DETRUSOR INSTABILITY

INTRODUCTION
 Over 200million people world wide experience problems
associated with U.I.
 Impact on health resources and quality of life.
 50-100million suffer from O.A.B. syndrome.
 U.I. affects 50% of woman occasionally and 10% regularly.

VARIOUS TYPES OF INCONTINENCE

 Urge incontinence (Detrusor over activity).
 Stress incontinence.
 Unaware incontinence.
 Continuous Leakage.
 Nocturnal Enuresis.
 Post Void Dribbling.
 Extra Uretheral Incontinence.

DEFINITION (I.C.S.)
Unstable bladder is one that is shown objectively to contract
sponteneously or on provocation during the filling phase of
cystometry while the patient is attempting to inhibit micturition

TERMINOLOGY
 Uninhibited detrustor
 Detrusor reflex instabilty
 Over active bladder
 Detrusor Instability
 Detrusor hyper reflexia-Neuropathy

INCIDENCE
 Common condition, which are with age
 10% of post menopausal women with climacteric symptoms
nd
 2 commonest cause of urinary incontinence (30-50% of
cases)
AETIOLOGY
 No specific underlying cause, but some probabilities exist
- Idiopathic - 29%
 - Psychosomatic - Neutrotic personality
- - Respond to psychotherapy
- Neuropathic (Upper motor neuron lesion)
- Multiple sclerosis
- Spinal injuries
- Incontinence surgery - Due to extensive dissection at
bladder neck
- Out flow tract obstruction-rare

PATHOPLY SIOLOGY

 Motor nerves supply to the bladder

- Via parasympathetic Ner4veous system
- S2-s4
- Pelvic Nerves (Nerve erigentes)
- Stimulates detrusor contraction
- Effect mediated by Ach (muscarinic receptors)

SYMPATHETIC
- T11-L3
- Via hypogastric Nerves
- Acts predominantly on and receptors - relaxation of
detrusor muscle
- Stimulates and receptors to cause contraction of
bladder neck and urethra.
 Parasympathetic Stimulation - Incontinence
- Sympathetic stimulation - continence
- Bladder fills with little increase in intra vesical
pressure
(3-5cm water)
- Desire to void - 150 - 200ml
- Strong desire to void - 400 - 600ml

PATHOPHYSIOLOGY OF DETRUSOR INSTABILITY REMAINS A

MYSTERY.
 THEORIES
 Detrusor muscle contracts more than normal
 Increase and adrenergic activity leading to detrusor
contraction
 Reduction in long term innervation of the bladder leading to
a change in the property of the muscles

CLINICAL PRESENTATION
The term OAB syndrome refer to a spectrum of lower urinary
tract symptoms, namely:
 Frequency > 8 voids/day
 Urgency - sudden desire (difficult to control)
 Nocturia - waking more than once to void
 Incontinence - urge, stress, coital
Noctunal enuresis.

CLINICAL EVALUATION

HISTORY

 Presenting symptoms
 Presence of other urinary tract symptoms to rule out other
causes.

• Voiding difficulty
• Haemauria
• Dysuria etc.
 History of neurological conditions.
• spinal injury, multiple sclerosis
 Psychollogical problems - Neurosis
 Pelvic survey
 Drugs - diurectics, anticholinergics
 Other gynaecological problems - VUF, prolapse pelvic
masses, etc.
 Excessive fluid intake - coffee.

PHYSICAL EXAMINATION
 PELVIC MASSES
 DISTENDED BLADDER - URINARY RETENTION
VE - prolapse
- Fistula
 - Oestrogen deficiency,
- Stress incontinence
- Neurological assessment at the vulva
- Sensation
- Lower limb reliexe.

INVESTIGATIONS

(IN UROYNAECOLOGY)
1. Urinalysi / mlcls
2. E&U
3. Bladder diary (By patient)
- time of micturition
- voiding volume
- incontinence episodes
- pad usage
- fluid intake
- degree of urgency / incontinence
- method of choice for evaluation

4. PAD TEST
• Confirm and quantify leakage
a. simple test - 10 - 15 minutes
b. extended:
- wear preweighed pad
- drink 500ml of water
- simple exercise for 30 minutes
- more provocative exercise and weigh pads
- > 1g = positive

5. QUALITY OF LIFE QUESTIONNAIRE

- Physical, emotional, social and mental burden.

6. ESTIMATION OF RESIDUAL VOLUME

A. Catheter method
B. USS
 30ml - may be abnormal

URODYNAMIC STUDIES
1. UROMETRY: Measure flow rate and volume
 flow rate ie. < 15ml / s = abnormal
 voiding volume - < 150ml = abnormal
  T voiding time

2. CYSTOMETRY = Instill N/S at 10 - 100ml / min. into

bladder.
 Measures pressure volume changes in bladder.
 Residual volume 50ml.
 First desire to void = 150 - 200ml
 Patient should be able to interupt the ……

ABNORMAL CYSTOMETRY
 LEAKAGE ON COUGHING IN THE ABSENCE OF A
RISE IN DETRUSOR PRESSURE (gsi)
 SPONTANEOUS OR PROVOKED DETRUSOR
CONTRACTION WHICH THE PATIENT CANNOT
SUPPRESS DURING THE FILLING PHASE
(DETRUSOR INSTABILITY)

3. VIDEO CYSTOMETRY
 Uses contract media (urograffin)
 View lower urinary tract during micturition.
 Tumours, calculi, bladder neck opening incontinence
etc.
IMMAGING
1. Cystoscopy
2. IVU - co-existing loin pain, prolapse, recurrent
UTI,fistula.
3. USS (TV & Trans urethra)

TREATMENT

 Medical
 Surgical
 Others

MEDICAL
1. DRUGS REDUCE DETRUSOS CONTRACTILITY
ANTIMASCURINIC Drugs (Ach antagonist)
 They I, bladder contractility
 T bladder capacity, darifencis, otibutinin

2. DRUGS THAT AFFECT SENSORY NEURONS.

  Used for Neuropathic etiology (detrusor hypereflexia)
 Capsisin - blocks afferent sensory fibers
 Resin interotoxin - destroy sensory Neurone terminals.

3. DRUGS THAT ALTER OUT FLOW TRACT RESISTANCE

Oestrogen - atrophic genital changes

4. DRUGS THAT I, URINE PRODUCTION

• For Nucturia and Nuctional enuresis
• Synthetic vasopressin - antidiuretic effect
• I, urine out put during sleep.

5. ANTI DEPRESSANTS
Local anaesthetic and sedative-sedative properties
Used for Nocturnal enuresis

SURGICAL TREATMENT
1. 'CLAM' Cystoplasty
 most popular
 bisect bladder almost completely
 patch of gut (25cm ileum) put in place to reduce
contration

PROBLEMS
 Inneficient voiding - use catheter
 Mucus retention in urine
 Malignant changes - chronic exposure to urine
 Electrolyte problems

2. Auto augmentation
3. Urinary diversion - ileal conduit

OTHERS
BLADDER TRAINING
 Programme of sheduled voiding
 increase Intervals between void

BIOFEED BACK
 During cystometry
 Increasing patients awareness to stabilize detrusor presure
 Patent is thought to inhibit detrusor constractions

Phycholoneapy
 Neurotic (phychological aetiology)

Maximal electrical stimulation

 Vaginal or anal to inhibit contractions.