc MA. Effects of duloxetine, a combined serotonin and norepinephrine reuptake inhibitor, on central neural control of lower urinary tract function in the chloralose-anesthetized female cat. J Pharmacol Exp Ther. 1995;274(2): Thor KB. Serotonin and norepinephrine involvement in efferent pathways to the urethral rhabdosphincter: implications for treating stress urinary incontinence. Urology. 2003;62(4 suppl 1):3-9. S224 Vol. 4 (3C) March 2004
Urinary incontinence (UI) affects as many
EXPLORING NEW HORIZONS IN STRESS INCONTINENCE: THE NEUROUROLOGY CONNECTION W. Glenn Hurt, MD* ABSTRACT As many as one-third of women are affected by urinary incontinence, the most common of which being
More informationDuloxetine in women awaiting surgery
DOI: 1.1111/j.1471-528.6.879.x www.blackwellpublishing.com/bjog Review article H Drutz Ontario Power Generation Building, Toronto, Ontario, Canada Correspondence: Prof. Dr H Drutz, Mount Sinai Hospital,
More informationOveractive Bladder: Diagnosis and Approaches to Treatment
Overactive Bladder: Diagnosis and Approaches to Treatment A Hidden Condition* Many Many patients self-manage by voiding frequently, reducing fluid intake, and wearing pads Nearly Nearly two-thirds thirds
More informationNew approaches in the pharmacological treatment of stress urinary incontinence
International Journal of Gynecology and Obstetrics 86 Suppl. 1 (2004) S1 S5 New approaches in the pharmacological treatment of stress urinary incontinence Keywords: Stress urinary incontinence; Epidemiology;
More informationATLAS OF URODYNAMICS. Bladder. Pure. Pves. Pabd. Pdet EMG. Bladder. volume. Cough Strain IDC. Filling. Pure. Pves. Pabd. Pdet EMG
2 Normal Micturition The micturition cycle (urine storage and voiding) is a nearly subconscious process that is under complete voluntary control. Bladder filling is accomplished without sensation and without
More informationThe Neurogenic Bladder
The Neurogenic Bladder Outline Brandon Haynes, MD Resident Physician Department of Urology Jelena Svircev, MD Assistant Professor Department of Rehabilitation Medicine Anatomy and Bladder Physiology Bladder
More informationFunctional anatomy of the female pelvic floor and lower urinary tract Stefano Floris, MD, PhD Department of Obstetrics and Gynaecology
Functional anatomy of the female pelvic floor and lower urinary tract Stefano Floris, MD, PhD Department of Obstetrics and Gynaecology Ospedale San Giovanni di Dio, Gorizia, Italy ANATOMY URINARY CONTINENCE
More informationSignal transduction underlying the control of urinary bladder smooth muscle tone Puspitoayu, E.
UvA-DARE (Digital Academic Repository) Signal transduction underlying the control of urinary bladder smooth muscle tone Puspitoayu, E. Link to publication Citation for published version (APA): Puspitoayu,
More informationObjectives. Prevalence of Urinary Incontinence URINARY INCONTINENCE: EVALUATION AND CURRENT TREATMENT OPTIONS
URINARY INCONTINENCE: EVALUATION AND CURRENT TREATMENT OPTIONS Lisa S Pair, MSN, CRNP Division of Urogynecology and Pelvic Reconstructive Surgery Department of Obstetrics and Gynecology University of Alabama
More informationSummary. Neuro-urodynamics. The bladder cycle. and voiding. 14/12/2015. Neural control of the LUT Initial assessment Urodynamics
Neuro-urodynamics Summary Neural control of the LUT Initial assessment Urodynamics Marcus Drake, Bristol Urological Institute SAFETY FIRST; renal failure, dysreflexia, latex allergy SYMPTOMS SECOND; storage,
More informationBen Herbert Alex Wojtowicz
Ben Herbert Alex Wojtowicz 54 year old female presenting with: Dragging sensation Urinary incontinence Some faecal incontinence HPC Since May 14 had noticed a mass protruding from the vagina when going
More informationTREATMENT METHODS FOR DISORDERS OF SMALL ANIMAL BLADDER FUNCTION
Vet Times The website for the veterinary profession https://www.vettimes.co.uk TREATMENT METHODS FOR DISORDERS OF SMALL ANIMAL BLADDER FUNCTION Author : SIMONA T RADAELLI Categories : Vets Date : July
More informationRenal Physiology: Filling of the Urinary Bladder, Micturition, Physiologic Basis of some Renal Function Tests. Amelyn R.
Renal Physiology: Filling of the Urinary Bladder, Micturition, Physiologic Basis of some Renal Function Tests Amelyn R. Rafael, MD 1 Functions of the Urinary Bladder 1. storage of urine 150 cc 1 st urge
More informationPhysiology & Neurophysiology of lower U.T.
Physiology & Neurophysiology of lower U.T. Classification of voiding dysfunction Evaluation of a child with voiding dysfunction Management Storage Ø Adequate volume of urine Ø At LOW pressure Ø With NO
More informationNEUROGENIC BLADDER. Dr Harriet Grubb Dr Alison Seymour Dr Alexander Joseph
NEUROGENIC BLADDER Dr Harriet Grubb Dr Alison Seymour Dr Alexander Joseph OUTLINE Definition Anatomy and physiology of bladder function Types of neurogenic bladder Assessment and management Complications
More informationNeurourology, especially the video urodynamic
NEUROUROLOGIC FINDINGS WITH APPLICABILITY TO INCONTINENCE AND URETHRAL FUNCTION * Edward J. McGuire, MD ABSTRACT Neurourology is applicable to urinary incontinence and obstructive uropathy in the general
More informationDr. Aso Urinary Symptoms
Haematuria The presence of blood in the urine (haematuria) is always abnormal and may be the only indication of pathology in the urinary tract. False positive stick tests and the discolored urine caused
More informationRegulation of the Urinary Bladder Chapter 26
Regulation of the Urinary Bladder Chapter 26 Anatomy 1. The urinary bladder is smooth muscle lined internally by transitional epithelium and externally by the parietal peritoneum. Contraction of the smooth
More informationPhysiologic Anatomy and Nervous Connections of the Bladder
Micturition Objectives: 1. Review the anatomical organization of the urinary system from a physiological point of view. 2. Describe the micturition reflex. 3. Predict the lines of treatment of renal failure.
More informationThis Special Report supplement
...INTRODUCTION... Overactive Bladder: Defining the Disease Alan J. Wein, MD This Special Report supplement to The American Journal of Managed Care features proceedings from the workshop, Overactive Bladder:
More informationChapter 23. Micturition and Renal Insufficiency
Chapter 23 Micturition and Renal Insufficiency Voiding Urine Between acts of urination, the bladder is filling. detrusor muscle relaxes urethral sphincters are tightly closed accomplished by sympathetic
More informationURINARY TRACT NERVOUS SYSTEM DISORDERS: DRUG THERAPY REVIEW
Vet Times The website for the veterinary profession https://www.vettimes.co.uk URINARY TRACT NERVOUS SYSTEM DISORDERS: DRUG THERAPY REVIEW Author : Ian Battersby Categories : Vets Date : August 3, 2009
More informationThe lower urinary tract is composed of the bladder and the urethra the 2
URINARY INCONTINENCE IN WOMEN Neurophysiology of Stress Urinary Incontinence Michael B. Chancellor, MD, Naoki Yoshimura, MD, PhD Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh,
More informationThe Management of Female Urinary Incontinence. Part 1: Aetiology and Investigations
The Management of Female Urinary Incontinence Part 1: Aetiology and Investigations Dr Oseka Onuma Gynaecologist and Pelvic Reconstructive Surgeon 4 Robe Terrace Medindie SA 5081 Urinary incontinence has
More informationUrogynecology in EDS. Joan L. Blomquist, MD Greater Baltimore Medical Center August 2018
Urogynecology in EDS Joan L. Blomquist, MD Greater Baltimore Medical Center August 2018 One in three like me Voiding Issues Frequency/Urgency Urinary Incontinence neurogenic bladder Neurologic supply
More informationUrodynamics in Neurological Lower Urinary Tract Dysfunction. Mr Chris Harding Consultant Urologist Freeman Hospital Newcastle-upon-Tyne
Urodynamics in Neurological Lower Urinary Tract Dysfunction Mr Chris Harding Consultant Urologist Freeman Hospital Newcastle-upon-Tyne Learning Objectives Review functional neurology relevant to lower
More informationNeural control of the lower urinary tract in health and disease
Neural control of the lower urinary tract in health and disease Jalesh N. Panicker MD, DM, FRCP Consultant Neurologist and Clinical lead in Uro-Neurology The National Hospital for Neurology and Neurosurgery
More informationLower Urinary Tract Symptoms K Kuruvilla Zachariah Associate Specialist
Lower Urinary Tract Symptoms K Kuruvilla Zachariah Associate Specialist Lower Urinary Tract Symptoms Storage Symptoms Frequency, urgency, incontinence, Nocturia Voiding Symptoms Hesitancy, poor flow, intermittency,
More informationUrinary Incontinence in Women: Never an Acceptable Consequence of Aging
Urinary Incontinence in Women: Never an Acceptable Consequence of Aging Catherine A. Matthews, MD Associate Professor Chief, Urogynecology and Pelvic Reconstructive Surgery University of North Carolina,
More informationVarious Types. Ralph Boling, DO, FACOG
Various Types Ralph Boling, DO, FACOG The goal of this lecture is to increase assessment and treatment abilities for physicians managing urinary incontinence (UI) patients. 1. Effectively communicate with
More informationNeurogenic bladder. Neurogenic bladder is a type of dysfunction of the bladder due to neurological disorder.
Definition: Neurogenic bladder Neurogenic bladder is a type of dysfunction of the bladder due to neurological disorder. Types: Nervous system diseases: Congenital: like myelodysplasia like meningocele.
More informationManagement of Female Stress Incontinence
Management of Female Stress Incontinence Dr. Arvind Goyal Associate Professor (Urology& Renal Transplant) Dayanand Medical College & Hospital, Ludhiana, Punjab, India Stress Incontinence Involuntary loss
More information3/20/10. Prevalence of OAB Men: 16.0% Women: 16.9% Prevalence of OAB with incontinence (OAB wet) Men: 2.6% Women: 9.3% Dry. Population (millions) Wet
1 Prevalence of OAB Men: 16.0% Women: 16.9% Stewart WF, et al. World J Urol. 2003;20:327-336. Prevalence of OAB with incontinence (OAB wet) Men: 2.6% Women: 9.3% Stewart WF, et al. World J Urol. 2003;20:327-336.
More informationCompassionate and effective management
IMPACT OF STRESS URINARY INCONTINENCE ON QUALITY OF LIFE * Paul Abrams, MD, FRCS ABSTRACT Evaluating the impact of stress urinary incontinence (SUI) on quality of life (QOL) is of paramount importance,
More informationProlapse and Urogynae. By Sarah Rangan & Daniel Warrell
Prolapse and Urogynae By Sarah Rangan & Daniel Warrell Anatomy and physiology of the pelvic supports The pelvic floor supports the pelvic viscera and vaginal, urethral and rectal openings Endopelvic fascial
More informationNeuropathic Bladder. Magda Kujawa Consultant Urologist Stockport NHS Foundation Trust 12/03/2014
Neuropathic Bladder Magda Kujawa Consultant Urologist Stockport NHS Foundation Trust 12/03/2014 Plan Physiology- bladder and sphincter behaviour in neurological disease Clinical consequences of Symptoms
More informationIncontinence: The silent scourge of the young and old. The International Continence Society has. In this article:
Focus on CME at the University of Toronto Incontinence: The silent scourge of the young and old By Sender Herschorn, BSc, MDCM, FRCSC In this article: 1. What is the workup for urinary incontinence? 2.
More informationPathophysiological Rationale for Surgical Treatments of Stress Urinary Incontinence
Pathophysiological Rationale for Surgical Treatments of Stress Urinary Incontinence Urology Grand Rounds April 6, 2005 Herman Christopher Kwan R4 A familiar case? 62 year old female initial presentation
More informationNEUROMODULATION FOR UROGYNAECOLOGISTS
NEUROMODULATION FOR UROGYNAECOLOGISTS Introduction The pelvic floor is highly complex structure made up of skeletal and striated muscle, support and suspensory ligaments, fascial coverings and an intricate
More informationObjectives. Key Outlines:
Objectives! Iden8fy and describe the Func8onal Anatomy of Urinary Bladder! Describe the mechanism of filling and emptying of the urinary bladder! Cystometrogram! Appreciate neurogenic control of the mechanism
More informationURINARY INCONTINENCE. Urology Division, Surgery Department Medical Faculty, University of Sumatera Utara
URINARY INCONTINENCE Urology Division, Surgery Department Medical Faculty, University of Sumatera Utara Definition The involuntary loss of urine May denote a symptom, a sign or a condition Symptom the
More informationThe new International Continence Society
ROLE OF CYSTOMETRY IN EVALUATING PATIENTS WITH OVERACTIVE BLADDER ADAM J. FLISSER AND JERRY G. BLAIVAS ABSTRACT Overactive bladder (OAB) can be caused by a variety of conditions. We believe that cystometrography
More informationSynaptic Transmission
Synaptic Transmission Graphics are used with permission of: Pearson Education Inc., publishing as Benjamin Cummings (http://www.aw-bc.com) Page 1. Introduction Synaptic transmission involves the release
More informationChapter 14 The Autonomic Nervous System Chapter Outline
Chapter 14 The Autonomic Nervous System Chapter Outline Module 14.1 Overview of the Autonomic Nervous System (Figures 14.1 14.3) A. The autonomic nervous system (ANS) is the involuntary arm of the peripheral
More informationUrodynamic findings in women with insensible incontinence
bs_bs_banner International Journal of Urology (2013) 20, 429 433 doi: 10.1111/j.1442-2042.2012.03146.x Original Article: Clinical Investigation Urodynamic findings in women with insensible Benjamin M Brucker,
More informationOriginal Article. Annals of Rehabilitation Medicine INTRODUCTION
Original Article Ann Rehabil Med 2014;38(3):342-346 pissn: 2234-0645 eissn: 2234-0653 http://dx.doi.org/10.5535/arm.2014.38.3.342 Annals of Rehabilitation Medicine Phasic Changes in Bladder Compliance
More informationOveractive bladder can result from one or more of the following causes:
Overactive bladder can affect people of any age; however, it is more common in older people. Effective treatments are available and seeing your doctor for symptoms of overactive bladder often results in
More informationAUTONOMIC NERVOUS SYSTEM PART I: SPINAL CORD
AUTONOMIC NERVOUS SYSTEM PART I: SPINAL CORD How is the organization of the autonomic nervous system different from that of the somatic nervous system? Peripheral Nervous System Divisions Somatic Nervous
More informationModule 3 Causes Of Urinary Incontinence
Causes Of Urinary Incontinence V4: Last Reviewed September 2017 Learning Outcomes Appreciate the numerous requirements and skills necessary for the person to achieve and maintain urinary continence Discuss
More informationSpinal Cord Injury. R Hamid Consultant Neuro-Urologist London Spinal Injuries Unit, Stanmore & National Hospital for Neurology & Neurosurgery, UCLH
Spinal Cord Injury R Hamid Consultant Neuro-Urologist London Spinal Injuries Unit, Stanmore & National Hospital for Neurology & Neurosurgery, UCLH SCI 800 1000 new cases per year in UK Car accidents 35%
More informationVideo-urodynamics. P J R Shah Institute of Urology and UCH
Video-urodynamics P J R Shah Institute of Urology and UCH Bladder Function Storage Capacity and Pressure Emptying Pressure/flow/emptying URODYNAMIC INVESTIGATIONS Free urine flow rate Urethral pressure
More informationDefinitions of IC: U.S. perspective. Edward Stanford MD MS FACOG FACS Western Colorado
Definitions of IC: U.S. perspective Edward Stanford MD MS FACOG FACS Western Colorado PURPOSE OF A DEFINITION? Identifies with specificity those patients who are most likely to have the disease. Identifies
More informationTreatment Outcomes of Tension-free Vaginal Tape Insertion
Are the Treatment Outcomes of Tension-free Vaginal Tape Insertion the Same for Patients with Stress Urinary Incontinence with or without Intrinsic Sphincter Deficiency? A Retrospective Study in Hong Kong
More informationIntroduction to Autonomic
Part 2 Autonomic Pharmacology 3 Introduction to Autonomic Pharmacology FUNCTIONS OF THE AUTONOMIC NERVOUS SYSTEM The autonomic nervous system (Figure 3 1) is composed of the sympathetic and parasympathetic
More informationLa vescica iperattiva: dalla diagnosi ai nuovi approcci terapeutici
La Prostata nel Mirino Napoli, 1 dicembre 2016 La vescica iperattiva: dalla diagnosi ai nuovi approcci terapeutici Giorgio Annoni Cattedra e Scuola di Specializzazione in Geriatria Università degli Studi
More informationBill Landry BScPT, BScH, MCPA, CAFCI Family Physiotherapy Centre of London
Bill Landry BScPT, BScH, MCPA, CAFCI blandry@fpclondon.com Family Physiotherapy Centre of London Objectives To describe the scope of post-prostatectomy incontinence To describe what s been done To provide
More informationNonsurgical treatment remains a major PROCEEDINGS NEW ADVANCES IN THE NONSURGICAL MANAGEMENT OF STRESS URINARY INCONTINENCE *
NEW ADVANCES IN THE NONSURGICAL MANAGEMENT OF STRESS URINARY INCONTINENCE * Nicolette S. Horbach, MD, FACOG ABSTRACT Most patients with stress urinary incontinence (SUI) warrant a trial of nonsurgical
More informationMr. GIT KAH ANN. Pakar Klinikal Urologi Hospital Kuala Lumpur.
Mr. GIT KAH ANN Pakar Klinikal Urologi Hospital Kuala Lumpur drgitka@yahoo.com 25 Jan 2007 HIGHLIGHTS Introduction ICS Definition Making a Diagnosis Voiding Chart Investigation Urodynamics Ancillary Investigations
More informationDuloxetine in the treatment of stress urinary incontinence
REVIEW Duloxetine in the treatment of stress urinary incontinence Wolfgang H Jost 1 Parvaneh Marsalek 2 1 Department of Neurology, Deutsche Klinik für Diagnostik, Wiesbaden, Germany; 2 Lilly Deutschland
More informationUrinary incontinence. Urology Department. Patient Information Leaflet
Urinary incontinence Urology Department Patient Information Leaflet Introduction This leaflet is for people who have been diagnosed with urinary incontinence. It contains information about the bladder,
More informationTable 1. International Consultation on Incontinence recommendations for frail older adults
Table 1. International Consultation on Incontinence recommendations for frail older adults Clinicians need to assess and manage co-existing co morbid conditions which are known to have an impact on continence
More informationUpdate on duloxetine for the management of stress urinary incontinence
REVIEW Update on duloxetine for the management of stress urinary incontinence Maya Basu Jonathan RA Duckett Department of Obstetrics and Gynaecology, Medway Maritime Hospital, Gillingham, Kent, UK Correspondence:
More informationThe Autonomic Nervous System Outline of class lecture for Physiology
The Autonomic Nervous System Outline of class lecture for Physiology 1 After studying the endocrine system you should be able to: 1. Describe the organization of the nervous system. 2. Compare and contrast
More informationREVIEW OF CAUSES, EVALUATION, AND TREATMENTS URINARY INCONTINENCE 101
REVIEW OF CAUSES, EVALUATION, AND TREATMENTS URINARY INCONTINENCE 101 March 5, 2014 Kevin E Miller, MD Department of Obstetrics and Gynecology University of Kansas School of Medicine- Wichita URINARY INCONTINENCE
More informationUrinary Incontinence for the Primary Care Provider
Urinary Incontinence for the Primary Care Provider Diana J Scott FNP-BC https://youtu.be/gmzaue1ojn4 1 Assessment of Urinary Incontinence Urge Stress Mixed Other overflow, postural, continuous, insensible,
More informationMechanisms of Disease: central nervous system involvement in overactive bladder syndrome
Mechanisms of Disease: central nervous system involvement in overactive bladder syndrome Karl-Erik Andersson SUMMARY The pathophysiology of overactive bladder syndrome (OABS) and detrusor overactivity
More informationUP DATE MANAGEMENT OF URINARY INCONTINENCE IN ADULT
UP DATE MANAGEMENT OF URINARY INCONTINENCE IN ADULT Yunizaf, MD Division of Urogynecology Department of Obstetrics and Gynecology School of Medicine, University of Indonesia/ Dr. Cipto Mangunkusumo Hospital
More informationPREPARED FOR: U.S. Army Medical Research and Materiel Command Fort Detrick, Maryland
Award Number: W81XWH-12-1-0445 TITLE: An investigation into the nature of non-voiding contractions resulting from detrusor hyperreflexia in neurogenic bladders following spinal cord injury PRINCIPAL INVESTIGATOR:
More informationPRE-OPERATIVE URODYNAMIC
PRE-OPERATIVE URODYNAMIC STUDIES: IS THERE VALUE IN PREDICTING POST-OPERATIVE STRESS URINARY INCONTINENCE IN WOMEN UNDERGOING PROLAPSE SURGERY? Dr K Janse van Rensburg Dr JA van Rensburg INTRODUCTION POP
More informationUpdates in the nonpharmacological. treatment on overactive bladder
Updates in the nonpharmacological treatment on overactive bladder Overactive Bladder Also known as urgency-frequency syndrome Symptoms Urgency Daytime frequency Nocturia Urge urinary incontinence Sudden
More informationUrogynaecology. Colm McAlinden
Urogynaecology Colm McAlinden Definitions Urinary incontinence compliant of any involuntary leakage of urine with many different causes Two main types: Stress Urge Definitions Nocturia: More than a single
More informationIncontinence. Anatomy The human body has two kidneys. The kidneys continuously filter the blood and make urine.
Incontinence Introduction Urinary incontinence occurs when a person cannot control the emptying of his or her urinary bladder. It can happen to anyone, but is very common in older people. Urinary incontinence
More informationIntegrated Cardiopulmonary Pharmacology Third Edition
Integrated Cardiopulmonary Pharmacology Third Edition Chapter 3 Pharmacology of the Autonomic Nervous System Multimedia Directory Slide 19 Slide 37 Slide 38 Slide 39 Slide 40 Slide 41 Slide 42 Slide 43
More informationNeural control of the lower urinary tract
Neural control of the lower urinary tract Jalesh N. Panicker Consultant Neurologist and Honorary Senior Lecturer The National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology Queen
More informationIncontinence. When I was given this topic in urology to discuss with you today I
Incontinence When I was given this topic in urology to discuss with you today I was slightly disappointed. I personally see mostly men for problems such as stones, benign prostatic hyperplasia, prostate
More informationTraining a Wayward Bladder
D. James Ballard, PT, DPT, GCS The University of Utah, Dept. of Physical Therapy Training a Wayward Bladder Agenda 1. Discuss urinary incontinence 2. Review pelvic floor and lower urinary tract functional
More informationUrinary incontinence is defined (since
THE EPIDEMIOLOGY AND EVALUATION OF URINARY INCONTINENCE * David H. Thom, MD, PhD ABSTRACT The prevalence of urinary incontinence varies by definition, age, and sex. Urinary incontinence defined as leakage
More informationProlapse & Urogynaecology. Hester Mannion and Fabi Sica
Prolapse & Urogynaecology Hester Mannion and Fabi Sica Take home messages Prolapse and associated incontinence is very common It has a devastating effect on the QoL of the patient and their partner Strategies
More informationUsing Physiotherapy to Manage Urinary Incontinence in Women
Using Physiotherapy to Manage Urinary Incontinence in Women Bladder control problems are common, and affect people of all ages, genders and backgrounds. These problems are referred to as urinary incontinence
More informationAutonomic Nervous System
Autonomic Nervous System Keri Muma Bio 6 Organization of the Nervous System Efferent Division Somatic Nervous System Voluntary control Effector = skeletal muscles Muscles must be excited by a motor neuron
More informationReview Article Pelvic Floor Dysfunction, Body Excreta Incontinence and Continence
Cronicon OPEN ACCESS GYNAECOLOGY Review Article Pelvic Floor Dysfunction, Body Excreta Incontinence and Continence Abdel Karim M El Hemaly 1 * and Laila ASE Mousa 1 1 Professor of Obstetrics and gynaecology,
More informationUrodynamic and electrophysiological investigations in neuro-urology
Urodynamic and electrophysiological investigations in neuro-urology Pr. Gerard Amarenco Neuro-Urology and Pelvic-Floor Investigations Department Tenon Hospital, Assistance Publique Hôpitaux de Paris, Er6,
More informationHuman Anatomy. Autonomic Nervous System
Human Anatomy Autonomic Nervous System 1 Autonomic Nervous System ANS complex system of nerves controls involuntary actions. Works with the somatic nervous system (SNS) regulates body organs maintains
More informationAutonomic Nervous System. Lanny Shulman, O.D., Ph.D. University of Houston College of Optometry
Autonomic Nervous System Lanny Shulman, O.D., Ph.D. University of Houston College of Optometry Peripheral Nervous System A. Sensory Somatic Nervous System B. Autonomic Nervous System 1. Sympathetic Nervous
More informationBrief involuntary urine loss associated with an increase in abdominal pressure. Pathophysiology of Stress Urinary Incontinence Edward J.
TREATMENT OF SUI Pathophysiology of Stress Urinary Incontinence Edward J. McGuire, MD Department of Urology, University of Michigan Medical Center, Ann Arbor, MI All cases of stress urinary incontinence
More informationAutonomic Nervous System. Part of the nervous system that controls most of the visceral functions of the body ( Automatically?
Autonomic Response? Autonomic Nervous System Part of the nervous system that controls most of the visceral functions of the body ------ ( Automatically?) Classification Of CNS Autonomic Nervous System
More informationHuman Anatomy and Physiology - Problem Drill 15: The Autonomic Nervous System
Human Anatomy and Physiology - Problem Drill 15: The Autonomic Nervous System Question No. 1 of 10 Which of the following statements is correct about the component of the autonomic nervous system identified
More informationnumber Done by Corrected by Doctor
number 13 Done by Tamara Wahbeh Corrected by Doctor Omar Shaheen In this sheet the following concepts will be covered: 1. Divisions of the nervous system 2. Anatomy of the ANS. 3. ANS innervations. 4.
More informationOveractive Bladder Syndrome
Overactive Bladder Syndrome behavioural modifications to pharmacological and surgical treatments Dr Jos Jayarajan Urologist Austin Health, Eastern Health Warringal Private, Northpark Private, Epworth Overactive
More informationFemale Pelvic Medicine & Reconstructive Surgery
Female Pelvic Medicine & Reconstructive Surgery APPLICATION FOR NEW FELLOWSHIP Name of Institution: McGill University Location: Royal Victoria Hospital (Glen Site), St Mary s Hospital Centre Type of Fellowship:
More informationUrinary Incontinence. Lora Keeling and Byron Neale
Urinary Incontinence Lora Keeling and Byron Neale Not life threatening. Introduction But can have a huge impact on quality of life. Two main types of urinary incontinence (UI). Stress UI leakage on effort,
More informationManagement of Urinary Incontinence in Older Women. Dr. Cecilia Cheon Department of Obs. & Gyn. Queen Elizabeth Hospital
Management of Urinary Incontinence in Older Women Dr. Cecilia Cheon Department of Obs. & Gyn. Queen Elizabeth Hospital Epidemiology Causes Investigation Treatment Conclusion Elderly Women High prevalence
More informationAutonomic Nervous System Dr. Ali Ebneshahidi
Autonomic Nervous System Dr. Ali Ebneshahidi Nervous System Divisions of the nervous system The human nervous system consists of the central nervous System (CNS) and the Peripheral Nervous System (PNS).
More informationChapter 17. Nervous System Nervous systems receive sensory input, interpret it, and send out appropriate commands. !
Chapter 17 Sensory receptor Sensory input Integration Nervous System Motor output Brain and spinal cord Effector cells Peripheral nervous system (PNS) Central nervous system (CNS) 28.1 Nervous systems
More informationGlossary of terms Urinary Incontinence
Patient Information English Glossary of terms Urinary Incontinence Anaesthesia (general, spinal, or local) Before a procedure you will get medication to make sure that you don t feel pain. Under general
More informationCHAPTER 15 LECTURE OUTLINE
CHAPTER 15 LECTURE OUTLINE I. INTRODUCTION A. The autonomic nervous system (ANS) regulates the activity of smooth muscle, cardiac muscle, and certain glands. B. Operation of the ANS to maintain homeostasis,
More informationPUBOVAGINAL SLING IN THE TREATMENT OF STRESS URINARY INCONTINENCE FOR URETHRAL HYPERMOBILITY AND INTRINSIC SPHINCTERIC DEFICIENCY
Urological Neurology International Braz J Urol Official Journal of the Brazilian Society of Urology PUBOVAGINAL SLING IN SUI Vol. 29 (6): 540-544, November - December, 2003 PUBOVAGINAL SLING IN THE TREATMENT
More informationCANINE AND FELINE INCONTINENCE: URINE TROUBLE
CANINE AND FELINE INCONTINENCE: URINE TROUBLE Kaitlin Lonc, DVM Small Animal Internal Medicine Resident Department of Small Animal Clinical Sciences Michigan State University College of Veterinary Medicine
More informationUrinary System and Fluid Balance. Urine Production
Urinary System and Fluid Balance Name Pd Date Urine Production The three processes critical to the formation of urine are filtration, reabsorption, and secretion. Match these terms with the correct statement
More informationNervous Systems: Diversity & Functional Organization
Nervous Systems: Diversity & Functional Organization Diversity of Neural Signaling The diversity of neuron structure and function allows neurons to play many roles. 3 basic function of all neurons: Receive
More information