URONEUROLOGIA ? ? ? Considerações: O trauma raqui medular (TRM) Principal causa de mortalidade no passado 80% na 1ª Guerra 40% na 2ª Guerra 25% na Guerra da Correia Percentual insignificante na Guerra do Vietnã ? ? ?

URONEUROLOGIA Estabelecimento de Centros Especializados CATETERISMO Intermitente LIMPO Sistematização do cateterismo intermitente como método de esvaziamento da bexiga na prevenção do REFLUXO

óbito URONEUROLOGIA BEXIGA NEUROGÊNICA HIPERREFLEXA PRESSÃO DE MICÇÃO ELEVADA REFLUXO VÉSICO URETERAL URETEROCALIPIELECTASIA HIDRONEFROSE SECUNDÁRIA INFECÇÃO SEGUIDA DE CICATRIZ RENAL PERDA PROGRESSIVA DA FUNÇÃO RENAL INSUFICIÊNCIA RENAL óbito

UroNeurologia 1- Ciclo miccional normal 2- Bexiga neurogênica (hiperatividade x hiperreflexia x disfunção esficteriana) 3- Diagnóstico 4- Tratamentos

Quanto tempo sobrevive um LM ?? Distribuição dos LM’s por tempo de sobrevida após a lesão

Quanto tempo sobrevive um LM ?? Distribuição dos LM’s por tempo de sobrevida após a lesão

Quanto tempo sobrevive um LM ?? Distribuição dos LM’s por tempo de sobrevida após a lesão

Quanto tempo sobrevive um LM ?? Distribuição dos LM’s por tempo de sobrevida após a lesão

Quanto tempo sobrevive um LM ?? Distribuição dos LM’s por tempo de sobrevida após a lesão

Ciclo normal da micção Storage phase Emptying phase Bladder pressure Bladder filling Detrusor relaxes + Urethra contracts Pelvic floor contracts Bladder filling Detrusor relaxes + Urethra contracts Pelvic floor contracts First sensation to void Detrusor relaxes + Urethra contraction increases Pelvic floor contracts First sensation to void Detrusor relaxes + Urethra contraction increases Pelvic floor contracts Normal desire to void Detrusor contracts + Urethra relaxes Pelvic floor relaxes MICTURITION Normal desire to void Detrusor contracts + Urethra relaxes Pelvic floor relaxes MICTURITION Detrusor relaxes + Urethra contracts Pelvic floor contracts Bladder filling KEY POINT: This diagram shows how the micturition cycle correlates with activities of the detrusor, urethra, and pelvic floor. ADDITIONAL INFORMATION: During the normal voiding process, a decrease in the intraurethral pressure and subsequent relaxation of the urethral sphincter precedes the contraction of the detrusor muscles of the bladder. At the same time, the pelvic floor muscles relax and the bladder neck forms a funnel. Parasympathetic stimulation of the detrusor muscle causes it to contract and the flow of urine begins. The contraction of the detrusor muscle is maintained throughout the voiding process. REFERENCES: Elbadawi A. Neuromuscular mechanisms of micturition. In: Yalla SV, et al, eds. Neurourology and Urodynamics: Principles & Practice; 1986.

CENTROS DE CONTROLE CONSCIÊNTE (PROPRIOCEPTIVOS) DA MICÇÃO NEUROFISIOLOGIA DO ATO MICCIONAL CÓRTEX CEREBRAL (Área da propriocepção ou proprioceptiva) – Lobo frontal do córtex cerebral localizado na parte mesencefálica. CENTRO DA MICÇÃO (Região do bulbo cerebral) INIBIÇÃO DO MÚSCULO DETRUSSOR (durante a fase de enchimento vesical)

Conhecimento neuroanatômico Neurofisiologia da Micção – Circuitos de Bradley e Reflexos de Mahoney. Bradley e cols.(1974), identificaram quatro tractos ou circuitos responsáveis pelo controle neurológico das vias urinárias inferiores. São eles: Tracto I – circuito cérebro-tronco / cerebral Tracto II – circuito tronco-cerebral / sacral Tracto III – circuito esfíncter-vesical / sacral Tracto IV – circuito cerebral / sacral.

Reflexos da Micção - Mahoney FUNÇÃO EFEITO I. Reflexos que se originam com o aumento da tensão mural do detrusor A1 favorecem a retenção e a continência inibe a contração do detrusor A2 estimula o esfíncter interno B2 inicia a micção facilita a contração do detrusor C1 mantém a micção relaxa a musculatura lisa do trígono e uretra proximal C2 relaxa o esfíncter estriado externo II. Reflexos que se originam com o aumento da tensão mural do trígono e/ou presença de urina na uretra proximal A4 favorece continência e retenção estimula a contração do esfíncter externo III. Reflexos que se originam com a presença de urina na uretra proximal C3 estimula a contração do detrusor C4 C5 inibe o esfíncter externo IV. Reflexos que se originam com o aumento da tensão perineal ou dos músculos - do assoalho pélvico A3 favorece a continência D1 finaliza a micção V. Reflexo que se origina com a diminuição da tensão perineal e dos músculos do assoalho pélvico B1

URONEUROLOGIA NERVOS PERIFÉRICOS ENVOLVIDOS DIRETAMENTE NO CONTROLE MICCIONAL Parassimpáticos: S2 / S4 Simpáticos tóraco lombares: T10 / L2 Somáticos sacrais: S2 / S4

Neurotransmissores conhecidos e envolvidos no controle do trato urinário baixo Acetylcholine (ACh) Norepinephrine (NE) Serotonin (5-HT) Glutamate GABA Dopamine (DA) KEY POINT: These neurotransmitters are involved to varying extents in lower urinary tract control; therefore, they may be targets for inhibitory or stimulatory therapies. deGroat WC. Basic neurophysiology and neuropharmacology. In: Abrams P, et al, eds. Incontinence; 1999:105-154.

Inervação do trato urinário baixo +M3 Pelvic Nerve (Parasympathetic) ACh -3 +1 Hypogastric Nerve (Sympathetic) NE +N Pudendal Nerve (Somatic) ACh KEY POINT: These nerves and neurotransmitters regulate lower urinary tract (LUT) function by stimulating the bladder, relaxing the urethra, contracting the urethra, and contracting the rhabdosphincter when appropriate. ADDITIONAL INFORMATION: The pelvic nerve (parasympathetic) originates from the sacral spinal cord; it stimulates the bladder using acetylcholine and relaxes the urethra employing nitric oxide. The M3 receptor subtype is currently seen as the receptor responsible for contraction of the detrusor muscle. The hypogastric nerve (sympathetic) originates from the lumbar spinal cord and uses norepinephrine to contract the urethra. -adrenergic receptors also exist in the bladder; stimulation of these receptors results in direct relaxation of the detrusor smooth muscle. It appears that the action of the 3 receptor is responsible for detrusor muscle relaxation. This does not appear to be true for 1 or 2 selective antagonists. Somatic control via the pudendal nerve originates from the sacral spinal cord causing contraction of the striated urethral sphincter. Activity is mediated by acetylcholine. REFERENCES: Van Arsdalen K, Wein AJ. Physiology of micturition and continence. In: Krane RJ, Siroky MD, eds. Clinical Neurourology; 1991:25-82. deGroat WC. Basic neurophysiology and neuropharmacology. In: Abrams P, et al, eds. Incontinence; 1999:105-154.

Colinérgico Adrenérgico

A Conecção NeuroUrológica Periaquaductal Gray Storage Reflex Micturition Reflex Inhibition Pontine Micturition Center - - + Hypogastric Nerve SYM -ß3 Spinal Relay Neuron KEY POINT: This diagram outlines the nervous system components and pathways involved in the reflexes associated with urinary continence. ADDITIONAL INFORMATION: As the bladder begins to fill with urine, this stimulates stretch receptors in the bladder, whose activity is carried along pelvic nerve afferent fibers to the spinal cord. This activity is conveyed to the sympathetic nucleus, which in turn activates fibers carried along the hypogastric nerve, which releases norepinephrine (NE) to stimulate inhibitory beta adrenergic receptors in the detrusor to cause bladder relaxation and excitatory alpha adrenergic receptors in the urethra to cause urethral contraction. In addition, rapid increases in abdominal pressure and increased filling cause activation of sphincter motor neurons located in Onuf’s nucleus. This activity is conveyed along the pudendal nerve, which releases acetylcholine (ACh) to stimulate excitatory nicotinic cholinergic receptors and contraction of the striated urethral sphincter. This relaxation of the bladder, coupled with contraction of the bladder, promotes urine storage. When the bladder becomes distended to the point at which micturition should occur, activity from the pelvic nerve is carried to the periaquaductal gray and the pontine micturition center (PMC). The PMC, in turn, causes activation of sacral parasympathetic neurons whose axons traverse the pelvic nerve and cause release of ACh to stimulate excitatory muscarinic cholinergic receptors and contraction of the detrusor. Simultaneously, the PMC inhibits the sympathetic and somatic pathways to the urethra, allowing for urethral relaxation. Concurrent with urethral relaxation, there is a voluntary relaxation of the pelvic floor muscles. This coordinated contraction of the bladder and relaxation of the sphincter allows for efficient micturition to occur. Pelvic Nerve +1 +M2,3 PAR Pudendal Nerve +N ON Rhabdosphincter Adapted from: deGroat WC. Basic neurophysiology and neuropharmacology. In: Abrams P, et al, eds. Incontinence; 1999:105-154.

Sinergismo DE KEY POINT: Intrinsic sphincter deficiency (ISD) is another common cause of SUI. The urethra does not close completely and permits leakage even with minimal stress. ADDITIONAL INFORMATION: There are gradations of ISD; it is not an all-or-none phenomenon. REFERENCES: Staskin DR. Classification of voiding dysfunction. In: Cardozo L, Staskin DR, eds. Textbook of Female Urology and Urogynaecology; 2001:84-89.

Discinergismo DE KEY POINT: Intrinsic sphincter deficiency (ISD) is another common cause of SUI. The urethra does not close completely and permits leakage even with minimal stress. ADDITIONAL INFORMATION: There are gradations of ISD; it is not an all-or-none phenomenon. REFERENCES: Staskin DR. Classification of voiding dysfunction. In: Cardozo L, Staskin DR, eds. Textbook of Female Urology and Urogynaecology; 2001:84-89.

Exame Retal Massa Tônus e etividade esfincteriana Contração Voluntária Sensação perineal Impactação fecal Sphincter intacto KEY POINT: The rectal examination may include these specific considerations.

Exame neurológico sacral Sensação perineal Reflexo Bulbocavernoso (S2-S3) Anal (S2-S5) Movimento dos pés Contração voluntária do esfincter anal Baixa força muscular dos MMII KEY POINT: The sacral neurological examination may include these specific considerations.

Urinálise Bacteriúria Hematúria Piúria Glicosúria Proteinúria KEY POINT: A urinalysis will rule out infection and can be done by dipstick or microscope. A urinalysis often includes tests to detect nitrates and leukocyte esterase. ADDITIONAL INFORMATION: (Glycosuria is also called glucosuria.)

Outros exames (1ª linha) Urina residual Ultrason Cistoscopia KEY POINT: The postvoid residual (PVR) urine volume test measures the amount of urine left in the bladder after urination. Usually, about 50 mL or less of urine is left. ADDITIONAL INFORMATION: This basic test may be performed by a primary care provider prior to referral, or by a specialist upon referral. The most common method for measuring PVR is with a catheter that is inserted into the urethra within a few minutes of urination. Ultrasound is an alternative; it produces an image that reveals the amount of urine in the bladder and may detect abnormalities in the kidneys, bladder, and prostate. REFERENCES: Choe JM. E-Medicine J. 2002;3(1).

Outros exames (2ª linha) Uretrocistografia Cistografia isotópica Cintilografia renal DTPA Tomografia computadorizada (sem contrastes ou com creatinina normal) (Ressonância magnética nuclear) Eletromiografia do esfíncter externo Urografia excretora (creatinina normal)

Urodinâmica Cistometria Cystometrograma (CMG) Detecta contrações detrusoras, complacencia, urina residual, e determina capacidade vesical. Precede stress test Cystometrograma (CMG) Mede pressão / volume / perda urinária (PP) KEY POINT: These urodynamic tests may be performed by a specialist to determine the exact diagnosis or identify proper candidates for surgical management.

Tratamento 1- Anticolinérgico oral 2- Anticolinérgico local 3- Toxina botulínica 4- Resineferatoxina 5- Capsaicina 6- Rizotomia 7- Eletromodulação 8- Ampliação vesical 9- Esficterotomia 10- Seguimento

Tratamento

Tratamento CORTICAL T10 / T11 S2 / S4

Tratamento CORTICAL T10 / T11 S2 / S4

Tratamento CORTICAL T10 / T11 S2 / S4

Tratamento CORTICAL T10 / T11 S2 / S4

Tratamento OBJETIVOS DO TRATAMENTO 1- Aumentar a capacidade CISTOMÉTRICA 2- Evitar ITU 3- Evitar I.U. 4- Evitar R.V.U. 5- Aumentar a sobrevida 6- Aumentar a inclusão social