Basics on Bladder and Bowel A quick journey through some of our recent new insights on the nervous system, the lower urinary tract and gastrointestinal tract
Basics on Bladder and Bowel Basics on bladder and bowel physiology some recent new insights on nervous control of bladder and bowel storage and voiding functions independence and living a good life! En förebild för framtidens rehabilitering
Bladder and Bowel physiology
Bladder and Bowel physiology
Early development of bladder - Production of urine starts in gestational week 12-14 - -Bladder capacity at birth around 30 ml - Age 15-16 adult capacity of 400-500ml - In neonates bladder emptying is dyscoordinated Ref Gladh, Persson, et al. (2000).
Early development and maturation of bladder control Dyscoordination fades within first year as nervous system matures Age 1-2 a child can report sensation of bladder filling Age 4 voluntary control of initiation and inhibition of micturition reflex The importance of sensation! Ref Jansson, Hanson, et al. (2005).
Early development of bowel - Anorectal canal forms around gestational week 7-9 - Neuromuscular apparatus of the gastrointestinal tract develops early in the fetus - Normal patterns of innervation and contractile activity are achieved near birth
Early development and maturation of bowel control Age 1-2 a child can report sensation of bowel filling Age 2-4 voluntary control of initiation and inhibition of bowel emptying First sensation of rectal filling at about 45 ml, need to defecate from about 90 ml The importance of sensation!
Congenital neurogenic bladder and bowel dysfunction Myelomeningocele - A defect in the normal closure of the neural tube in gest wk 3-4 - Leads to a mix of central and periferal nerve lesions Decreased pelvic floor muscle tone and control Decreased colonic motility/ longer colonic transit time Overactive detrusor neurogenic overactivity poor compliance Underactive detrusor areflexia or hyporeflexia Overactive urethral sphfincter Underactive anal sphincter Sensory defects - often more pronounced than motor defects Other frames of reference to body sensations (interoception) Underactive urethral sphincter
The mature micturition reflex Storage Fowler and Griffiths 2010
The mature micturition reflex Voiding Fowler and Griffiths 2010
The mature bowel reflexes o o o o Intrinsic nervous system in submucosa of bowel wall coordinates motility, secretion, absorption Extrinsic nervous system modulates intrinsic system and is involved in voluntary control of defecation Complex sensory/ sampling mechanism for gas, liquids and solids Pelvic nerves and sympathetic nerves signal fullness of rectum à spinal cord à brain
Basics on storage and voiding functions * Bladder storage/ filling phase: Bladder = low pressure reservoir Urethral sphincter muscle stays closed Pelvic floor muscles contract Storage of reasonable volume for reasonable length of time
Basics on storage and voiding functions * Bladder voiding phase: Bladder contracts, bladder neck opens, contraction continues until bladder completely empty Urethral sphincter relaxed, stays open throughout emptying phase Pelvic floor muscles relaxed Complete emptying
Basics on storage and voiding functions * Bowel storage/ filling phase: Rectum = low pressure reservoir Internal anal sphincter muscle stays closed but relaxes when contents pass down into upper anal canal External anal sphincter stays closed Pelvic floor muscles contract Storage of reasonable volume for reasonable length of time
Basics on storage and voiding functions * Bowel voiding phase: Can be started by voluntary increase in abdominal pressure Internal anal sphincter relaxes External anal sphincter relaxes by voluntary control Pelvic floor muscles relax Slight contraction of rectum Complete emptying
Complications of bladder and bowel dysfunction Bladder Residualurin Infektioner Stenbildning Neurogen överaktiv blåsa +/- högt intravesikalt tryck Njurskada Inkontinens
Complications of bladder and bowel dysfunction Bladder Bowel Incontinence Residual urine Infections Stone formation Neurogenic overactivity/ decreased elasticity of bladder +/- increased intravesical pressure Kidney impairment Incontinence Constipation
How do we achieve the basic functions of storage and voiding? A toolbox of treatment possibilities
What s in the toolbox? - physical activity and training, rehabilitation - drinking and eating habits - technical and incontinence devices - aids to memory and organisation of daily life - motivation
What s more in the toolbox? Pharmacological treatment - to hold urine - to empty the bladder - to treat infections - to decrease risk of recurring infections - to regulate consistency of faeces - to empty the bowel
And next in the toolbox? Surgical treatment - to hold urine - to empty bladder/urine - to decrease risk of recurring infections - to irrigate bowel - to empty bowel Elisabeth Farrelly Astra Tech presymposium NosCos biannual congress 2011
Surgical options for bladder function Botulinumtoxin Reconstructive surgery - Bladder augmentation +/- mitrofanoff +/- artificial urinary sphincter - urinary diversion ( urostomi/ urinreservoar)
Överaktiv blåsa blåsförstoring med ileocystoplastik
AMS-800 = Scottprotes
Artificiell sfinkter ballong cuff pump
Surgical options for bowel function Botulinumtoxin treatment of stiff/ spastic anal sphincter Reconstructive surgery - ACE procedure (irrigation stoma) - Chait catheter stoma for irrigation - colostomy
And how do we preserve kidney function? By maintaining bladder function with v storage at low pressure v complete emptying at regular intervals A matter of survival and quality of life!
Basics on Bladder and Bowel Increased understanding of bladder and bowel function à improved management by individuals and health professionals Practical and technical aids for continence and voiding emptying are available and important! Practical and technical aids for memory and organisation are of great importance! Pharmaceutical and surgical options are well established and should be available when needed En förebild för framtidens rehabilitering
Basics on Bladder and Bowel Increased understanding of bladder and bowel function à improved management by individuals and health professionals Practical and technical aids for continence and voiding emptying are available and important Practical and technical aids for memory and organisation are of great importance! Pharmaceutical and surgical options are well established and should be available when needed En förebild för framtidens rehabilitering
Basics on Bladder and Bowel... and remember Treat the bladder as your friend and have a good life... Treat the kidneys as your friends and have a long life! En förebild för framtidens rehabilitering
The mature micturition reflex Neurogen blåsrubbning några exempel Fig. 2. A. Normal pattern of responses (activations) to infusion causing strong sensation, shown in sagittal, coronal and axial sections. B. Responses in urge incontinence, with strong sensation (urgency?) but with no detrusor overactivity: activation in orange, deactivation in blue; shown in sagittal section. Griffiths and Tadic 2010
New insights on the brain-bladder connection... From a mechanistic view towards a more dynamic and functional view Important insights for ALL urologists in understanding bladder outlet problems in understanding pain syndromes in understanding the age factor in our patients in understanding the importance of co-morbidities in estimating outcomes post major surgery in combining treatment modalities