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Bladder Dysfunction and Urinary Incontinence

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Author(s): F. faizi

Journal: Iranian Journal of Radiology
ISSN 1735-1065

Volume: 6;
Issue: S1;
Start page: 62;
Date: 2009;
Original page

ABSTRACT
  "nIn the name of God. Dear colleagues, ladies and gentlemen, it is a great honor to be here. Bladder dysfunction is serious enough to seek serious help. If you may know I am working in a private clinic which it is impossible to follow the patients so this lecture is based on unusual and rare cases who came to me. Bladder dysfunction (BD) is common among 30% of young and old people who are suffering from it, however it is more common in old ages. According to a research, women are more involved as in men which prostate has a role is more common. The usual cases were: "n1. A young girl, aged 20, who had to wake up five times during the night to micturate. "n2. Also a lady said when I roll in bed I wet myself. "n3. A young lady who always had to use a pad. "n4. A man said I can’t use underground. "n5. I cannot go out since I have to micturate every hour. "n6. One said I have to wake up every hour at night. "n7. Young people say we have to micturate 3-4 times at night. "n8. A young man said as soon as I feel to micturate I empty my bladder before I’ve reached the WC and I wet myself to the ankle, how could I have a job? "n9. Some women wet themselves when they cough. "nIn order to know and diagnosis, the physiology of bladder function must be known. "nThe bladder is divided into two parts: "nThe Dom, which is innervated by Beta-Adrenergic. It relaxes the bladder in order to comply the urine. "nFrom the orifice of the urether and posterior ridge of the trigon to the bladder neck or internal sphincter. The prostatic urethra plays a major role in conti- nence. It has two parts,   "n1: From the bladder neck to V.M. this is enclaved by extension of detrusor muscles like a sleeve. These muscles contract during ejaculation to prevent retrograde ejaculation. "nDistal urethra from V.M. to the external sphincter which is covered by voluntary muscles. "nThe internal pressure of the urethra is higher than the bladder. If the pressure of the bladder rises, the internal pressure of the urethra should also increase. In women, the internal pressure of the urethra is short, and even if it has poorly developed they wet themselves when they cough. "nThe causes of BD: "nAs you see there are 17 causes, which 11 are related to the bladder. The bladder is responsible for retaining the urine and voiding. "nPathophysiology: "nThe bladder and sphincter should work in a coordinated manner: "nDuring the course of a day, an average person will void approximately 4-8 times. The urinary bladder is in storage mode for most of the day, allowing an individual to engage in more important activities than urination. "nNormal bladder function consists of 2 phases—filling and emptying. The normal micturition cycle requires the urinary bladder and the urethral sphincter working together as a coordinated unit to store and empty urine. During urinary storage, the bladder acts as a low-pressure receptacle, while the urinary sphincter maintains high resistance to urinary flow to keep the bladder outlet closed. During urine elimination, the bladder contracts to expel urine while the urinary sphincter opens (low resistance) to allow unobstructed urinary flow and bladder emptying. "nFilling phase: "nDuring the filling phase, the bladder accumulates increasing volumes of urine while the pressure inside the bladder remains low. The pressure within the bladder must be lower than the urethral pressure during the filling phase. If the bladder pressure is greater than the urethral pressure (resistance), urine will leak out. "nThe filling of the urinary bladder depends on the intrinsic viscoelastic properties of the bladder and the inhibition of the parasympathetic nerves. Thus, bladder filling is primarily a passive event. "nSympathetic nerves also facilitate urine storage in the following ways: "nSympathetic nerves inhibit the parasympathetic nerves from triggering bladder contractions. "nSympathetic nerves directly cause relaxation and expansion of the detrusor muscle. "nSympathetic nerves close the bladder neck by constricting the internal urethral sphincter. This sympathetic input to the lower urinary tract is constantly active during bladder filling. "nAs the bladder fills, the pudendal nerve becomes excited. Stimulation of the pudendal nerve results in contraction of the external urethral sphincter. Contraction of the external sphincter, coupled with that of the internal sphincter, maintains urethral pressure (resistance) higher than normal bladder pressure. The combination of both urinary sphincters is known as the continence mechanism. "nThe pressure gradients within the bladder and urethra play an important functional role in normal micturition. As long as the urethral pressure is higher than that of the bladder, patients will remain continent. If the urethral pressure is abnormally low or if the intravesical pressure is abnormally high, urinary incontinence will result. "nAs the bladder initially fills, a small rise in pressure occurs within the bladder (intravesical pressure). When the urethral sphincter is closed, the pressure inside the urethra (intraurethral pressure) is higher than the pressure within the bladder. While the intraurethral pressure is higher than the intravesical pressure, urinary continence is maintained. "nDuring some physical activities and with coughing, sneezing, or laughing, the pressure within the abdomen rises sharply. This rise is transmitted to both the bladder and urethra. As long as the pressure is evenly transmitted to both the bladder and urethra, urine will not leak. When the pressure transmitted to the bladder is greater than the urethra, urine will leak out, resulting in stress incontinence. "nEmptying phase: The storage phase of the urinary bladder can be switched to the voiding phase either involuntarily (reflexively) or voluntarily. Involuntary reflex voiding occurs in an infant when the volume of urine exceeds the voiding threshold. When the bladder is filled to capacity, the stretch receptors within the bladder wall signal the sacral cord. The sacral cord, in turn, sends a message back to the bladder indicating that it is time to empty the bladder. "nAt this point, the pudendal nerve causes relaxation of the levator ani so that the pelvic floor muscle relaxes. The pudendal nerve also signals the external sphincter to open. The sympathetic nerves send a message to the internal sphincter to relax and open, resulting in a lower urethral resistance. "nWhen the urethral sphincters relax and open, the parasympathetic nerves trigger contraction of the detrusor. When the bladder contracts, the pressure generated by the bladder overcomes the urethral pressure, resulting in urinary flow. These coordinated series of events allow unimpeded, automatic emptying of the urine. "nA repetitious cycle of bladder filling and emptying occurs in newborn infants. The bladder empties as soon as it fills because the brain of an infant has not matured enough to regulate the urinary system. Because urination is unregulated by the infant's brain, predicting when the infant will urinate is difficult. "nAs the infant brain develops, the PMC also matures and gradually assumes voiding control. When the infant enters childhood (usually at age 3-4 years), this primitive voiding reflex becomes suppressed and the brain dominates bladder function, which is why toilet training usually is successful at age 3-4 years. However, this primitive voiding reflex may reappear in people with spinal cord injuries. "nDelaying voiding or voluntary voiding: "nBladder function is automatic but completely governed by the brain, which makes the final decision on whether or not to void. The normal function of urination means that an individual has the ability to stop and start urination on command. In addition, the individual has the ability to delay urination until a socially acceptable time and place. The healthy adult is aware of bladder filling and can willfully initiate or delay voiding. "nIn a healthy adult, the PMC functions as an on-off switch that is activated by stretch receptors in the bladder wall and is, in turn, modulated by inhibitory and excitatory neurologic influences from the brain. When the bladder is full, the stretch receptors are activated. The individual perceives the activation of the stretch receptors as the bladder being full, which signals a need to void. "nWhen an individual cannot find a bathroom nearby, the brain bombards the PMC with a multitude of inhibitory signals to prevent detrusor contractions. At the same time, an individual may actively contract the levator muscles to keep the external sphincter closed or initiate distracting techniques to suppress urination. "nThus, the voiding process requires coordination of both the ANS and somatic nervous system, which are in turn controlled by the PMC located in the brainstem. "nPathophysiology: "nIf a problem occurs within the nervous system, the entire voiding cycle is affected. Any part of the nervous system may be affected, including the brain, pons, spinal cord, sacral cord, and peripheral nerves. A dysfunctional voiding condition results in different symptoms, ranging from acute urinary retention to an overactive bladder or to a combination of both. "nUrinary incontinence results from a dysfunction of the bladder, the sphincter, or both. Bladder overactivity (spastic bladder) is associated with the symptoms of urge incontinence, while sphincter underactivity (decreased resistance) results in symptomatic stress incontinence. A combination of detrusor overactivity and sphincter underactivity may result in mixed symptoms. "nBrain lesion: "nLesions of the brain above the pons destroy the master control center, causing a complete loss of voiding control. The voiding reflexes of the lower urinary tract—the primitive voiding reflex—remain intact. Affected individuals show signs of urge incontinence, or spastic bladder (medically termed detrusor hyperreflexia or overactivity). The bladder empties too quickly and too often, with relatively low quantities, and storing urine in the bladder is difficult. Usually, people with this problem rush to the bathroom and even leak urine before reaching their destination. They may wake up frequently at night to void. Typical examples of a brain lesion are stroke, brain tumor, or Parkinson disease. Hydrocephalus, cerebral palsy, and Shy-Drager syndrome also are brain lesions. Shy-Drager syndrome is a rare condition that also causes the bladder neck to remain open.Spinal cord lesion: "nDiseases or injuries of the spinal cord between the pons and the sacral spinal cord also result in spastic bladder or overactive bladder. People who are paraplegic or quadriplegic have lower extremity spasticity. Initially, after spinal cord trauma, the individual enters a spinal shock phase where the nervous system shuts down. After 6-12 weeks, the nervous system reactivates. When the nervous system becomes reactivated, it causes hyperstimulation of the affected organs. For example, the legs become spastic. "nThese people experience urge incontinence. The bladder empties too quickly and too frequently. The voiding disorder is similar to that of the brain lesion except that the external sphincter may have paradoxical contractions as well. If both the bladder and external sphincter become spastic at the same time, the affected individual will sense an overwhelming desire to urinate but only a small amount of urine may dribble out. The medical term for this is detrusor-sphincter dyssynergia because the bladder and the external sphincter are not in synergy. Even though the bladder is trying to force out urine, the external sphincter is tightening to prevent urine from leaving. "nThe causes of spinal cord injuries include motor vehicle and diving accidents. Multiple sclerosis (MS) is a common cause of spinal cord disease in young women. Those with MS also may exhibit visual disturbances, known as optic neuritis. Children born with myelomeningocele may have spastic bladders and/or an open urethra. Conversely, some children with myelomeningocele may have a hypocontractile bladder instead of a spastic bladder. "nSacral cord injury: "nSelected injuries of the sacral cord and the corresponding nerve roots arising from the sacral cord may prevent the bladder from emptying. If a sensory neurogenic bladder is present, the affected individual may not be able to sense when the bladder is full. In the case of a motor neurogenic bladder, the individual will sense the bladder is full and the detrusor may not contract, a condition known as detrusor areflexia. These individuals have difficulty eliminating urine and experience overflow incontinence; the bladder gradually overdistends until the urine spills out. Typical causes are a sacral cord tumor, herniated disc, and injuries that crush the pelvis. This condition also may occur after a lumbar laminectomy, radical hysterectomy, or abdominoperineal resection. "nSome teenagers suddenly develop an abnormal voiding pattern and often are evaluated for tethered cord syndrome, a neurologic condition in which the tip of the sacral cord is stuck near the sacrum and cannot stretch as the child grows taller. Ischemic changes of the sacral cord associated with the tethering cause the manifestation of dysfunctional voiding symptoms. "nType of incontinence-Symptomatologic categories : "nStress incontinence = involuntary leakage from effort or exertion, or sneezing or coughing.  Usually related to poor sphincter function and/or increased urethral mobility. "nUrge incontinence = involuntary leakage accompanied or proceeded by urgency. Usually related to detrusor overactivity "nMixed incontinence = features of both "nOverflow incontinence = associated with overdistention of the bladder, e.g. form detrusor paralysis or bladder outflow obstruction. "nPost prostectatomy BD: "nFollowing the removal of prostate the length of the remaining urethra is very important. It should be 18 mm in rest, and 13 mm in strain. If the length of opposition tissue or the functional urethra which is left is less than 13mm, the patient is incontinent and must always use a pad. Between these two lengths the patient will have leaks during daily activities. Manipulation of this functional urethra during operation worsens the continents. Preserving the tissue round the urethra will improve. "nNow what are the diagnoses of the mentioned disorders? "nThe young man who voids before reaching the WC suffered from detrusor instability and pons malfunction. "n The girl who has to wake up five times at night suffered from detrusor overactive and urge incontinence. "n In the case of the young man who voids his bladder before reaching the WC, the diagnosis is sphincter dyssynergia, detrusor instability and pons malfunction.  The two women: the one who used pads as she wetted herself constantly and the other case who wet herself while she rolled in bed suffered from the above mentioned dysfunctions. "nThe lower activity of the detrusor is common in old age. Those who feel their bladder is not empty although they have voided and no residue is left have continuous detrusor activity. "nThe man who wakes up every hour was because of improper operation since the bladder sphincter has been damaged and 5mm of functional urethra has been left open. Therefore, as soon as urine reaches the open area it triggers the external sphincter to open. "nChronic prostatitis inputs an impulse to the bladder to void. "nAs far as treatment is concerned its not my specialty to discuss, I should say there is no proper cure for all the cases. Anti-cholinergic drugs relax the bladder and increase the tone of the external sphincter, so it is the benefit of over activity. The anti alpha-adrenogenic decreases and relaxes the internal sphincter, urethra and prostetic smooth muscles. They are three types” Thank you for your time. 
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