排尿障礙治療中心 版權所有 Physiology of Micturition Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital, Hualien

排尿障礙治療中心 版權所有 Neuroanatomy of Micturition Storage – Stability and good compliance of Bladder Empty – Contraction of detrusor and opening of Urethra Parasympathetic - Pelvic nerve Sympathetic - Hypogastric nerve Somatic nerves- Pudendal nerve

排尿障礙治療中心 版權所有 Neuroanatomy of Lower Urinary Tract

排尿障礙治療中心 版權所有 Neuroanatomy of Micturition Micturition reflex center – sacral cords 2-4 Micturition control center – pons Sensory motor center – frontal lobe Limbic system Cerebellum, Basal ganglia

排尿障礙治療中心 版權所有 Neuroanatomy of Micturition

排尿障礙治療中心 版權所有 Sensory Afferents A-delta fibers – Micturition reflex, stretch and fullness sensation C-fibers – Noxious sensation, capsaicin sensitive primary afferents (CSPA) Dual sensory afferents in mammalian urinary bladder

排尿障礙治療中心 版權所有 Dual Sensory Innervation of Urinary Bladder

排尿障礙治療中心 版權所有 Storage of Urine Stable bladder Good compliance Competent urethra- mucosa, submucosa, smooth muscles, striated skeletal muscles (external sphincter) Good pressure transmission and hammock effect during stress

排尿障礙治療中心 版權所有 Stable Bladder in Filling Phase

排尿障礙治療中心 版權所有 Positive Pressure Transmission during Coughs in UPP Tracing

排尿障礙治療中心 版權所有 Poor Pressure Transmission during Coughs in Stress UPP

排尿障礙治療中心 版權所有 High Leak Point Pressure in SUI with good Hammock Effect

排尿障礙治療中心 版權所有 Empty of Urine Sustained detrusor contraction- cholinergic parasympathetic fibers Relaxation of bladder neck – alpha- adrenergic sympathetic nerves Relaxation of external sphincter- cholinergic pudendal nerves Patent non-obstructive urethra

排尿障礙治療中心 版權所有 Detrusor Contraction during Voiding Phase

排尿障礙治療中心 版權所有 Bladder Outlet Obstruction during Voiding Phase in Man

排尿障礙治療中心 版權所有 Bladder Outlet Obstruction during Voiding Phase in Woman

排尿障礙治療中心 版權所有 Neurophysiology of Micturition Reflexes 排尿中樞 PONS 胸腰髓 T 10 -L 2 薦髓 S 2,3,4 交感神經節 膀胱 膀胱頸 括約肌

排尿障礙治療中心 版權所有 Modulation of Sympathetic nerves in Parasympathetic Ganglion 往橋腦排尿中樞 T 10 -L 2 髓 薦髓 S 2,3,4 逼尿肌核 SIN 副交感神經節 尿道外括約肌

排尿障礙治療中心 版權所有 Innervation of Lower Urinary Tract Bladder- cholinergic parasympathetic- contraction; beta- adrenergic & NO – relaxation Bladder neck – alpha-adrenergic- contration Urethral muscles- cholinergic parasympathetic, NO, cholinergic somatic nerves

排尿障礙治療中心 版權所有 Physiology of Urine Storage First sensation of filling Fullness sensation Urge sensation Premicturition urge sensation- phasic detrusor contraction Increased activity of urethral sphincter during filling

排尿障礙治療中心 版權所有 Urodynmic Tracing in Micturition

排尿障礙治療中心 版權所有 Initiation of Micturition- Relaxation of External Sphincter

排尿障礙治療中心 版權所有 Sustained Detrusor Contraction- Urethrovesical Reflex Stretch receptors in urethral wall Detrusor overactivity in urgency- frequency syndrome and SUI Role of incompetent bladder neck Low detrusor contractility in incompetent urethral sphincter after prostatectomy

排尿障礙治療中心 版權所有 Micturition detrusor pressure- depends on urethral resistance High voiding pressure indicates a greater urethral resistance Low voiding pressure indicates a lower urethral resistance or a low detrusor contractility Efficient bladder empty depends on a sustained detrusor contraction

排尿障礙治療中心 版權所有 Detrusor instability and Inadequate contractility (DHIC)

排尿障礙治療中心 版權所有 Low Detrusor Pressure in Woman with SUI

排尿障礙治療中心 版權所有 Low Detrusor Pressure and BOO

排尿障礙治療中心 版權所有 Detrusor overactivity and BPO

排尿障礙治療中心 版權所有 Efficient Bladder Empty Hypersensitive bladder- low detrusor contractility Inadequate contractility in elderly Bladder outlet obstruction- Bladder neck dysfunction, Prostatic enlargement, Urethral stricture, Cystocele, External sphincter dyssynergia

排尿障礙治療中心 版權所有 Urethral Stricture and BOO

排尿障礙治療中心 版權所有 Anterior Urethral Valve and BOO

排尿障礙治療中心 版權所有 Cystocele and BOO

排尿障礙治療中心 版權所有 Autonomic Dysreflexia

排尿障礙治療中心 版權所有 Detrusor External Sphincter Dyssynergia

排尿障礙治療中心 版權所有 Dysfunctional Voiding in Woman

排尿障礙治療中心 版權所有 Pseudodyssynergia in Girl with Incontinence and UTI

排尿障礙治療中心 版權所有 Pharmacology of Micturition- Increase storage efficiency Reduce detrusor overactivity Anticholinergic agents- oxybutynine, flavoxate, imipramine Ganglion blocker- bentyl Beta-adrenergic agents Botulinum toxin Vanilloid receptor blockers- capsaicin, resiniferatoxin

排尿障礙治療中心 版權所有 Detrusor Overactivity after Resiniferatoxin Treatment

排尿障礙治療中心 版權所有 Initial Excitatory Responses after Capsaicin Treatment

排尿障礙治療中心 版權所有 Pharmacology of Micturition- Increase empty efficiency Parasympathomimetic agent- Urecholine Adrenergic blockers- inhibition of detrusor relaxation (?)

排尿障礙治療中心 版權所有 Pharmacology of Micturition- Increase outlet resistance Increase smooth muscle tone Imipramine, methylephedrine Increase striated muscle tone Nitric oxide synthase inhibitor Pelvic floor muscle training

排尿障礙治療中心 版權所有 Pharmacology of Micturition- Decrease outlet resistance Decrease bladder neck & urethral resistance Alpha-adrenergic blockers- dibenyline, terazosin, tamsulosin, doxazosin Nitric oxide donors Botulinum toxin Polysynaptic blocker – baclofen, diazepam

排尿障礙治療中心 版權所有 Reduction of MUCP after Nitric Oxide Donors (NTG)

排尿障礙治療中心 版權所有 Improved Voiding Efficiency after Botulinum Toxin Injection

排尿障礙治療中心 版權所有 Decreased MUCP after Botulinum Toxin Injection

排尿障礙治療中心 版權所有 Combination of Medication- Improve Voiding Efficiency Increased bladder sensation- intravesical capsaicin, RTX Detrusor overactivity- anticholinergic, intravesical RTX, botulinum toxin Detrusor underactivity – parasympathomimetics, alpha-blocker, NO donors, striated muscle relaxant, periurethral botulinum toxin injection

排尿障礙治療中心 版權所有 Combined Medication – Improved Voiding Efficiency Urethral sphincter hypertonicity- alpha-blocker, NO donors, striated skeletal muscle relaxant Urethral sphincter overactivity- alpha-blocker, striated muscle relaxant, NO donors, botulinum toxin Bladder neck dysfunction- alpha- adrenergic blocker

排尿障礙治療中心 版權所有 Combined Medication- Improved Storage Efficiency Detrusor Overactivity- anticholinergics, sympathomimetics, imipramine Intrinsic sphincter deficiency- imipramine, sympathomimetics DHIC- depends on voiding efficiency and grades of incontinence