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What stimulates the bladder to empty?

Acetylcholine is the primary excitatory neurotransmitter involved in bladder emptying.

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DYSFUNCTIONAL VOIDING

Dysfunctional voiding is an abnormality of bladder emptying in neurologically normal individuals in which there is increased activity of external sphincter during voluntary voiding. It is a learned behavior, which differentiates it from true DESD that was described earlier (Fig. 30-4). Thus, the terms pseudodyssynergia and learned voiding dysfunction have also been used to describe the condition. Dysfunctional voiding may result in various LUTS, both storage and emptying symptoms. It may also be responsible for recurrent urinary tract infections, acute or chronic urinary retention, and, in severe cases, upper and lower urinary tract decompensation. In 1973, Hinman and Bauman popularized the concept of dyscoordination between the detrusor and the activity of the pelvic floor-external sphincter complex in neurologically normally individuals. Much of the literature describes this phenomenon, also known as the nonneurogenic neurogenic bladder, or Hinman's syndrome, as occurring in children and adolescents who typically present with enuresis, recurrent urinary tract infections, and sometimes hydronephrosis. In 1978, Allen and Bright used the term dysfunctional voiding to describe failure to coordinate detrusor and sphincter activity in children. The literature is replete with reports of this condition in children; in adults, however, much less has been written, although it has been reported to cause various LUTS, incomplete emptying, incontinence, and recurrent urinary tract infections. In 1999, Nitti et al. found dysfunctional voiding to be the most common abnormality of the voiding phase in women presenting with LUTS. Dysfunctional voiding in children was originally thought to be a response to psychosocial problems. The condition is now recognized as a developmental abnormality, whereby there is persistence of the transitional phase between infantile reflexogenic voiding and normal volitional voiding of adulthood. Several theories are known on why dysfunctional voiding occurs in adults. The most plausible is that it represents a learned behavior in response to an adverse event or condition, such as inflammation, irritation, infection (cystitis, urethritis, vaginitis), urethral diverticulum, pelvic inflammatory disease, anorectal disease, or trauma. Other authors have suggested that dysfunctional voiding may result from voluntary withholding of urination in individuals who work long hours. Kaplan et al. (1980) proposed that “the stress of modern society may manifest itself in this region of the body.” McGuire and Savastano (1984) attributed the behavior to a primary abnormality of detrusor overactivity with the dyssynergic sphincter response developing as a result of sudden unanticipated detrusor contractility. Contraction of the pelvic floor-external sphincter complex is a normal response to control urgent urination and results in a reflex inhibition of the detrusor. When this becomes habitual over time, the abnormal incoordination carries over to voluntary voiding, resulting in an intermittent urinary stream and residual urine. The treatment of dysfunctional voiding has evolved over the years. Kaplan et al. (1980) reported success with diazepam in six women with “urethral syndrome” who demonstrated a staccato voiding pattern with increased external sphincter or pelvic floor EMG activity during voiding. As in children, biofeedback and behavioral modification have become our recommended treatment for women with dysfunctional voiding. Biofeedback has also been proven to be successful in adult men. In cases where there is also detrusor overactivity or impaired compliance, anticholinergic medications can be used in addition to biofeedback. Interestingly, in the study by Deindl et al. (1998), biofeedback was successful in cases of pubococcygeus dysfunction but not in cases of true external urethral sphincter dysfunction. Several clinicians, including ourselves, have had anecdotal success with amitriptyline. Just as in the treatment of DESD, endoscopic and transperineal urethral injections of botulinum toxin-A have been performed in women with dysfunctional voiding. In a study by Kuo (2003) on 103 women with urinary retention and voiding complaints, of whom 39 had dysfunctional voiding, there was an 84.5% 4-week success rate with 50–100 U intraurethral injection of botulinum toxin-A. Finally, the role of neuromodulation, which has been described for the treatment of idiopathic urinary retention, needs to be defined specifically with respect to dysfunctional voiding.

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sciencedirect.com - Bladder Emptying - an overview | ScienceDirect Topics