排尿障礙治療中心 版權所有 physiology of micturition hann-chorng kuo department of...

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Physiology of Micturition

Hann-Chorng KuoDepartment of Urology

Buddhist Tzu Chi General Hospital, Hualien

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Neuroanatomy of Micturition

Storage– Stability and good compliance of BladderEmpty – Contraction of detrusor and opening of UrethraParasympathetic - Pelvic nerveSympathetic - Hypogastric nerveSomatic nerves- Pudendal nerve

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Neuroanatomy of Lower Urinary Tract

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Neuroanatomy of Micturition

Micturition reflex center – sacral cords 2-4Micturition control center – ponsSensory motor center – frontal lobeLimbic systemCerebellum, Basal ganglia

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Neuroanatomy of Micturition

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Sensory Afferents

A-delta fibers – Micturition reflex, stretch and fullness sensationC-fibers – Noxious sensation, capsaicin sensitive primary afferents (CSPA)Dual sensory afferents in mammalian urinary bladder

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Dual Sensory Innervation of Urinary Bladder

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Storage of Urine

Stable bladderGood complianceCompetent urethra- mucosa, submucosa, smooth muscles, striated skeletal muscles (external sphincter)Good pressure transmission and hammock effect during stress

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Stable Bladder in Filling Phase

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Positive Pressure Transmission during Coughs in UPP Tracing

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Poor Pressure Transmission during Coughs in Stress UPP

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High Leak Point Pressure in SUI with good Hammock Effect

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Empty of Urine

Sustained detrusor contraction- cholinergic parasympathetic fibersRelaxation of bladder neck – alpha-adrenergic sympathetic nervesRelaxation of external sphincter- cholinergic pudendal nervesPatent non-obstructive urethra

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Detrusor Contraction during Voiding Phase

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Bladder Outlet Obstruction during Voiding Phase in Man

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Bladder Outlet Obstruction during Voiding Phase in Woman

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Neurophysiology of Micturition Reflexes

排尿中樞 PONS

胸腰髓 T10-L2

薦髓 S2,3,4

交感神經節

膀胱膀胱頸括約肌

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Modulation of Sympathetic nerves in Parasympathetic Ganglion

往橋腦排尿中樞

T10-L2 髓

薦髓 S2,3,4 逼尿肌核SIN

副交感神經節

尿道外括約肌

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Innervation of Lower Urinary Tract

Bladder- cholinergic parasympathetic- contraction; beta-adrenergic & NO– relaxationBladder neck – alpha-adrenergic- contrationUrethral muscles- cholinergic parasympathetic, NO, cholinergic somatic nerves

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Physiology of Urine Storage

First sensation of fillingFullness sensationUrge sensationPremicturition urge sensation- phasic detrusor contractionIncreased activity of urethral sphincter during filling

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Urodynmic Tracing in Micturition

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Initiation of Micturition- Relaxation of External Sphincter

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Sustained Detrusor Contraction- Urethrovesical Reflex

Stretch receptors in urethral wallDetrusor overactivity in urgency- frequency syndrome and SUIRole of incompetent bladder neckLow detrusor contractility in incompetent urethral sphincter after prostatectomy

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Micturition detrusor pressure- depends on urethral resistance

High voiding pressure indicates a greater urethral resistanceLow voiding pressure indicates a lower urethral resistance or a low detrusor contractilityEfficient bladder empty depends on a sustained detrusor contraction

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Detrusor instability and Inadequate contractility (DHIC)

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Low Detrusor Pressure in Woman with SUI

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Low Detrusor Pressure and BOO

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Detrusor overactivity and BPO

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Efficient Bladder Empty

Hypersensitive bladder- low detrusor contractilityInadequate contractility in elderlyBladder outlet obstruction- Bladder neck dysfunction, Prostatic enlargement, Urethral stricture, Cystocele, External sphincter dyssynergia

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Urethral Stricture and BOO

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Anterior Urethral Valve and BOO

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Cystocele and BOO

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Autonomic Dysreflexia

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Detrusor External Sphincter Dyssynergia

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Dysfunctional Voiding in Woman

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Pseudodyssynergia in Girl with Incontinence and UTI

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Pharmacology of Micturition- Increase storage efficiency

Reduce detrusor overactivityAnticholinergic agents- oxybutynine, flavoxate, imipramineGanglion blocker- bentylBeta-adrenergic agentsBotulinum toxinVanilloid receptor blockers- capsaicin, resiniferatoxin

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Detrusor Overactivity after Resiniferatoxin Treatment

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Initial Excitatory Responses after Capsaicin Treatment

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Pharmacology of Micturition- Increase empty efficiency

Parasympathomimetic agent- UrecholineAdrenergic blockers- inhibition of detrusor relaxation (?)

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Pharmacology of Micturition- Increase outlet resistance

Increase smooth muscle tone Imipramine, methylephedrine

Increase striated muscle tone Nitric oxide synthase inhibitor Pelvic floor muscle training

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Pharmacology of Micturition- Decrease outlet resistance

Decrease bladder neck & urethral resistanceAlpha-adrenergic blockers- dibenyline, terazosin, tamsulosin, doxazosinNitric oxide donorsBotulinum toxin Polysynaptic blocker – baclofen, diazepam

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Reduction of MUCP after Nitric Oxide Donors (NTG)

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Improved Voiding Efficiency after Botulinum Toxin Injection

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Decreased MUCP after Botulinum Toxin Injection

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Combination of Medication- Improve Voiding Efficiency

Increased bladder sensation- intravesical capsaicin, RTXDetrusor overactivity- anticholinergic, intravesical RTX, botulinum toxinDetrusor underactivity – parasympathomimetics, alpha-blocker, NO donors, striated muscle relaxant, periurethral botulinum toxin injection

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Combined Medication – Improved Voiding Efficiency

Urethral sphincter hypertonicity- alpha-blocker, NO donors, striated skeletal muscle relaxantUrethral sphincter overactivity- alpha-blocker, striated muscle relaxant, NO donors, botulinum toxinBladder neck dysfunction- alpha-adrenergic blocker

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Combined Medication- Improved Storage Efficiency

Detrusor Overactivity- anticholinergics, sympathomimetics, imipramineIntrinsic sphincter deficiency- imipramine, sympathomimeticsDHIC- depends on voiding efficiency and grades of incontinence