VOIDING

DYSFUNCTION AND URODYNAMICS

Edgar Lim, MD

Symptoms:
Nocturia - at least once a night
Frequency rate ; Polyuria - volume
Incomplete voiding - > 0mL residual volume
Straining to void
Urinary retention
Incontinence

Prostate volume normal up to 20g
If no symptoms, do not treat

Functional Features of the Bladder:
Normal capacity of 400-500mL
Sensation of fullness 100-150cc
Accommodate carious volumes without change
of intraluminal pressure - compliance
Initiate and sustain effective contraction
Voluntary initiation or inhibition of voiding
Parasympathetic Innervation: S2-S4
Sympathetic Innervation: T10-L2
Somatic afferent: pudendal nerve
Visceral afferent: sympathetic and
parasympathetic nerves
Normal bladder pressure at rest = 0

The micturition reflex
Reflex pathways via the spinal cord and pons
Medial Pontine
o Contraction: Detrusor
o Relaxation: External sphincter
Lateral Pontine
o Contraction: External sphincter
o Relaxation: Detrusor


Cerebral (suprapontine) control



Pons


Spinal cord

Sensation of fullness = 100-200mL

Compliance = volume/pressure

Bladder capacity and intravesial pressure relationship
Causes of reduced bladder capacity
o Enuresis/incontinence
o Bladder infection
o Bladder contracture due to fibrosis
o Upper motor neuron lesions
o Defunctionalized bladder
o Post-surgical bladder
Causes of increased bladder capacity
o Sensory neuropathic disorders
o Lower motor neuron lesions
o Chronic urinary tract obstruction
Low intravesical pressure:
o Normal capacity
o Large capacity
Sensory deficits (DM)
Flaccid motor neuron lesions
Large bladder (due to
repeated stretching)

Spastic Neuropathic Bladder
1. Reduced bladder capacity
2. Involuntary detrusor contraction
3. Increased intravesical voiding pressure
4.
5. Increased tone of internal sphincter

Flaccid Neuropathic Bladder
1. Large capacity
2. Lack of voluntary detrusor contraction
3. Low intravesical pressure
4. Mild trabeculation
5. Decreased tone of external sphincter

Sphincter function
Urethral pressure profile
o Urethral pressure at every level of the
sphincter unit
Urethral closure pressure = difference between
bladder pressure and urethral pressure

Anatomic length vs. functional length of the urethra
Functional length of the sphincteric unit
portion with positive closure pressure (where
urethral pressure > intravesical pressure)
Maximum closure pressure
o In women, at the center of the urethra
Functional length = 4cm
o In men, peak in membranous urethra
Functional length = 6-7cm

Urinary incontinence
Stress incontinence
o With effort
o Ex. Coughing, standing, sneezing, sitting
Genuine stress incontinence (anatomic)
o Hypermobility of the vesicourethral
segment owing to pelvic floor
weakness
Intact spincter
Weak pelvic floor support

Bladder

Uninhibited Detrusor contraction
Facilitation of micturition reflex
Urethra (Urethritis/Prostatitis)
Bladder (Cystitis/Obstructie Hypertrophy)

Urodynamic studies
Evaluation of the voiding problems involving the
lower urinary tract
Uroflowmetry
o Flow rate of <10 mL per second
(definitive evidence of obstruction)
Cystometry
o Bladder function
o Fairly constant intraluminal pressure
until the bladder nears capacity; then a
moderate rise until capacity is reached,
then a sharp rise as voiding is initiated

[ohmyGAD! B2016]

Anatomic abnormality
Urge incontinence
o Feel like going to the bathroom
o Ex. Before you reach it, you leak
Combination
Post prostatectomy incontinence
o Functional length of the sphincteric
segment above the genitourinary
diaphragm determines the degree of
incontinence
False (overflow) incontinence
o BPH
o Distended hypogastrium

Urethral resistance
Striated external sphincter 50% of striated
urethral resistance
Smooth muscle for proximal urethral closure
pressure
Urethral closure pressure normally resposnds to
bladder filling, change in position or stressful
events like coughing
Sphincteric mechanism augments urethral
resistance reflexively undre stress to prevent
leakage.

b. Intrinsic sphincter damage

c. Combination
C. Combination
Failure to empty
A. Because of the bladder
Neurologic
Myogenic
Psychologic
Idiopathic
B. Because of the outlet
Anatomic
o Prostatic obstruction
o Bladder neck
contracture
o Urethral stricture
Functional
o Sphincter dyssynergia
C. Combination

Complications of neuropathic bladder
Infection
Hydronephrosis
o Renal damage
Stone formation
Sexual dysfunction
Autonomic dysreflexia

Detrusor/sphincter dyssynergia
Filling cystometry normal
Closure pressure above average
Detrusor contraction associated with
simultaneous increase in urethral closure
pressure
Bladder contracts but sphincter does not relax
Dysruption of pontine control upper spinal
cord injury
Normal: sphincter relaxes first before bladder
contracts, can hold as long as 3 hours

Spinal shock
Up to 6 months
o Invariably presents with initial flaccid
paralysis

Autonomic dysreflexia
Sympathetically mediated reflex behavior
Cord lesion above the sympathetic outflow from
the cord
Symptoms may be triggered by the
overdistended bladder
o Increase blood pressure, bradycardia,
sweating, headache
o Maybe fatal

Treatment of incontinence
Conservative measures
1. Failure of reservoir function
a. Anti-cholinergic drugs
b. Anti-histamines
c. Musculotropic relaxants
d. Tricyclic anti-depressants
2. Failure of retention function
a. Catheterization e.g. ICP
b. Pharmacologic agents
Bethanechol -
parasympathomimetic

Functional classification of voiding dysfunction
Failure to store
A. Because of the bladder
Overactivity
1. Involuntary contractions
2. Decreased compliance
Eg. Neurologic
lesions/injury, fibrosis
Hypersensitivity
1. Inflammation/infection
2. Neurologic
3. Psychologic
4. Idiopathic
B. Because of the outlet
a. Genuine stress incontinence

[ohmyGAD! B2016]