2. 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

3. 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

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

5. 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

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

7. 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

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

9. 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

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

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

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

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

14. 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

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

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

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

18. 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

19. 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

20. 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

21. 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

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

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

24. 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

25. 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

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

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

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

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

30. 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

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

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

33. 排尿障礙治療中心 版權所有 Cystocele and BOO

34. 排尿障礙治療中心 版權所有 Autonomic Dysreflexia

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

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

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

38. 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

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

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

41. 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 (?)

42. 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

43. 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

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

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

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

47. 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

48. 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

49. 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