sat elisabeth basics on bladder and bowel

8/11/2019 Sat Elisabeth Basics on Bladder and Bowel

1/34

Basics on Bladder and Bowel

A quick journeythrough some of ourrecent new insights onthe nervous system,the lower urinary tractand gastrointestinaltract


2/34

En frebild fr framtidens rehabilitering


Basics on bladder and bowel physiology

some recent new insights onnervous control of bladder and bowel

storage and voiding functions

independence and living a good life!


3/34

Bladder and Bowel physiology


4/34

Bladder and Bowel physiology


5/34

Early development of bladder

- Production of urine startsin gestational week 12-14

-

-Bladder capacity at birtharound 30 ml

- Age 15-16 adult capacityof 400-500ml

- In neonates bladderemptying is dyscoordinated

Ref Gladh, Persson, et al. (2000).


6/34

Early development and maturation ofbladder control

! Dyscoordination fadeswithin first year asnervous systemmatures

! Age 1-2 a child canreport sensation ofbladder filling

! Age 4 voluntary controlof initiation and

inhibition of micturitionreflex! The importance of

sensation!

Ref Jansson, Hanson, et al. (2005).


7/34

Early development of bowel

- Anorectal canal formsaround gestational week

7-9

- Neuromuscular apparatusof the gastrointestinal tract

develops early in the fetus- Normal patterns ofinnervation and contractileactivity are achieved nearbirth


8/34

Early development and maturation ofbowel control

! Age 1-2 a child canreport sensation ofbowel filling

! Age 2-4 voluntarycontrol of initiation andinhibition of bowelemptying

! First sensation of rectalfilling at about 45 ml,

need to defecate fromabout 90 ml

! The importance ofsensation!


9/34


10/34

The mature micturition reflex

Fowler and Griffiths 2010

Storage


11/34


Fowler and Griffiths 2010

Voiding


12/34

The mature bowel reflexeso Intrinsic nervous system

in submucosa of bowelwall coordinates motility,secretion, absorption

o Extrinsic nervous systemmodulates intrinsicsystem and is involved involuntary control ofdefecation

o Complex sensory/sampling mechanism for

gas, liquids and solidso Pelvic nerves and

sympathetic nerves signalfullness of rectum " spinal cord " brain


13/34

Basics on storage and voidingfunctions

* Bladder storage/ fillingphase:Bladder = low pressure reservoirUrethral sphincter muscle staysclosedPelvic floor muscles contract

Storage of reasonablevolume for reasonablelength of time


14/34


* Bladder voidingphase:

Bladder contracts, bladder neckopens, contraction continues untilbladder completely empty

Urethral sphincter relaxed, staysopen throughout emptying phase

Pelvic floor muscles relaxed

Complete emptying


15/34


* Bowel storage/filling phase:Rectum = low pressurereservoir

Internal anal sphincter musclestays closed but relaxes whencontents pass down into upperanal canalExternal anal sphincter staysclosed

Pelvic floor muscles contract

Storage of reasonablevolume for reasonable lengthof time


16/34


* Bowel voidingphase:Can be started by voluntaryincrease in abdominal pressureInternal anal sphincter relaxes

External anal sphincter relaxesby voluntary controlPelvic floor muscles relaxSlight contraction of rectum

Complete emptying


17/34

Residualurin Infektioner

Stenbildning Neurogen veraktiv blsa +/- hgtintravesikalt tryck Njurskada Inkontinens

Complications of bladder andbowel dysfunction

! Bladder


18/34

Complications of bladder andbowel dysfunction

! Bladder

! Incontinence! Residual urine! Infections! Stone formation! Neurogenic overactivity/

decreased elasticity ofbladder +/- increasedintravesical pressure

! Kidney impairment

! Bowel

! Incontinence

! Constipation


19/34

How do we achieve the basicfunctions of storage and voiding?

A toolbox of treatmentpossibilities


20/34

Whats 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


21/34


22/34

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 presymposiumNosCos biannual congress 2011


23/34

Surgical options for bladder function

Reconstructive surgery

- Bladder augmentation+/- mitrofanoff+/- artificial urinary sphincter

- urinary diversion( urostomi/ urinreservoar)

Botulinumtoxin


24/34

veraktiv blsa blsfrstoring med ileocystoplastik


25/34

AMS-800 = Scottprotes


26/34


27/34

Surgical options for bowel function

Reconstructive surgery

- ACE procedure (irrigationstoma)

- Chait catheter stoma forirrigation

- colostomy

Botulinumtoxin treatment of stiff/spastic anal sphincter


28/34

And how do we preservekidney function?

By maintaining bladder function with# storage at low pressure# complete emptying at regular intervals

A matter of survival and quality of life!


29/34



Increased understanding of

bladder and bowel function " improvedmanagement by individuals and healthprofessionals

Practical and technical aids forcontinence and voiding emptying areavailable and important!

Practical and technical aids for memoryand organisation are of great importance!

Pharmaceutical and surgical options arewell established and should be availablewhen needed


30/34



Increased understanding of

bladder and bowel function " improvedmanagement by individuals and healthprofessionals

Practical and technical aids forcontinence and voiding emptying areavailable and important

Practical and technical aids for memoryand organisation are of great importance!

Pharmaceutical and surgical options arewell established and should be availablewhen needed


31/34


... and remember

Treat the bladderas your friendand have a good life ...

Treat the kidneysas your friends and have a long life!



32/34


33/34


Neurogen blsrubbning ngra exempel

Fig. 2. A. Normal pattern of responses (activations) to infusion causingstrong sensation, shown in sagittal, coronal and axial sections. B. Responses inurge incontinence, with strong sensation (urgency?) but with no detrusor overactivity:activation in orange, deactivation in blue; shown in sagittal section.Griffiths and Tadic 2010


34/34

From a mechanistic view towards a more dynamic andfunctional 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

New insights on the brain-bladderconnection ....

sat elisabeth basics on bladder and bowel

Documents