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Bladder.pptx

Chapter 35: Disorders of the Bladder and Lower Urinary Tract

Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

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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

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Four Layers of the Bladder

Outer Serosal Layer

Covers upper surface; is continuous with the peritoneum

Detrusor Muscle

A network of smooth muscle fibers

Submucosal Layer

Loose connective tissue

Inner Mucosal Lining

Transitional epithelium

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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

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Question #1

Is the following statement True or False?

The micturition reflex involves both sympathetic and parasympathetic input.

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Answer to Question #1

True

Rationale: The reflex is both conscious and unconscious.

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Storage and Emptying of Urine

Involves involuntary (autonomic nervous system) and voluntary control (somatic nervous system)

The parasympathetic nervous system promotes bladder emptying.

The 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

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ANS Drugs

Nicotinic Receptors

Sympathetic neurons

Increase bladder storage

Muscarinic Receptors

Inhibit sympathetic neurons

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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

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Question #2

Increased PVR volumes is the result of _______________.

Hematuria

Detrusor muscle weakness

Infection

Drug treatment

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Answer to Question #2

B. Detrusor muscle weakness

Rationale: Detrusor muscle weakness results in decreased void pressure and therefore greater volume left in the bladder.

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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

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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

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Common Causes of Neurogenic Bladder

Stroke and advanced age

Parkinson disease

Spinal cord injury

Injury to the sacral cord or spinal roots

Radical pelvic surgery

Diabetic neuropathies

Multiple sclerosis

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Neurogenic Bladder Disorders #1

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 the CNS centers.

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Neurogenic Bladder Disorders #2

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.

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Goals of Treatment for Neurogenic Bladder Disorders

Prevent bladder overdistention

Prevent urinary tract infections

Prevent potentially life-threatening renal damage

Reduce the undesirable social and psychological effects of the disorder

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Treatments for Neurogenic Bladder Disorders

Catheterization

Bladder retraining

Pharmacologic manipulation

Surgical procedures

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Question #3

Which of the following is not a cause of neurogenic bladder?

Parkinson disease

Spinal cord injury

Alzheimer disease

Injury to the sacral cord or spinal roots

Radical pelvic surgery

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Answer to Question #3

C. Alzheimer disease

Rationale: Alzheimer disease is primarily a cognitive condition, not motor related.

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Types of Incontinence #1

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)

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Types of Incontinence #2

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

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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

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Elderly Incontinence

Overall capacity of the bladder is reduced.

Urethral closing pressure is reduced.

Detrusor muscle function declines with aging.

To larger PVR volumes

Advancing age

Restricted mobility

Increased medication

Comorbid illness

Infection

Stool impaction

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Bladder Cancer

Signs

Increased frequency

Urgency

Dysuria

Hematuria

Cancerous Lesion Types

Superficial

Invasive

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Diagnostic Measures for Cancer of the Bladder

Cytologic studies

Excretory urography

Cystoscopy

Biopsy

Ultrasonography

CT scans

MRI

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Treatment Methods for Bladder Cancer

Treatment methods depend on

The cytologic grade of the tumor

The lesion’s degree of invasiveness

Methods include

Surgical removal of the tumor

Radiation therapy

Chemotherapy

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