排尿障礙治療中心 版權所有 The Spastic Sphincter Hann-Chorng Kuo Department of Urology...
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排排排排排排排排 排排排排 The Spastic The Spastic Sphincter Sphincter Hann-Chorng Kuo Hann-Chorng Kuo Department of Urology Department of Urology Buddhist Tzu Chi General H Buddhist Tzu Chi General H ospital ospital
排尿障礙治療中心 版權所有 The Spastic Sphincter Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital
The Spastic Sphincter Hann-Chorng Kuo Department of Urology
Buddhist Tzu Chi General Hospital
Slide 2
Function of urethral sphincter Provide adequate urethral
resistance at filling phase to prevent incontinence Provide
adequate urethral resistance at filling phase to prevent
incontinence Active relaxation during voiding phase for micturition
Active relaxation during voiding phase for micturition Inhibition
of detrusor nucleus to postpone voiding before threshold Inhibition
of detrusor nucleus to postpone voiding before threshold Release of
inhibitory effect on detrusor nucleus at initiation of voiding
(on-off switch) Release of inhibitory effect on detrusor nucleus at
initiation of voiding (on-off switch)
Slide 3
Anatomy of male urethral sphincter
Slide 4
Anatomy of Female Urethral sphincter
Slide 5
Toilet training A learning process influences voiding
Traditional voiding control by age 3 Traditional voiding control by
age 3 CNS plasticity and adaptation to sensory input of micturition
process CNS plasticity and adaptation to sensory input of
micturition process Retentive behavior of children Retentive
behavior of children Parent pushing of toilet training Parent
pushing of toilet training Behavioral stress to muscles and change
in functional integrity of tissue Behavioral stress to muscles and
change in functional integrity of tissue
Slide 6
The overactive sphincter Incorrect conditioning of voiding
reflexes during CNS maturing Incorrect conditioning of voiding
reflexes during CNS maturing Symptoms ranging from incontinence to
retention Symptoms ranging from incontinence to retention Chronic
LUT dysfunction is maintained by permanently up-regulated sacral
reflex arcs Chronic LUT dysfunction is maintained by permanently
up-regulated sacral reflex arcs Dysfunctional voiding develops
Dysfunctional voiding develops
Slide 7
The Pelvic Floor Deep layer Levator ani provide relaxation
during micturition and defecation (S3,4), contraction to lift
pelvic organ upward and compression Deep layer Levator ani provide
relaxation during micturition and defecation (S3,4), contraction to
lift pelvic organ upward and compression Transverse perinealis,
ischeocavernous, bulbocavernous, urethral sphincter, anal sphincter
muscles (S2) provide squeezing effect on pelvic organs Transverse
perinealis, ischeocavernous, bulbocavernous, urethral sphincter,
anal sphincter muscles (S2) provide squeezing effect on pelvic
organs
Slide 8
Anatomy of Pelvic Floor
Slide 9
Innervation of Pelvic Floor Perineal skin sensation from S2
nerve Perineal skin sensation from S2 nerve Skin sensation can be
impaired unilaterally or bilaterally in S2 nerves Skin sensation
can be impaired unilaterally or bilaterally in S2 nerves Loss of
skin sensation often reflects a loss of urethral sphincter
integrity Loss of skin sensation often reflects a loss of urethral
sphincter integrity Deficits in S3,4 nerves are not associated with
significant incontinence Deficits in S3,4 nerves are not associated
with significant incontinence Hypersensitivity of bladder is often
mirrored hypersensitivity of the levator (S3,4) Hypersensitivity of
bladder is often mirrored hypersensitivity of the levator
(S3,4)
Slide 10
Neuroregulation of sacral nerves in micturition reflex Loss of
pudendal afferent input can dampen the detrusor reflex Loss of
pudendal afferent input can dampen the detrusor reflex Enhanced
afferent input to micturition center can augment detrusor reflex
Enhanced afferent input to micturition center can augment detrusor
reflex Supraspinal inhibition or increased inhibitory input to
micturition center can suppress detrusor reflex Supraspinal
inhibition or increased inhibitory input to micturition center can
suppress detrusor reflex Chronic anxiety or via behavioral pathway
can cause loss of volitional or ability to relax the sphincter with
void efforts Chronic anxiety or via behavioral pathway can cause
loss of volitional or ability to relax the sphincter with void
efforts
Slide 11
Pathophysiology of pelvic floor dysfunction Changes in peptide
release from nerve endings secondary to stress (supraspinal)
Changes in peptide release from nerve endings secondary to stress
(supraspinal) Enhanced release of inflammatory or
neural-sensitizing peptides into tissue (local inflammation)
Enhanced release of inflammatory or neural-sensitizing peptides
into tissue (local inflammation) Inadequate pelvic floor control
due to learned behavior (dysfunctional voiding) Inadequate pelvic
floor control due to learned behavior (dysfunctional voiding)
Slide 12
Detrusor instability and Holding urine during involuntary
DI
Slide 13
CNS Control of Pelvic floor Medial part of dorsal pontine
tegmentum (M- region) sphincter relaxation and detrusor contraction
Medial part of dorsal pontine tegmentum (M- region) sphincter
relaxation and detrusor contraction Lateral part of pontine
tegmentum sphincter contraction and detrusor inhibition Lateral
part of pontine tegmentum sphincter contraction and detrusor
inhibition Onuf s nucleus spinal control center of pelvic floor
linkage to paraventricular nucleus Onuf s nucleus spinal control
center of pelvic floor linkage to paraventricular nucleus
Slide 14
Micturition and Continence center in CNS
Slide 15
Central peptide pools linked to CNS centers regulating LUT
function Paraventricular peptide pool Vasopressin, oxytocin,
substance P Somatostatin, dopamine, neurotensin Glucagon, renin
Corticotropin-releasing factor Met- and leu-enkephalin Nucleus Onuf
peptides (for sphincter control) Somatostatin, neuropeptide Y,
serotonin Substance P (from paraventricular nucleus, dorsal and
ventral roots) Met-and leu-enkephalin
Slide 16
Neurobiological background of pelvic floor dysfunction
Slide 17
Clinical assessment of a hypertonic pelvic floor LUT Symptoms
frequency, urgency, suprapubic, perineal, deep pelvic pain, lower
backpain, slow stream, intermittency, recurrent UTI, retention LUT
Symptoms frequency, urgency, suprapubic, perineal, deep pelvic
pain, lower backpain, slow stream, intermittency, recurrent UTI,
retention Constipation or difficult defecation Constipation or
difficult defecation Sexual dysfunction Sexual dysfunction Insomnia
and other somatic complaints Insomnia and other somatic
complaints
Slide 18
Important past history Current symptoms? Since when?
development over the last time? change in last time? Pain? Where?,
character?, intensity (using visual analog scale 0-10), Change over
time? Micturition? Any problems?, double voiding?, infections?m
burning?, inability to void? Defecation? Frequency, consistency
Sexual life? Dysfunction?, emotional problems?, female: vaginism?
Childhood prolonged bedwetting?, excessive exercises to achieve
early urinary continence?, punishment for bedwetting?, retentive
voiding habits (I.e.,low micturition frequency?), sexual abuse
(female)? Adolescence Female:painful menses?,frequent urinary tract
infections? Male:urinary tract infections Adulthood Female:
childbirths?, vaginal delivery?, pelvic surgery?, infections?,
voiding habits over time,profession, personal satisfaction
Male:voiding habits, profession,social life
Slide 19
Hypertonic pelvic floor = hypertonic urethral sphincter?
Urethral sphincter and external anal sphincter are mainly
innervated by S2 Urethral sphincter and external anal sphincter are
mainly innervated by S2 Levator ani are innervated by S3,4 Levator
ani are innervated by S3,4 Reflex coordination to bladder sensory
input is synchronized in most of cases Reflex coordination to
bladder sensory input is synchronized in most of cases Isolated
denervation or impairment in conduction may occur Isolated
denervation or impairment in conduction may occur
Slide 20
Hypertonic urethral sphincter Straining to initiate
voiding
Slide 21
Hypertonic urethral sphincter Straining to open urethra
Slide 22
Hypertonic urethra = hyperactive urethra? Hypertonic urethra
indicates increased and sustained urethral pressure (tonic) during
resting state Hypertonic urethra indicates increased and sustained
urethral pressure (tonic) during resting state Hyperactive urethra
indicates increased activity of urethral sphincter during voiding
state Hyperactive urethra indicates increased activity of urethral
sphincter during voiding state A spastic urethral sphincter causes
difficulty in initiation of voiding A spastic urethral sphincter
causes difficulty in initiation of voiding
Slide 23
Hyperactive urethral sphincter during initiation &
voiding
Slide 24
SCI with type 1 DESD and low detrusor contractility
Slide 25
States of dysfunctional voiding due to spastic sphincter 1.
Fill phase (normally very stable pressure 60-80 cmH 2 O) Pathology
High sphincter pressure (>80) Hypersensitivity Clonic or
hyperreflexic dynamic Spasms (pain)versus spontaneous relaxations
(leakage episodes) 2.Transition phase (normally smooth)
PathologyNonrelaxation Hesitant/delayed relaxation Precipitous
relaxation Aborted relaxation Rising sphincter pressures 3.Void
phase (normally coordinated) Pathology Partial relaxations
Intermittency of sphincter relaxation 4.Recovery stage (normally
smooth) Pathology Intermittency (dribbling)
Slide 26
Clinical assessment of pelvic floor muscle function Uterine
prolapse or cystocele Uterine prolapse or cystocele Sensation of
perineal skin Sensation of perineal skin Anal tone measurement Anal
tone measurement Volitional contraction of pelvic floor Volitional
contraction of pelvic floor Search for inflammatory sources
(hemorrhoid, prostatitis, vaginitis) Search for inflammatory
sources (hemorrhoid, prostatitis, vaginitis) Focal neurological
findings (Bulbocavernous reflex, deep tendon reflex) Focal
neurological findings (Bulbocavernous reflex, deep tendon
reflex)
Slide 27
Digital rectal examination of Pelvic floor muscles Deep and
superficial sphincter muscle tone, weak, high, or normal? Deep and
superficial sphincter muscle tone, weak, high, or normal?
Hypersensitivity or tenderness of the levator or urethral sphincter
Hypersensitivity or tenderness of the levator or urethral sphincter
Motor identity of sphincter muscles or levator ani muscles Motor
identity of sphincter muscles or levator ani muscles Voluntary
repetitive contractions of sphincter and levator muscles Voluntary
repetitive contractions of sphincter and levator muscles
Slide 28
Tentative diagnosis of pelvic floor hypertonicity Spastic
urethral sphincter a chronic hypertonic urethral sphincter causing
functional bladder outlet obstruction Spastic urethral sphincter a
chronic hypertonic urethral sphincter causing functional bladder
outlet obstruction Poor relaxation of pelvic floor muscles
inadequate relaxation during voiding causing hesitancy, low
intermittent flow Poor relaxation of pelvic floor muscles
inadequate relaxation during voiding causing hesitancy, low
intermittent flow Non-relaxing pelvic floor or urethral sphincter
-- no relaxation during voiding efforts by abdominal straining or
Valsalva maneuver Non-relaxing pelvic floor or urethral sphincter
-- no relaxation during voiding efforts by abdominal straining or
Valsalva maneuver
Slide 29
Diagnosis based on initial investigations LUT symptoms LUT
symptoms Negative urinalysis or urine culture Negative urinalysis
or urine culture High pelvic floor muscle tone High pelvic floor
muscle tone Low maximal flow rate and obstructive intermittent flow
pattern Low maximal flow rate and obstructive intermittent flow
pattern No evidence of BPH or other pathology No evidence of BPH or
other pathology Voiding diary verified LUTS Voiding diary verified
LUTS
Urodynamics Uroflowmetry & EMG Uroflowmetry & EMG
Cystometrogram & EMG Cystometrogram & EMG Pressure flow
study Pressure flow study Videourodynamic study Videourodynamic
study Urethral pressure profilometry Urethral pressure profilometry
Pudendal nerve latency time Pudendal nerve latency time Evoke
potential study Evoke potential study
Slide 32
Intermittent Flow
Slide 33
Relaxation of urethral sphincter at initiation of voiding
Slide 34
Poor relaxation of urethral sphincter during voiding
Slide 35
Intermittency due to poor relaxation of ES
Slide 36
Pseudodyssynergia in CVA causing high voiding pressure
Slide 37
Inhibition of detrusor contraction by urethral sphincter during
voiding
Slide 38
Stop test volitional sphincter contraction and inhibition of
voiding
Slide 39
Guarding reflex during uninhibited detrusor contractions
Slide 40
Coordinated sphincter activity during filling phase in
Enterocystoplasty
Slide 41
Increased sphincter activity causing isolated obstruction in
detrusor areflexia
Slide 42
DHIC and increased sphincter activity during filling
Slide 43
Detrusor overactivity and overactive sphincter & pelvic
floor
Slide 44
Type I DESD in C5,6 SCI
Slide 45
Type II DESD in Thoracic SCI
Slide 46
Urethral sphincter v Pelvic floor muscles analogue?
Slide 47
Discoordinated urethral sphincter in dysfunctional voiding
Slide 48
Chronic pelvic floor spasticity A cause of pelvic pain?
Increased muscle tone of pelvic floor muscles Spasticity of
urethral sphincter Spasticity of external anal sphincter
Hypertonicity of pyriformis muscles Fascitis of pubococcygeus or
coccygeus muscles Physiotherapy and medication for pelvic floor
spasticity can relieve pelvic pain Should search for tendered
points or infection
Slide 49
Chronic prostatitis syndrome Symptoms of frequency, urethral
irritation, hesitancy, intermittency, residual urine sensation,
perineal pain and lower back pain Symptoms of frequency, urethral
irritation, hesitancy, intermittency, residual urine sensation,
perineal pain and lower back pain Spastic urethral sphincter might
be a cause of chronic prostatitis or reflux abacterial prostatitis
Spastic urethral sphincter might be a cause of chronic prostatitis
or reflux abacterial prostatitis Treated as spastic sphincter may
work Treated as spastic sphincter may work
Slide 50
Spastic urethral syndrome and constipation Chronic constipation
causes hypertonic anal sphincter and hence, pelvic floor muscles
Chronic constipation causes hypertonic anal sphincter and hence,
pelvic floor muscles Poor relaxation of pelvic floor muscles
results in inhibition of detrusor contractions during voiding Poor
relaxation of pelvic floor muscles results in inhibition of
detrusor contractions during voiding Concomitant treatment of
constipation can relieve voiding symptoms Concomitant treatment of
constipation can relieve voiding symptoms
Slide 51
Treatment of spastic urethral sphincter Behavioral therapy:
hydration, laxatives, time voiding, changing voiding posture
Behavioral therapy: hydration, laxatives, time voiding, changing
voiding posture Physiotherapy: pelvic floor muscle exercises
Physiotherapy: pelvic floor muscle exercises Electric stimulation :
interferential current stimulation Electric stimulation :
interferential current stimulation Biofeedback: visual or
Uroflowmetry & EMG Biofeedback: visual or Uroflowmetry &
EMG Medication: baclofen, alpha-adrenergic blockers, estrogen,
combination therapy Medication: baclofen, alpha-adrenergic
blockers, estrogen, combination therapy Urethral injection of
botulinum A toxin Urethral injection of botulinum A toxin
Slide 52
Therapeutic results of baclofen and terazosin in treatment of
spastic urethral sphincter IPSSQmax Residual urine
BaselineTratedBaselineTreatedBaselineTreated Baclofen (n=73)
15.26.710.45.714.39.716.78.165.733.937.521.7 % of change
31.621.516.8712.742.934.1 Baclofen plus
12.77.961.4.514.811.022.677.558.121.831.0131.2 Terazosin (n=64) %
of change 51.727.452.731.146.529.3 Statistics*P