Micturition Lecture Notes PDF

objectives By the end of this lecture the student should be able to: -understand the physiology of micturition -realize the different types of voiding dysfunction -utilize the proper PT modality for voiding disorders the smooth muscle of the bladder wall (detrusor muscle) is c...

objectives By the end of this lecture the student should be able to: -understand the physiology of micturition -realize the different types of voiding dysfunction -utilize the proper PT modality for voiding disorders the smooth muscle of the bladder wall (detrusor muscle) is composed of an interlacing network of fibers running in various directions. showed that at the male urethral orifice, circular smooth muscle fibres provide an internal urethral sphincter while in females the muscle in this region is arranged longitudinally so there is no internal sphincter. the male urethra consists of prostatic, membranous and spongy parts, with a total length of a bout eight inches Proximal Urethral Continence Mechanism the proximal urethral sphincter can maintain passive continence; it is normally competent when the detrusor is at rest but opens widely in association with a detrusor contraction, in a stable bladder, the bladder neck can maintain urinary continence without a functional distal mechanism  During normal filling there is also a gradual increase in the urethral resistance which helps to prevent urine loss as the bladder fills; the detrusor should remain inactive with no involuntary contractions. When the bladder has filled to a specific volume, tension receptors in the bladder sense fullness and when there is an appropriate time and place, a voluntary micturition reflex is initiated. This reflex should lead to complete bladder emptying. This is accomplished by relaxation of the pelvic floor and resultant decrease in the urethral resistance, accompanied by a sustained detrusor contraction, which forces urine out of the bladder  Neural supply for the lower urinary tract Autonomic nervous system Innervates smooth ms. detrusor & Somatic nervous system proximal sphinctersphintcter Pudendal nerve Sympathetic N system Parasympathetic N system ( pelvic n) Innervates striated (hypogastric n) Responsible for emptying external sphincter & responsible for filling pelvic floor muscles.  Reversible Causes of Urinary Incontinence DIAPPERS Delirium Infection Atrophic vaginitis Pharmacological Psychological Endocrine Restricted mobility Stool impaction Types of Urinary Incontinence 1-Urge Incontinence: Urge incontinence is an involuntary loss of urine associated with a strong desire to void (urgency) it is usually associated with the urodynamic finding of involuntary detrusor contraction known as detrusor instability (DI). so a smaller increase in volume causes urgency or incontinence Infection, inflammation and neurological problems are common causes  2- Stress Incontinence Stress incontinence is involuntary loss of urine during: - coughing -sneezing -laughing, -any physical activity that increases the intra-abdominal pressure, in the absence detrusor contraction or an over distended bladder. In normal continent subjects, urethral pressure exceeds vesical pressure, both at rest and during increases in intra-abdominal pressure. Pelvic floor muscle weakness is a common cause -Based on the pressure transmission theory: As equal rise in vesical and urethral pressure was due to the transmission of intra- abdominal pressure to the bladder and the part of the proximal urethra above the pelvic floor. Pressure transmission theory  Mixed Incontinence a combination symptoms of urge and stress incontinence  Overflow Incontinence: Overflow incontinence is involuntary loss of urine associated with over distension of the bladder. -bladder never feels empty -urine dribbles even after voiding -inability to void when the urge is felt  Functional incontinence Urinary loss may be caused by factors outside the lower urinary tract such as chronic impairment of physical or cognitive functioning or both.  Management Kegel ex Behavioral therapy Functional Magnetic Stimulation (FMS) Electrical Stimulation Biofeedback Acupuncture  Electrical Stimulation Surface stimulation Neuro -modulation  Neuro-modulation -Intravesical electrical stimulation -Direct bladder stimulation -Implanted Sacral root stimulation  Surface stimulation -TENS -Functional electrical stimulation -Pudendal n. stimulation (rectal) -Lower limb stimulation - Functional magnetic stimulation -Interferential stimulation -Posterior tibial n. stimulation  Enuresis ( Bed-wetting) Enuresis is defined as the repeated voiding of urine into clothes or bed at least twice a week for at least 3 consecutive months in a child who is at least 5 yr of age (the age when volitional control of micturition is expected).  Bed wetting Two physical functions prevent bedwetting. The first is a hormone that reduces urine production at night (anti-diuretic hormone – ADH-) released by hypothalamus and stored in the posterior pituitary gland. The second is the ability to wake up when the bladder is full. Children usually achieve nighttime dryness by developing one or both of these abilities Bedwetting Classification of enuresis Daytime symptoms nocturnal Mono- symptomatic Primary Never dry from birth diurnal Poly - symptomatic total Secondary Get dry for 6 months at least  Causes of bedwetting 1-Neurological-developmental delay 2-Genetics 3- Bladder problems 4-Insufficient anti-diuretic hormone (ADH) production 5-Psychological 6-Infection/disease 7-Sleep disorders 8 -Improper toilet training  PT treatment of enuresis The best approach to treatment is to reassure the child and parents that the condition is self-limited and to avoid punitive measures that can affect the child's psychologic development adversely. 1- Proper toilet training 2-behavioral 3-alarm 4-acupuncture 5-motivation & psychological support  Fluid intake should be restricted after 6 or 7 pm. The parents should be certain that the child voids at bedtime. A voiding extraneous caffeine and diuretic fluids after 4 pm also is beneficial.  Star chart for dry nights, child earns praise and a star each morning if his bed is dry. The child should not be blamed for wet bed. Waking children a few hours after they go to sleep to have them void often allows them to awaken dry.