ALT

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ALT ÜRINER SISTEM FIZYOLOJISI VE PATOFIZYOLOJI

• Doç.Dr.Semih Ayan

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AÜS- Anatomi
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Miksiyon fizyolojisi- Anatomi

• Iseme merkezinin beyindeki lokalizasyonu
• Frontal lob (iseme merkezi)
• Iseme merkezinin primer fonksiyonu
• detrusor kasina inhibitör sinyaller göndererek
  kasilmasini engellemek, istenen miksiyon zamanina
  kadar idrar depolanmasini saglamak.

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Pons

• Miksiyon kontrolünde Beyin ile mesane arasindaki
  ikinci merkez
• Pons (Pontin iseme merkezi)
• Ponsun fonksiyonu?
• Mesane ile sfinkterlerin uyum içinde çalismasini
  saglamak mesane kasilirken üretral sfinkter
  gevsemeli-

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PMC

• Mesane dolulugu ? detrusor kasinda gerilme
  reseptörlerinin çalismasi ? ponsa sinyal ? beyin
• Beyinden pons gelen inhibitör yanit ile uygun
  ortam bulunana kadar isemenin bekletilmesi için
  mesane kasilmalarinin durmasi
• Uygun ortam bulundugunda beyinden ponsa eksitatör
  sinyaller yollanarak isemeye izin verilmesi

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PMC

• PMCnin eksitasyonu ile
• Uretral sfinkter?
• açilma
• Detrusor?
• kasilma
• Beyinin ponsun kontrolünü saglamasi
• 2 - 4 yas

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PMCden sonraki merkez.

• Spinal kord

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Spinal Kord

• Fonksiyonu
• Mesaneden duyusal uyari ? Sakral kord ? Pons ?
  Beyin ? Pons ? Spinal kord ? Sakral kord ? Mesane
• Ponsla sakral kord arasindaki yolagi saglar
• Normal iseme için spinal kord intakt olmali

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Spinal Kord

• Sakral spinal kord önemi?
• Sakral refleks merkezi
• Mesane kontraksiyonlarindan sorumlu
• Primitif iseme merkezi
• Infantlarda beyin ile mesane arasindaki kontrol
  henüz gelismemis iken mesane dolumu ile
  eksitatör sinyal ? sakral kord ? refleks merkezi
  ? istemsiz detrusor kontraksiyonlari

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Mesane nöroanatomisi

• Sempatik reseptörler
• Adrenerjik
• _ ?1
• Trigone, mesane boynu, urethra
• Mesane boynundaki düz kaslari kontrakte tutarak
  kontinansa katki
• ?2-Adrenerjikler
• Mesane boynu ve gövdesinde
• Isemede mesane boynunun gevsemesi
• Mesanenin depolanma için gevsetilmesi

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Mesane nöroanatomisi

• Parasempatik reseptörler
• Kolinerjik (Muskarinik)
• Anatomik yerlesim
• mesane, trigon, mesane boynu, uretra

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Miksiyon fizyolojisi

• istirahatte, mesane ve mesane boynu sempatik
  sistemin kontrolünde
• Normal mesanede
• Detrüsor basincinda artma olmadan kapasite
  artabilmeli
• Dolum esnasinda mesane boynu kapali kalabilmeli
• Parasempatik stimülasyon inhibe edilerek iseme
  refleksi bastirilabilmelidir

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Miksiyon fizyolojisi

• Miksiyon istendiginde
• Parasempatik sistem aktivasyonu
• Sempatik sistem etkisinin kalkmasi ile Detrusor
  kontraksiyonu ve mesane boynu açilmasi
• Pudendal sinir inhibisyonu ? eksternal sfinkter
  açilmasi ? istemli miksiyon

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Miksiyon fizyolojisi

• Somatik sistem (Pudendal sinir)
• Eksternal uretral sfinkter
• Pelvik dösemeyi innerve eder
• S2-S4deki Onuf nükleusundan köken alir
• pudendal sinir aktivasyonu ? eksternal sfinkter
  ve pelvik taban kaslarinin kontraksiyonu

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Miksiyon fizyolojisi

• Normal mesane fizyolojisinin iki fazi vardir
• Dolum (depolama) (sempatik kontrol)
• Mesane boynu ve üretral sfinkter kapali
• Düsük basinçla gelen idrar için saglanan kapasite
• Bosaltim (parasempatik kontrol)
• Detrusor konraksiyonu
• Mesane boynu ve Sfinkterin açilmasi

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Sistogram
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Ürodinami

• Dolum sistometrisi
• Basinç-akim çalismasi
• Elektromyografi
• Videosistoüretrografi

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Stabil Mesane
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Detrusor Hiperaktivitesi
The normal detrusor if filled slowly accepts 300
- 600 ml without rise in pressure. If the bladder
undergoes phasic contraction while the patient is
trying to inhibit voiding this is called Detrusor
overactivity. Note the low bladder capacity
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Düsük kompliyansli mesane
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Nörojenik Detrusor Hiperaktivitesi
Cystometry Neurogenic detrusor overactivity is
overactivity in the presence of confirmed
neuropathy in this case Multiple Sclerosis. Often
the detrusor is unstable without sensation and
the pressure involved tend to be higher than
idiopathic instability
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Sistoskopi

• Nedeni aydinlatilamayan irritatif iseme
  semptomlari
• Mesane kanseri süphesi
• Mesane boynunun degerlendirilmesi
• Mesanede tas, yabanci cisim varligi süphesi

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Problemler

• siniflama
• Mesaneden kaynaklanan depolama problemi
• Mesane çikimindan kaynaklanan depolama
  problemleri
• Mesaneden kaynaklanan bosaltma problemi
• Mesane çikimindan kaynaklanan bosaltma problemi

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Medications

• Alpha-adrenergic drugs
• Location - Bladder neck receptors
• Function - Increase bladder outlet resistance by
  contracting the bladder neck
• Example - pseudoephedrine

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Medications

• Estrogen derivatives
• Mechanism - Increases the tone of urethral muscle
  by up-regulating the alpha-adrenergic receptors
  in the surrounding area
• Mechanism - Enhances alpha-adrenergic contractile
  response to strengthen pelvic muscles
• Use inStress incontinence

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Medications

• Anticholinergic drugs
• Function - Inhibit involuntary bladder
  contractions
• Adverse effects
• Blurred vision
• Dry mouth
• Heart palpitations
• Drowsiness
• Facial flushing
• Ex. Pro-banthine, Levsin

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Medications

• Antispasmodic drugs
• Function - Relax the smooth muscles of the
  urinary bladder
• Function - Direct spasmolytic action on the
  smooth muscle of the bladder
• Adverse effects similar to anticholinergic agent
• Impaired mental alertness and physical
  coordination
• Ex. Ditropan, Detrol

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Medications

• Tricyclic antidepressant drugs
• Mechanism - Increase norepinephrine and
  serotonin levels
• Mechanism - Anticholinergic and direct muscle
  relaxant effects on the urinary bladder
• Ex. elavil

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Pathophysiology

• Brain Lesions stroke, tumor, CP, Parkinsons
  disease, hydrocephalus
• Above the pons
• Destroys the master control center, causing a
  complete loss of voiding control
• Primitive voiding reflex remains intact
• S/Sx
• Urge incontinence or spastic bladder
• Bladder empties too often with relatively low
  quantities
• Storing urine in the bladder is difficult

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Pathophysiology

• SCI (after resolution of spinal shock)
• Urge incontinence
• External sphincter may have paradoxical
  contractions
• Detrusor-sphincter dyssynergia

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Pathophysiology

• Peripheral nerve injury - Diabetes mellitus,
  severe genitoanal herpes, pernicious anemia,
  neurosyphilis, and AIDS
• Result in silent/painless urinary retention
• DM - lose the sensation of bladder filling first,
  then difficulty urinating

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CVA

• Brain may enter into a temporary acute cerebral
  shock phase
• Bladder retention with detrusor areflexia
• Then detrusor hyperreflexia with coordinated
  urethral sphincter activity
• PMC released from the cerebral inhibitory center
• S/Sx
• Urinary frequency, urgency, and urge
  incontinence
• Treatment
• Early indwelling catheter or CIC
• Hyperreflexia Timed void anticholinergics

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Brain Tumor

• Detrusor hyperreflexia with coordinated urethral
  sphincter
• S/Sx
• Urinary frequency
• Urgency
• Urge incontinence
• Treatment
• Anticholinergics

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Parkinsons Disease

• Characterized by detrusor hyperreflexia and
  urethral sphincter bradykinesia
• S/Sx
• Urinary frequency
• Urgency
• Nocturia
• Urge incontinence
• Treatment
• Anticholinergic agents

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Multiple Sclerosis

• Focal demyelinating lesions of the CNS often
  involve the posterior and lateral columns of the
  C spinal cord
• Poor correlation between the clinical symptoms
  and urodynamic findings
• UD
• Detrusor hyperflexia (50-90 with MS)
• Approx 50 demonstrate DSD-DH
• 20-30 have detrusor areflexia
• Treatment individualized

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Diabetic cystopathy

• Usually, 10 years after the onset of DM
• Autonomic and peripheral neuropathy
• Segmental demyelination
• Impaired nerve conduction
• S/Sx
• Loss of sensation of bladder filling
• Loss of motor function
• Urodynamics
• Elevated residual urine
• Decreased bladder sensation
• Impaired detrusor contractility
• Detrusor areflexia.

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Herniated Disc

• Lumbar disc herniation ? irritation of the sacral
  nerves ? detrusor hyperreflexia
• Acute compression of sacral roots (trauma) ?
  detrusor areflexia.
• Urodynamics
• Sacral nerve injury
• Detrusor areflexia with intact bladder sensation
• ? internal sphincter denervation may occur
• Striated sphincter is preserved