75

Neuromuscular Dysfunction of the

Lower Urinary Tract

Alan J. Wein; Roger R. Dmochowski

Questions

1.What is the general pattern of voiding dysfunction secondary to neurologic lesions above the level of the brainstem?

a.Involuntary bladder contractions, smooth sphincter dyssynergia, striated sphincter synergy

b.Involuntary bladder contractions, smooth sphincter synergy, striated sphincter synergy

c.Involuntary bladder contractions, smooth sphincter synergy, striated sphincter dyssynergia

d.Detrusor hypocontractility, smooth sphincter synergy, striated sphincter synergy

e.Detrusor areflexia, smooth sphincter synergy, striated sphincter synergy

2.What is the general pattern of voiding dysfunction that results from complete lesions of the spinal cord above the level of S2 after recovery from spinal shock?

a.Involuntary bladder contractions, smooth sphincter dyssynergia, striated sphincter synergy

b.Involuntary bladder contractions, smooth sphincter synergy, striated sphincter synergy

c.Involuntary bladder contractions, smooth sphincter synergy, striated sphincter dyssynergia

d.Detrusor hypocontractility, smooth sphincter synergy, striated sphincter synergy

e.Detrusor areflexia, smooth sphincter synergy, striated sphincter

synergy

3.Which of the following is the most common long-term expression of lower urinary tract dysfunction after a cerebrovascular accident (CVA)?

a.Detrusor areflexia

b.Lack of sensation of filling

c.Impaired bladder contractility

d.Striated sphincter dyssynergia

e.Detrusor overactivity

4.Urinary incontinence is most likely to occur in a patient after a CVA if which of the following areas is affected?

a.Internal capsule

b.Basal ganglia

c.Thalamus

d.Cerebellum

e.Hypothalamus

5.In a post-CVA patient who exhibits urgency and frequency but no incontinence, the state of striated sphincter activity can most commonly be best described as:

a.uninhibited relaxation.

b.dyssynergia.

c.fixed voluntary tone.

d.pseudodyssynergia.

e.myotonus.

6.A 65-year-old man who has sustained a stroke but is otherwise in good health has symptoms of hesitancy, straining to void, urgency, and frequency. The optimal next step in management is:

a.anticholinergic therapy.

b.transurethral resection of the prostate (TURP).

c.transurethral incision of the bladder neck and prostate.

d.clean intermittent catheterization.

e.full urodynamic evaluation.

7.When considering the subject of voiding dysfunction associated with brain tumors, which of the following areas is more likely to be associated with urinary retention than with urinary incontinence?

a.Pituitary gland

b.Cerebellum

c.Posterior fossa

d.Hypothalamus

e.Frontal cortex

8.The most common pattern of micturition in children and adults who have cerebral palsy (CP) and no other complicating neurologic condition is:

a.abnormal filling/storage because of detrusor overactivity; normal emptying.

b.normal filling/storage; normal emptying.

c.normal filling/storage; abnormal emptying because of smooth sphincter dyssynergia.

d.normal filling/storage; abnormal emptying because of striated sphincter dyssynergia.

e.abnormal filling/storage because of detrusor overactivity; abnormal emptying because of striated sphincter dyssynergia.

9.The most common urodynamic findings in individuals with CP who do exhibit lower urinary tract dysfunction are:

a.detrusor areflexia, coordinated sphincters.

b.detrusor overactivity, smooth sphincter dyssynergia, striated sphincter dyssynergia.

c.detrusor overactivity, smooth sphincter synergy, striated sphincter dyssynergia.

d.decreased detrusor compliance, coordinated sphincters.

e.detrusor overactivity, coordinated sphincters.

.Deficiency of which of the following compounds in the nigrostriatal pathway accounts for most of the classic clinical motor features of Parkinson disease (PD)?

a.Dopamine

b.Norepinephrine

c.Acetylcholine

d.Serotonin

e.l-Dopa

.The most common urodynamic abnormality found in patients with voiding dysfunction secondary to PD is:

a.impaired sensation during filling.

b.striated sphincter dyssynergia.

c.striated sphincter bradykinesia.

d.detrusor overactivity.

e.impaired detrusor contractility.

.Which of the following is more common in patients with PD than in patients with multiple system atrophy (MSA)?

a.Intrinsic sphincter deficiency

b.Evidence of striated sphincter denervation on an electromyogram

c.Decreased compliance

d.Incontinence after TURP

e.Disease diagnosis preceding voiding and erectile symptoms

.The lesions seen in multiple sclerosis most commonly affect which of the following locations in the nervous system?

a.Thoracic spinal cord

b.Sacral spinal cord

c.Cervical spinal cord

d.Lumbar spinal cord

e.Midbrain

.Which of the following urodynamic findings is least common in patients with multiple sclerosis and voiding dysfunction?

a.Detrusor overactivity

b.Detrusor areflexia

c.Impaired detrusor contractility

d.Striated sphincter dyssynergia

e.Smooth sphincter dyssynergia

.The incidence of upper urinary tract deterioration is greatest in which of the following?

a.Multiple sclerosis

b.Multiple system atrophy

c.PD

d.Spinal cord injury (SCI)

e.Diabetes

.Which of the following most accurately reflects the number of patients with HIV/AIDS, overall, with moderate or severe voiding problems?

a.15% or less

b.15% to 25%

c.25% to 40%

d.40% to 60%

e.60% to 80%

.The sacral spinal cord terminates in the cauda equina at approximately the spinal column level of:

a.T10.

b.L1.

c.L2.

d.L3.

e.S1.

.In spinal shock, findings generally include all of the following EXCEPT:

a.acontractile bladder.

b.areflexic bladder.

c.open bladder neck.

d.absent guarding reflex.

e.maximal urethral closure pressure above normal.

.All of the following are risk factors for upper urinary tract deterioration in a patient with a suprasacral SCI EXCEPT:

a.high-pressure storage.

b.high detrusor leak-point pressure.

c.chronic bladder overdistention.

d.high abdominal leak-point pressure.

e.vesicoureteral reflux with infection.

.The presence of true detrusor-striated sphincter dyssynergia implies a neurologic lesion between the:

a.pons and the sacral spinal cord.

b.cerebral cortex and the pons.

c.cervical and the sacral spinal cord.

d.sacral spinal cord and the striated sphincter.

e.cauda equina and the striated sphincter.

.An SCI at which of the following cord levels would be most likely to be associated with autonomic hyperreflexia?

a.Cervical

b.Thoracic

c.Lumbar

d.Sacral

e.Cauda equina

.Which of the following is least characteristic as a finding in autonomic hyperreflexia?

a.Headache before bladder contraction

b.Hypertension

c.Flushing above the level of the lesion

d.Tachycardia

e.Sweating above the level of the lesion

.The most common urodynamic findings in a male with autonomic hyperreflexia include all EXCEPT:

a.detrusor overactivity.

b.decreased compliance.

c.striated sphincter dyssynergia.

d.smooth sphincter dyssynergia.

e.decreased bladder capacity.

.Which of the following is NOT among the treatments for, or prophylaxis of, autonomic hyperreflexia?

a.α-Adrenergic blockade

b.β-Adrenergic blockade

c.Ganglionic blockade

d.Spinal anesthesia

e.General anesthesia

.In a male patient with detrusor-striated sphincter dyssynergia, a high detrusor leak-point pressure, high-pressure vesicoureteral reflux, and beginning upper urinary tract deterioration, which of the following is least likely, as an isolated procedure, to halt or reverse the upper tract changes?

a.Ureteral reimplantation

b.Augmentation cystoplasty

c.Dorsal root ganglionectomy

d.Anticholinergic therapy and intermittent catheterization

e.Sphincterotomy

.The American Paraplegic Society guidelines for urologic care of SCI include all EXCEPT:

a.annual follow-up after injury for 5 to 10 years, then every other year if doing well.

b.upper and lower urinary tract evaluation initially and yearly for 5 to 10 years, then every other year.

c.cystoscopy annually for those with an indwelling catheter.

d.urodynamic evaluation initially, yearly for 5 to 10 years, then every other year.

e.neurologic evaluation initially and yearly for an indefinite period.

.In a patient with voiding dysfunction secondary to myelomeningocele who has slightly decreased compliance, detrusor areflexia, and low-pressure moderate

occurrence of urinary retention after radical pelvic surgery?

a.Anticholinergic therapy

b.Clean intermittent catheterization

c.TURP

d.External sphincterotomy

e.Bethanechol chloride

.The urodynamic parameter most likely to distinguish urinary retention due to prostatic obstruction from urinary retention due to "classic diabetic cystopathy" is:

a.uroflow.

b.residual urine volume.

c.bladder compliance.

d.vesical pressure.

e.detrusor pressure.

.Detrusor-striated sphincter dyssynergia is least expected to occur with which of the following conditions?

a.Multiple sclerosis

b.SCI

c.Stroke

d.Autonomic hyperreflexia

e.Transverse myelitis

.Differentiation of bladder neck obstruction from dysfunctional voiding is most easily and accurately made by:

a.filling cystometry.

b.voiding cystometry.

c.cystourethroscopy.

d.flowmetry and residual urine determination.

e.video-urodynamic study.

.Which of the following is not a typical finding in a patient with Fowler syndrome?

a.Female younger than 30 years

b.Unable to void for a day or more with no urgency

c.Bladder capacity of less than 1 L

d.Increasing lower abdominal discomfort

e.Electromyographic (EMG) abnormalities

.Which of the following with the typical history is the most specific study to make the diagnosis of Fowler syndrome?