PGS.TS Cao Phi Phong

2017

A. Liên hệ đến sự phối hợp của central nervous system (CNS) vàperipheral nervous system (PNS)B. Khởi đầu cerebral cortexC. Bước đầu là giãn striated external urethral sphincter (EUS) qua ức chế somatic efferentsD. ức chế sympathetic efferentsE. Hoạt hóa parasympathetic efferents gây bladder contraction và urethral smooth muscle relaxation

Cơ chế sự đi tiểu

a. Pontine micturition center (PMC) hay Barrington nucleus : phối hợp hoạtđộng detrusor và urethral sphincter.b. Tín hiệu từ lower urinary tract đượctiếp nhận periaqueductal grey matter (PAG) và chuyển tiếp tới insula.c. Anterior cingulate gyrus (hồi đaitrước) kiểm soát micturition reflexes.d. Prefrontal cortex quyết định bài tiếttự chủ

a. Somatic nervous system S2 to S4, pudendal nerve

i. Striated external urinary sphincter(cơ vòng vân ngoài niệu đạo)

(A) Striated sphincter contraction: nicotinic cholinergic receptors(B) Preganglionic efferent nerves từ S2 - S4.(C) Thân bào ở trong Onuf’s nucleus.(D) Nerve fibers theo pudendal nerve đến EUS, điều chỉnh kiểm soátcơ vòng tự chủ.(E) Phóng thích acetylcholine kích thích nicotinic cholinergic receptors trong EUS, gây co cơ (storage).

b. Autonomic nervous system

i. Parasympathetic pathways S2 to S4, pelvic nerve

(A) Co thắc Detrusor: muscarinic receptors(B) Preganglionic efferent nerves: S2 - S4.(C) Đi theo pelvic nerve đến inferior pelvic plexus kế cận BQ điểu chỉnh co thắc BQ(D) Phóng thích acetylcholine kích thích muscarinicacetylcholine receptors (M3) BQ, gây co cơ (emptying)

ii. Sympathetic pathways T11 to L2, hypogastric nerve

(A) Dãn smooth muscle: β-adrenergic receptors(B) Preganglionic efferent nerves: T10 - L2.(C) Ganglia: paraganglia (cạnh vertebrae), preganglia (giữa vertebrae và end organ), hay peripheral ganglia (trong end organ).(D) Nerves đi theo hypogastric nerve đến inferior pelvic plexus, điều chỉnh co cơ trơn niệu đạo (urethral smooth muscle) và ức chế phó giao cảm

ii. Sympathetic pathways T11 to L2, hypogastric nerve

(E) phóng thích norepinephrine kích thích beta-3 adrenergic receptor trong BQ , gây dãn cơ (storage).

(F) phóng thích norepinephrine kích thích alpha-1 adrenergic receptors trong involuntary sphincter, gây sphincter contraction (storage).

A. Thất bại chứa (Failure to store)

1. Bladder: hoạt động quá mức (idiopathic, neurogenic), giảmcompliance, gia tăng sensation

2. Outlet(chổ ra): stress urinary incontinence, sự thiếu hụtintrinsic sphincteric

B. Thất bại làm trống(Failure to empty)

1. Bladder: kém hoạt động, mất co lại2. Outlet:

+ giải phẫu học (tumor, detrusor sphincter dyssynergia, chổ hẹp), + chức năng (dysfunctional voiding, Fowler’s syndrome [failure of urethral sphincter relaxation in young women], primary bladder neck obstruction)

3. Cả hai

A. Suprapontine (bao gồm cerebral cortex): + detrusor overactivity: bladder và sphincter synergy, + normal bladder sensation, thường bài tiết thích hợp

B. Pons to spinal cord above S2 (upper motor neuron damage): + detrusor sphincter dyssynergia + spastic paresis lower limbs

C. S2 to S4 (lower motor neuron damage): + acontractile detrusor, + flaccid striated sphincter, + flaccid lower limbs

D. Peripheral nerves: + acontractile detrusor + absent bladder sensation

A. Bệnh sử

1. Urinary symptoms

a. Số lần, thể tích nước tiểu , không kiềm chếb. Ngập ngừng, độ mạnh của dòng chảy, làm trống không

hoàn toàn

2. Tổng quan triệu chứng

a. Gastrointestinal (GI): tần số và hằng định vận động của ruộtb. Nhu cầu đập vỡ ra từng mảnh (Need to splint): dùng ngón tay

đè ép trên âm đạo hay đáy chậu ( vagina or perineum) giúp đạtđược cảm giác bài tiết hoàn toàn trong lúc đại tiện, không cótác động mạnh bằng tay

Symptoms associated with level of neurologic lesion

Tăng hoạt động

cơ detrusor

+/- Detrusor cơ

vòng mất đồng

vận

Mất phản xạ

detrusor

B. Thăm khám

1. Tổng quát: thể trạng, tình trạng dinh dưỡng, sự khéo léo chi trên2. Khám bụng: presence of masses, đánh giá constipation3. Khám thần kinh: đánh giá perineal sensation4. Khám vùng chậu ở phụ nữ

a. Evidence of leakage with coughb. Presence of pelvic organ prolapse beyond the hymenc. Strength of anal sphincter, presence of hemorrhoids

C. Testing

1. Voiding diary (nhật ký bài tiết): record volume voided, fluid consumed, incontinence episodes, pads/diapers for 3 days2. Postvoid residual(lượng thừa còn lại sau bài tiết)3. Noninvasive uroflow4. Urodynamic study: with or without video (video to assess outlet)

In patients with spinal cord injury (SCI), wait until spinal shock resolves (~12 weeks).

5. Cystoscopy6. Upper tract imaging: voiding cystourethrogram (assess for

reflux), renal ultrasound (US) (assess for hydronephrosis, stones, renal scarring)

A. Detrusor function: normal (N), overactive (O), acontractile (A), detrusor underactivity (D)

B. Detrusor compliance: normal (N), decreased (D), increased (I)

bladder compliance

A general term for the relationship between changes in the bladder volume and

changes in pressure on the detrusor muscle; the ability of the bladder to stretch in

response to an increase in volume of urine.

Is Low Bladder Compliance Predictive of Detrusor Overactivity?

Detrusor Function - The Prognosis and Management of the Neurogenic Bladder

C. Smooth sphincter activity: synergic (S), dyssynergic (D), open (O)

D. Striated sphincter activity: synergic (S), dyssynergic (D), bradykinetic (B), impaired voluntary control (I), fixed tone (F)

Detrusor Function, Sphincteric Function, and Bladder Compliance Associated With Common Neurologic Diseases

A. Bảo tồn upper urinary tract / renal function

B. Tránh nhiễm trùng

C. Sức chứa BQ phù hợp, áp suất bên trong thấp ngăn ngừa tổnthương phía trên

D. Làm trống, áp suất bên trong thấp thích hợp

E. Kiểm soát đi tiểu

Bốn bước tiến hành

recurrent urinary tract infection (UTI)

Posterior urethral valve (PUV) disorder is an obstructive developmental

anomaly in the urethra and genitourinary system of male newborns

Micturating Cysto-urethrogram

USG abdomen (abdominal ultrasound)

Nghi ngờ rối loạn bài tiết

Loại trừ nguyên nhân

giải phẫu/thần kinh

Số lần, thể tích,

biểu đồ tai biến

Đặt sonde tiểu vệ sinh sạch sẽ ngắt quảng (CIC): BQ

không hoạt động, nước tiểu còn thừa nhiều và kém đáp

ứng điều trị

F. Thất bại chứa (Failure to store)

1. Bladder: overactive bladder idiopathic

a. Bladder retraining ( tái huấn luyện BQ)b. Dietary modification(sự thay đổi chế độ ăn uống)c. Pelvic floor physical therapy( điều trị vật lý sàn chậu)d. Pharmacotherapy(điều trị thuốc)

i. Anticholinergics: + Oxybutynin*, tolterodine, trospium chloride, fesoterodine,

solifenacin, darifenacin

ii. β-3 agonists: + Mirabegron

*(brand names Ditropan, Lyrinel XL, Lenditro (South Africa), Uripan (Middle East)

Generic Name: mirabegron

Brand Name: Myrbetriq

Antmuscarinics are the most widely used drugs for urgency and urge incontinence,

acting either selectively or nonselectively on muscarinic receptors in the bladder.

The first-line medications in this group include oxybutynin and tolterodine (with

once-daily formulations now available). The main side effect is dry mouth, with less

common effects of blurred vision, drowsiness, and constipation. Darifenacin and

solifenacin are newer anticholinergics, with greater specificity for the M3 receptor

(the predominant type in the bladder), and therefore possibly fewer side effects.

Trospium chloride has been promoted as having less central nervous system side

effects because it does not cross the blood-brain barrier

Anticholinergic Medication for Treatment of Detrusor Overactivity

MirabegronMirabegron is a beta-3 adrenergic agonist. It works by relaxing muscles in

the bladder.

Usual Adult Dose for Urinary Incontinence

-Initial dose: 25 mg orally once a day

-Maintenance dose: 25 to 50 mg orally once a day based on

individual patient efficacy and tolerability

Comments:

-This drug may be taken with or without food.

-Tablets should be taken with water, swallowed whole, and should not be

chewed, divided, or crushed.

Use: For the treatment of overactive bladder (OAB) with symptoms of urge

urinary incontinence, urgency, and urinary frequency

Điều trị ức chế alpha 1 adrenergic

Alpha blockers: doxazocin 0,5-1mg/ngày trong kháng trị

e. Refractory treatments (fail pharmacotherapy)

i. Sacral nerve stimulation (InterStim)

ii. Botulinum A toxin 100 units

iii. Posterior tibial nerve stimulation

iv. Thêm vào cystoplasty

Botulinum A toxin (BoNT/A) has been much used in the treatment of various

disorders of overactive skeletal muscle and has more recently been successfully

introduced in the treatment of bladder overactivity by injection into the detrusor

smooth muscle under cystoscopic guidance (Popat et al., 2005; Schurch et al.,

2005). This agent can now be given on an outpatient basis with use of local

anesthesia (Harper et al., 2003; Schurch et al., 2000). The effect lasts 6 to 12

months before repeat injections are required, and early results suggest that

subsequent injections are as just as efficacious as the first (Grosse et al., 2005).

2. Bladder: neurogenic detrusor overactivity

a. Bladder retrainingb. Dietary modificationc. Pelvic floor physical therapyd. Pharmacotherapy

i. Anticholinergics: + Oxybutynin, tolterodine, trospium chloride, fesotero-dine,

solifenacin, darifenacin

i i. β-3 agonists: + Mirabegron

e. Refractory treatments (fail pharmacotherapy)

i. Botulinum A toxin 200 unitsii. Posterior tibial nerve stimulationiii. Thêm vào cystoplasty

3. Outlet (chổ thoát): stress urinary incontinence( không kềm chế nước tiểu quá mức)

a. Pelvic floor physical therapyb. Incontinence pessary (vòng nâng)c. Intra-urethral bulking agents( căng phồng)d. Mid-urethral synthetic sling(quàng dây kéo lên)e. Pubovaginal fascial sling

G. Thất bại làm trống (Failure to empty)

1. Bladder: underactive, acontractile

a. Timed, double voidingb. Intermittent self-catheterization (ISC)c. Suprapubic tubed. Sacral nerve stimulation (only in nonobstructive idiopathic urinary retention)e. Catheterizable stomaf. Indwelling Foley catheter (last resort)

2. Outlet:

a. Pelvic floor physical therapyb. ISCc. Botulinum A toxin 100 units into urinary sphincter (off-label usage)d. Sacral nerve stimulation in Fowler’s syndrome

1. Dùng phổ biến intermittent catheterization trong điều tri

neurogenic bladder.

2. Incomplete emptying có thể gia tăng detrusor overactivity,

và overactive bladder kéo dài kích thích đáp ứng residual

volume bởi co thắc và gây triệu chứng khẩn cấp và số lần

tiểu (symptoms of urgency and frequency).

3. Incomplete emptying ở bn bệnh lý tủy sống gây ra bởi

kết hợp detrusor sphincter dyssynergia xảy ra trong khi

cố gắng bài tiết và duy trì kém co thắc cơ detrusor trong

pha bài tiết

4. Thường đồng ý residual volume đáng kể là 100 mL. Đây

là thể tích trong vượt quá số lượng này có thể ích lợi

dùng intermittent self-catheterization

Giới thiệu đầu tiên 1960, nhưng sau đó: clean hơn là

sterile technique

Used in children with spina bifida and even the elderly with

disorders of bladder emptying,

it has proved highly effective in many patients with MS and

various other neurogenic bladder disorders

Patients often are unaware of the extent to which they incompletely empty the

bladder, and the amount of residual volume may be a surprise for both the patient

and the doctor. For this reason, measurement of this parameter is the single most

important determination in planning bladder management

The volume may be measured either with ultrasound examination or using in-out

catheterization. The advantage of the latter procedure is that it familiarizes the

patient with catheterization, making teaching the technique of self-catheterization

easier. Intermittent catheterization is best performed by the patients themselves,

who should be taught by someone experienced in the method, such as nurse

continence advisors in the United Kingdom

Although bacteriuria is noted in 50% of patients doing clean intermittent self-

catheterization, the incidence of symptomatic urinary tract infections fortunately is

low. Transient hematuria in the early stages of learning the method is common

Algorithm showing the recommended management of neurological

incontinence. CISC, clean intermittent self-catheterization; PVR, postvoid

residual

In spinal cord disease, a combination of intermittent self-

catheterization and an oral anticholinergic deals effectively

with both aspects of bladder malfunction, the intermittent

catheterization for the incomplete emptying and the

anticholinergic for overactivity.

In a patient with a borderline significant residual volume,

starting an anticholinergic

.

This should be suspected if the medication has some initial

beneficial effect for several days that then disappears. Also, it

is advisable for a patient who has marked hesitancy and

difficulty in initiating micturition to wait to start an

anticholinergic until intermittent catheterization is well

established, because otherwise the patient is at risk of going

into complete retention.

This combined approach works well in patients with spinal

cord disease such as MS, provided that the patient is not too

severely disabled.

It also is highly effective in the earlier stages of MSA,

because incomplete bladder emptying is particularly likely to

present a problem in that disorder.

Intermittent self-catheterization is the main means of

symptomatic relief in women with urinary retention, although a

number of them find the technique unacceptable because of

discomfort on withdrawing the catheter, presumably caused by

the overactive muscle's contracting down on the catheter

Although an anticholinergic is effective in lessening detrusor overactivity, it

also may impair bladder emptying. The resulting increase in postmicturition

residual volume may then lead to worsening symptoms of urgency and

frequency. PVR, postvoid residual

Although a combination of anticholinergic medication

together with intermittent catheterization is the optimal

management for patients with detrusor overactivity and

incomplete bladder emptying, there comes a point when the

patient is no longer able to perform self-catheterization, or

when urge incontinence and frequency are unmanageable.

In patients with spinal cord disease, this point may be

reached when the patient is no longer weight-bearing and is

chair-bound, and at this stage an indwelling catheter

becomes necessary

If urge incontinence is the main problem and the bladder

empties completely, some men are able to wear an

external device attached around the penis. The simplest

and least obtrusive is a self-sealing latex condom sheath,

which can be put on each night or kept in place for up to 3

days. More elaborate body-worn appliances also are

available, but an expert must fit these. An effective

external appliance for women has yet to be devised.

An extradural sacral nerve stimulator can be highly effective

in lessening detrusor overactivity that is resistant to

anticholinergic medication (Abrams et al., 2003; Brazzelli et

al., 2006).

It seems highly likely that the mechanism of action of this

device is stimulation in the presacral region of the pelvic

afferents, which are known to have an inhibitory effect on the

detrusor. More difficult to explain is how it may have an effect

in young women with urinary retention, though this also

appears to be mediated by an afferent mechanism.

Implanting a stimulator is a two-stage procedure, the first

stage being a test phase, with a stimulating lead inserted

through an S3 foramen and connected to an external

stimulator for 3 days. This can be performed either as an

outpatient procedure with use of local anesthesia, with

insertion of a temporary lead, or with the patient under

general anesthesia with insertion of a special “tined” lead

that can facilitate completion of the second stage (Spinelli et

al., 2003).

If the patient's symptoms decrease significantly during this trial

period, as judged by measurement of residual volumes and

diary-recorded voided volumes, the patient is eligible for a

permanent stimulator.

This is implanted in a subcutaneous pocket and connected to

the stimulating lead. The stimulator is continuously active,

although its effect can be maintained at a subsensory level, so

that patients are not aware of its chronic action.

The permanent stimulators are expensive, and case selection

is crucial in order to minimize the need for revision procedures

In patients who have suffered a complete spinal cord

transection but in whom the caudal section of the cord and

its roots are intact, the implantation of a nerve root stimulator

should be considered.

This device was pioneered by Professor Giles Brindley and

his collaborators, and several thousand have now been

implanted worldwide.

The principle on which they work is that the stimulating

electrodes are placed around the lower sacral roots (S2-S4)

and activated by an external switching device.

The stimulating electrodes are implanted at a neurosurgical

procedure and usually are applied intrathecally to the anterior

roots, the posterior roots being cut at the same time. After the

implant, adjustments are made to the stimulation parameters

so that the patient obtains maximum benefit in terms of

making the bladder contract for voiding, assisting defecation,

or even producing a penile erection.

Although such devices often are highly effective in selected

cases, the additional neural deficit caused by the need for

section of the dorsal roots and consequent loss of reflex

erections has reduced its acceptance. These stimulators are

suitable only for patients with complete spinal cord lesions,

rather than partial cord lesions or progressive neurological

disease.

Various urological procedures can be carried out to treat

incontinence. They range from minimally invasive

procedures, (TVT, TOT) to increase bladder outflow

resistance, or implantation of an artificial urethral sphincter, to

the surgical techniques of increasing bladder capacity by

cystoplasty or urinary diversion into a conduit or

catheterizable reservoir.

A surgical procedure to rectify a disorder causing incontinence

in an otherwise fit and healthy person often is highly

successful, and even after spinal cord injury a surgical option

may be the best solution for long-term bladder management.

This does not apply, however, in patients with progressive

neurological disease causing incontinence.

For example, at a time when the bladder is becoming

unmanageable by a combination of intermittent catheterization

and an anticholinergic, the patient with MS may only just be

managingto remain independent. This is not the moment to

suggest major urological surgery, and in practice few patients

with progressive neurological disease affecting bladder control

opt for surgery. With the advent of botulinum toxin A, some of

these debilitating symptoms can now be better controlled

Urological Operations That May Be Performed to

Treat Various Causes of Incontinence

Pelvic floor exercise, also known as Kegel exercise, consists of repeatedly

contracting and relaxing the muscles that form part of the pelvic floor, now

sometimes colloquially referred to as the "Kegel muscles"

Can thiệp hành vi: tái huấn luyện bàng quang khởi động