Question

For each case of bladder abnormality A–E, select the most appropriate option from the following list. 

1. Atonic bladder with overflow. 

2. Stress incontinence. 

3. Chronic prostatic obstruction. 

4. Acute retention of urine. 

5. Automatic bladder. 

6. Bladder diverticulum. 

A. A 30-year-old woman with three children complains of wetting herself during coughing and sneezing. 

B. A 20-year-old woman had a spinal injury two years ago as a result of diving into shallow water. She has lost normal control of the urinary bladder but can initiate micturition when the bladder is fairly full by pressing on the lower abdomen. 

C. An 80-year-old man has been admitted to hospital as an emergency complaining of lower abdominal pain and inability to pass urine for 12 hours. In recent months he had noticed that the urinary stream was poor. On admission he has abnormal dullness to percussion over his lower abdomen and on rectal examination, enlargement of the prostate. 

D. A 29-year-old man was admitted to hospital following a neck injury and paralysis of the legs. On the day after admission, knee and ankle jerks cannot be elicited and he is incontinent of urine. 

E. A 75-year-old man complains of frequency of micturition and poor flow; his cystometrogram shows raised bladder pressures in the contracted state and an abnormally high residual volume.

Answer 1

A. Option 2 Stress incontinence. During coughing and sneezing intrathoracic and intraabdominal pressure is raised. In the presence of impaired sphincter action at the bladder outlet, a common consequence of damage during delivery, the raised pressure can expel some urine from the bladder. Laughing may have a similar effect. 

B. Option 5 Automatic bladder. The patient had a spinal injury which has led to loss of bladder control. Such injuries isolate the micturition centre in the sacral cord from higher centre control. In such patients the bladder can empty automatically when distended by means of the bladder stretch reflex centred in the sacral cord. Pressure on the abdomen can initiate the reflex at a convenient time before it occurs automatically. 

C. Option 4 Acute retention of urine. In elderly men, prostatic enlargement leads to progressive compression of the prostatic urethra. This leads to increasing resistance to flow so that the urinary stream is poor. If the obstruction becomes complete so that micturition is impossible, the bladder becomes painfully distended. 

D. Option 1 Atonic bladder with overflow. This is another case of spinal injury isolating the micturition centre in the sacral cord from higher centre control. However, in the acute phase that comes on immediately and lasts for some weeks after the injury, the patient usually shows a complete absence of spinal stretch reflexes below the level of the lesion spinal shock. The micturition stretch reflex is abolished so that the bladder loses tone, becomes distended and leaks uncontrollably due to the high pressure in the passively distended organ. Catheterization is important, to prevent damage to the bladder by such over-stretching. 

E. Option 3 Chronic prostatic obstruction. This is another case of prostatic obstruction but without acute retention of urine. Gradual narrowing of the prostatic urethra raises the urethral resistance which the bladder must overcome. Hypertrophy of the bladder wall occurs (as in the left ventricle in systemic hypertension), hence bladder pressure during a micturating cystometrogram (record of bladder pressure versus volume) is increased. As in the failing heart, the bladder muscle fails to empty as completely as usual.