Detrusor Instability

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%

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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

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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.

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• 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

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Oestrogen deficiency, Stress incontinence Neurological assessment at the vulva Sensation Lower limb reliexe. INVESTIGATIONS

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

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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

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QUALITY OF LIFE QUESTIONNAIRE Physical, emotional, social and mental burden.

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ESTIMATION OF RESIDUAL VOLUME A. Catheter method B. USS  30ml - may be abnormal

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URODYNAMIC STUDIES 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

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

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

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SURGICAL TREATMENT '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. 3.

Auto augmentation 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.