1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 35 Disorders of the Bladder and Lower Urinary Tract

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Structure of the Bladder Parts –Fundus (body) –Neck (posterior urethra) Urine: passes from the kidneys to the bladder through the ureters –Ureters: enter the bladder bilaterally at a location toward its base and close to the urethra –Trigone: the triangular area bounded by the ureters and the urethra

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Four Layers of the Bladder Outer serosal layer –Covers upper surface; continuous with the peritoneum Detrusor muscle –A network of smooth muscle fibers Submucosal layer –Loose connective tissue Inner mucosal lining –Transitional epithelium

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Three Main Levels of Neurologic Control of Bladder Function Spinal cord reflex centers –Sacral (S1 through S4) and thoracolumbar (T11 through L2) Innervation –Pelvic nerve innervates detrusor –Pudendal nerve –Hypogastric Micturition center in the pons Cortical and subcortical centers

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Storage and Emptying of Urine Involves involuntary (autonomic nervous system) and voluntary control (somatic nervous system) Parasympathetic nervous system promotes bladder emptying. Sympathetic nervous system promotes bladder filling. Striated muscles in the external sphincter and pelvic floor provide for voluntary control of urine. Low-pressure urine storage

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins ANS Drugs Nicotinic receptors –Sympathetic neurons –Increase bladder storage Muscarinic receptors –Inhibit sympathetic neurons

7. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Urine Tests and Studies Laboratory and radiographic studies –Urine tests and x-rays Urodynamic studies –Uroflowmetry –Cystometry –Urethral pressure profile –Sphincter electromyography –Ultrasound bladder scan

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Alteration in Bladder Function Types –Urinary obstruction with retention or stasis of urine –Urinary incontinence with involuntary loss of urine Causes –Structural changes in the bladder, urethra, or surrounding organs –Impairment of neurologic control of bladder function

9. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? The micturition reflex involves both sympathetic and parasympathetic input.

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True: The reflex is both conscious and and unconscious.

11. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Signs of Outflow Obstruction and Urine Retention Bladder distention Hesitancy Straining when initiating urination Small and weak stream Frequency Feeling of incomplete bladder emptying Overflow incontinence

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Common Causes of Neurogenic Bladder Stroke and advanced age Parkinson disease Spinal cord injury Injury to sacral cord or spinal roots Radical pelvic surgery Diabetic neuropathies Multiple sclerosis

13. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurogenic Bladder Disorders Spastic bladder dysfunction –Failure to store urine –Neurologic lesions above level of the sacral cord allow neurons in the micturition center to function reflexively without control from CNS centers.

14. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurogenic Bladder Disorders (cont.) Flaccid bladder dysfunction –Bladder emptying is impaired. –Neurologic disorders affect motor neurons in the sacral cord or peripheral nerves that control detrusor muscle contraction and bladder emptying.

15. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Goals of Treatment for Neurogenic Bladder Disorders Preventing bladder overdistention Preventing urinary tract infections Preventing potentially life-threatening renal damage Reducing the undesirable social and psychological effects of the disorder

16. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatments for Neurogenic Bladder Disorders Catheterization Bladder retraining Pharmacologic manipulation Surgical procedures

17. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following is not a cause of neurogenic bladder? a.Parkinson disease b.Spinal cord injury c.Alzheimer disease d.Injury to sacral cord or spinal roots e.Radical pelvic surgery

18. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer a.Parkinson’s disease b.Spinal cord injury c.Alzheimer disease: This is primarily a cognitive condition, not motor related. d.Injury to sacral cord or spinal roots e.Radical pelvic surgery

19. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Incontinence Stress incontinence –Involuntary loss of urine during coughing, laughing, sneezing, or lifting –Increases intra-abdominal pressure Urge incontinence –Involuntary loss of urine associated with a strong desire to void (urgency)

20. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Incontinence (cont.) Overflow incontinence –Involuntary loss of urine that occurs when intravesicular pressure exceeds the maximal urethral pressure because of bladder distention in the absence of detrusor activity Mixed incontinence –Combination of stress and urge incontinence

21. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatment Options for Incontinence Management depends on the type of incontinence, accompanying health problems, and the person’s age. Behavioral and pharmacological measures Exercises to strengthen the pelvic muscles Surgical correction Noncatheter devices to obstruct urine flow or collect urine Indwelling catheters Self-catheterization

22. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Elderly Incontinence Overall capacity of the bladder is reduced. Urethral closing pressure is reduced. Detrusor muscle function declines with aging. –Leads to larger postvoid residual volumes Restricted mobility Increased medication Comorbid illness Infection Stool impaction

23. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Bladder Cancer Signs –Increased frequency –Urgency –Dysuria –Hematuria Cancerous lesion types –Superficial –Invasive

24. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Diagnostic Measures for Cancer of the Bladder Cytologic studies Excretory urography Cystoscopy Biopsy Ultrasonography CT scans MRI

25. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatment Methods for Bladder Cancer Treatment methods depend on –Cytologic grade of the tumor –Lesion’s degree of invasiveness Methods include –Surgical removal of tumor –Radiation therapy –Chemotherapy

26. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Increased postvoid residual volumes are the result of _______________. a.Hematuria b.Detrusor muscle weakness c.Infection d.Drug treatment

27. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer a.Hematuria b.Detrusor muscle weakness: Detrusor muscle weakness results in decreased void pressure and therefore greater volume left in the bladder. c.Infection d.Drug treatment