• Therapy to Facilitate Bladder Filling and Urine Storage
  • Bladder related (inhibiting bladder contractility/decreasing sensory input/ increasing bladder capacity)
    • Augmentation cystoplasty
  • Outlet related (Increasing outlet resistance)
    • Vesicourethral urethral suspension with or without prolapse repair (female)
    • Sling procedures
    • TVT - tension free vaginal tape
    • Bladder outlet reconstruction
    • Artificial urinary sphincter
    • Closure of the bladder outlet
    • Urinary diversion

• Therapy to Facilitate Bladder Emptying and Voiding
• Bladder related (increasing intravesical pressure or facilitating bladder contractility)
  • Reduction cystoplasty
• Outlet related (decreasing outlet resistance)
  At the level of the smooth sphincter
  • Transurethral resection or incision of the bladder neck/smooth sphincter
  • Y-V plasty of the bladder neck
  
  At the level of the striated sphincter
  • Surgical sphincterotomy
  • Urethral stent
  • Pudendal nerve interruption

   

References

• Abrams P: Urodynamics, 2nd ed. London, Springer, 1997.
• Andersson K-E, Appell R, Cardozo L, et al: Pharmacological treatment of urinary incontinence. In: Abrams P, Khoury S, Wein A, eds. Incontinence. 1st International Consultation on Incontinence, June 28-July 1, 1998, Monaco. Co-sponsored by World Health Organization and International Union Against Cancer. Health Publications Ltd., 1999, pp 449-486, distributed by Plymbridge Distributors, Ltd.
• Brading AF, Fry CA, Maggi M, et al: Cellular biology. In: Abrams P, Khoury S, Wein A, eds. Incontinence. 1st International Consultation on Incontinence, June 28-July 1, 1998, Monaco. Co-sponsored by World Health Organization and International Union Against Cancer. Health Publications Ltd., 1999, pp 59-103, distributed by Plymbridge Distributors, Ltd.
• deGroat WC, Downie JW, Levin RM, et al: Basic neurophysiology and neuropharmacology. In: Abrams P, Khoury S, Wein A, eds. Incontinence. 1st International Consultation on Incontinence, June 28-July 1, 1998, Monaco. Co-sponsored by World Health Organization and International Union Against Cancer. Health Publications Ltd., 1999, pp 107-154, distributed by Plymbridge Distributors, Ltd.
• Nitti V: Practical Urodynamics. Philadelphia, Saunders, 1998.
• Rovner ES, Wein AJ: Pharmacologic treatment for non-BPH induced voiding dysfunction: Facilitation of bladder emptying, part 1. AUA Update Series. Houston, American Urological Association, Inc., vol. 17, lesson 33, pp 258-265, 1998.
• Rovner ES, Wein AJ: Pharmacologic treatment for non-BPH induced voiding dysfunction: facilitation of urine storage, part II. AUA Update Series. Houston, American Urological Association, Inc., vol. 17, lesson 34, pp 266-272, 1998. Steers WD: Physiology and pharmacology of the bladder and urethra. In: Walsh P, Retik A, Vaughan ED, Jr., Wein AJ, eds. Campbell's Urology, 7th ed. Philadelphia, Saunders, 1997, pp 870-916.
• Steers WD, Barrett DM, Wein AJ: Voiding dysfunction: Diagnosis, classification, and management. In: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW, eds. Adult and Pediatric Urology. St. Louis, Mosby-Yearbook, Inc., 1996, pp 1220-1326.
• Wein AJ: Pathophysiology and categorization of voiding dysfunction. In: Walsh P, Retik A, Vaughan ED, Jr., Wein AJ, eds. Campbell's Urology, 7th ed. Philadelphia, Saunders, 1997, pp 917-926.
• Wein AJ: Neuromuscular dysfunction of the lower urinary tract and its treatment. In: Walsh P, Retik A, Vaughan ED, Jr., Wein AJ, eds. Campbell's Urology, 7th ed. Philadelphia, Saunders, 1997, pp 953-1006. li
• Wein AJ, Barrett DM: Voiding Function and Dysfunction: A Logical and Practical Approach. New York, Year Book Medical Publishers, Inc., 1988. Wein AJ, Rovner, ES: Adult voiding dysfunction secondary to neurologic disease or injury. AUA Update Series. Houston, American Urological Association, Inc., vol. 18, lesson 6, 1999, pp 42-27.
• Wilson PD, Bo K, Bourcier A, et al: Conservative management in women. In: Abrams P, Khoury S, Wein A, eds. Incontinence. 1 st International Consultation on Incontinence, June 28-July 1, 1998, Monaco. Co-sponsored by World Health Organization and International Union Against Cancer. Health Publications Ltd., 1999, pp 581-636, distributed by Plymbridge Distributors, Ltd.
• Zderic SA, Levin RM, Wein AJ: Voiding function: Relevant anatomy, physiology, pharmacology and molecular aspects. In: Gillenwater JY, Grayhack JT,
• Howards SS, Duckett JW, eds. Adult and Pediatric Urology. St. Louis, Mosby-Yearbook, Inc., 1996, pp 1159-1219.

SELF-ASSESSMENT QUESTIONS

1. Regardless of differences regarding physiologic and pharmacologic details, what would most experts agree are the requirements for normal bladder filling and storage? Discuss the main points relating to the anatomy, neurophysiology, and neuropharmacology of each of these factors.
2. Regardless of differences regarding physiologic and pharmacologic details, what would most experts agree are the requirements for normal bladder emptying and voiding? Discuss the main points relating to the anatomy, neurophysiology, and neuropharmacology of each of these factors.
3. Broadly generalize the differences between the autonomic and somatic nervous systems. Discuss the terms parasympathetic and sympathetic.
4. What are the primary neurotransmitters released at postganglionic, parasympathetic, and sympathetic effector sites in the lower urinary tract? Discuss the distribution and the results of activation of the cholinergic and adrenergic receptors in lower urinary tract smooth muscle.
5. Discuss the differences in organization of the micturition reflex in a normal adult and in an adult with a T10 spinal cord transection following spinal shock.
6. Categorize each urodynamic study (flowmetry, residual urine, filling and voiding cystometry, detrusor and abdominal [Valsalva] leak point pressures, urethral profilometry, and electromyography) as to what they characterize with respect to bladder and outlet activity during the filling and storage and emptying and voiding phases of micturition.
7. Characterize the most common types of voiding dysfunction seen with the following neurologic injury(ies) and disease(s) in terms of sensation, bladder activity, smooth sphincter activity, striated sphincter activity: (1) cerebrovascular accident; (2) Parkinson's disease; (3) multiple sclerosis; (4) suprasacral spinal cord injury; (5) sacral spinal cord injury; (6) radical pelvic surgery; and (7) diabetes.
8. Discuss the usual types of management employed in the treatment of the voiding dysfunctions in question 7.
9. Describe and discuss the use of pressure flow urodynamic studies and video urodynamic studies.
10. Excluding extraurethral incontinence and incontinence due to lack of concern or to cognitive dysfunction, discuss the basic pathophysiology of urinary incontinence in the adult.
11. Discuss the classic differentiation between genuine stress urinary incontinence and intrinsic sphincter deficiency and the therapeutic implications of each.
12. Discuss the normal support mechanism(s) of the bladder neck and proximal urethra in the female and the various theories of pathophysiology of hypermobility related stress incontinence.
13. Discuss the possibilities and practicalities of pharmacologic therapy for (1) bladder overactivity; (2) decreased outlet resistance; (3) increased outlet resistance; and (4) decreased bladder contractility.
14. Discuss the theory(ies) behind the use of peripheral and central electrical stimulation in the treatment of bladder overactivity.
15. Discuss the surgical options for treating sphincteric incontinence in adult men.

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