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NEUROGENIC BLADDER A REVIEW
R.SRIVATHSAN
Fn features of bladder Normal capacity of 400–500 mL. Sensation of fullness. Ability to accommodate various volumes
without a change in intraluminal pressure. Ability to initiate and sustain a contraction
until the bladder is empty. Voluntary initiation or inhibition of voiding
despite the involuntary nature of the organ.
Neurogenic control Brain:
- Master control- Frontal lobe- Tonically inhibitory signals to detrusor.- Stroke,dementia,cancer, CP, parkinson,
shy drager syndrome….
Brain stem:- Pons- PMC.- inborn excitatory nature.- a relay switch in the voiding pathway.- coordinates the urethral sphincter
relaxation and detrusor contraction to facilitate urination.
- affected by emotions.- brain takes over the control of the pons
at age 3-4 years.- the stretch receptors of the detrusor
muscle send a signal to the pons, which in turn notifies the brain.
Sacral spinal cord:- Primitive voiding center – sacral reflex
center – bladder contractions.- Important intermediary between the
pons and the sacral cord.- Spinal injury: urinary frequency, urgency
and urge incontinence and are unable to empty bladder. [detrusor sphincter dyssynergia with detrusor hyperreflexia (DSD-DH)]. (multiple sclerosis).
- Or detrusor areflexia. (herniated disc/ tumor)
Peripheral nerves:
- Sympathetic: constantly active. [T10-L2].
1. Bladder to increase its capacity without increasing detrusor resting pressure (accommodation) and stimulates the internal urinary sphincter to remain tightly closed.
2.Sympathetic activity also inhibits para sympathetic stimulation [S2-4]
(opposite action).
Somatic nervous system:- External urinary sphincter and the pelvic
diaphragm.- Pudendal nerve [S2-3] originates from the
nucleus of Onuf and regulates the voluntary actions of the external urinary sphincter and the pelvic diaphragm.
- Shy- drager synd : lesion in Onuf nucleus.- Neuropraxia : after delivery- stress
incontinence.- Suprasacral-infrapontine spinal cord trauma
can cause overstimulation of the pudendal nerve - urinary retention.
Storage & voiding reflexes
Urinary tract innervation
Control of micturition
Definitions Neurogenic bladder is a malfunctioning bladder
due to any type of neurologic disorder. Detrusor hyperreflexia: Overactive bladder
[suprapontine upper motor neuron disease]. External sphincter functions normally. The detrusor muscle and the external sphincter function in synergy (in coordination).
DSD-DH - Overactive bladder symptoms - suprasacral spinal cord. Paradoxically, the patient is in urinary retention- detrusor and the sphincter are contracting at the same time; they are in dyssynergy.
Detrusor hyperreflexia with impaired contractility (DHIC) overactive bladder symptoms, but the detrusor cannot generate enough pressure to allow complete emptying. The external sphincter is in synergy with detrusor contraction. The condition is similar to urinary retention, but irritating voiding symptoms are prevalent.
Detrusor instability -overactive bladder symptoms without neurologic impairment. External sphincter normal.
Overactive bladder - urinary urgency, with or without urge incontinence with frequency and nocturia-neurologic or nonneurologic
Spinal above T6Complete cord transection above T6 - detrusor
hyperreflexia, striated sphincter dyssynergia, and smooth sphincter dyssynergia.
Autonomic dysreflexia - exaggerated sympathetic response to any stimuli below the level of the lesion. Inciting event - instrumentation of the bladder/ rectum (visceral distention).
Symptoms- sweating, headache, hypertension, and reflex bradycardia.
Decompress the rectum or bladder - reverses the effects of unopposed sympathetic outflow.
Terazosin/ spinal anesthetic may be used as a prophylaxis.
Below T6
Detrusor hyperreflexia, striated sphincter dyssynergia, and smooth sphincter dyssynergia no autonomic dysreflexia.
Mng: catherisation & anticholinergics.
Peripheral neuropathy Diabetic : sensory(first) & motor loss. Tabetic : areflexic. Herpetic : sacral nerve. Herniated disc : sensory + & motor -ve
Investigations Voiding diary. Pad test. PVRV. Uroflo. Filling cystometrogram : 1.bladder capacity
2.compliance 3.presence of phasic contractions (detrusor instability).
Voiding cystometrogram (pressure-flow study). [Detrusor instability]
Cystogram – static/ voiding. EMG. Cystoscopy Videourodynamics.
Uroflowmetry Uroflowmetry is the study of the flow of urine
from the urethra. The normal peak flow rate for males is 20–25
mL/s and for females 20–30 mL/s. Lower flow rates - outlet obstruction or a weak
detrusor. Higher flow rates - bladder spasticity or
excessive use of abdominal muscles to assist voiding.
Intermittent flow patterns generally reflect spasticity of the sphincter or straining to overcome resistance in the urethra
Normal urodynamics Measure:
Bladder pressure (Pves) (< 30cmH2O)
Rectal (abdominal) pressure
(Pabd) Calculate:
Detrussor Pressure
Pdet = Pves - Pabd
Components of urodynamics
Classification
International Continence Society:
(urodynamic based) Detrusor: Normal (N), hyperreflexic (+),
hyporeflexic (–) Striated sphincter: Normal (N),
hyperactive (+),incompetent(–) Sensation: Normal (N), hypersensitive
(+), hyposensitive (–)
Neurogenic bladder types
CerebralDetrussor instability due to loss of volitional
inhibition Suprasacral spinal
Detrussor sphincter dyssynergia Sacral & peripheral
Detrussor areflexia
Supraspinal. Spinal. Suprasacral. Sacral & peripheral.
Neurogenic bladder types
DD
CYSTITIS. Cystocoele. Chr urethritis. BOO. Psychiatric disturbances. Interstitial cystitis.
Complications
Hydronephrosis Infection. Calculus. Renal amyloidosis. Sexual dysfn. Autonomic dysreflexia.
Spastic bladder
(1) reduced capacity.
(2) involuntary detrusor contractions.
(3) high intravesical voiding pressures.
(4) Marked hypertrophy of the bladder wall.
(5) spasticity of the pelvic-striated muscle.
(6) autonomic dysreflexia in cervical cord lesion.
Flaccid bladder
1) Large capacity.
2) Lack of voluntary detrusor contractions.
3) Low intravesical pressure
4) Mild trabeculation (hypertrophy) of the bladder wall.
5) Decreased tone of the external sphincter.
Flaccid bladder
1) Large capacity.
2) Lack of voluntary detrusor contractions.
3) Low intravesical pressure
4) Mild trabeculation (hypertrophy) of the bladder wall.
5) Decreased tone of the external sphincter.
Spinal shock syndrome Flaccid spastic / flaccid (level). Drain the bladder – overdistension
causes detrusor smooth muscle dmg and limit functional recovery of the bladder.
Few principles:
- foleys’< 16Fr - silicone -changed every 3 wks - taped to abd wall.
Goals in treatment
Preservation of upper urinary tract Maintain adequate bladder capacity
with good compliance Promote low-pressure micturition Avoid bladder overdistension Prevent urinary tract infection Minimize use of Foley catheter Choose therapy that minimizes patient
risks while maximizing social, emotional, and vocational acceptability
Management Stress incontinence - surgical and
nonsurgical. Urge incontinence - behavioral
modification / bladder-relaxing agents. Mixed incontinence - medications as well as
surgery. Overflow incontinence - catheter regimen. Functional incontinence - treat the
underlying cause, such as urinary tract infection, constipation.
Anti incontinent measures
Pelvic floor exercises. Vaginal weights. Biofeedback. Electrical stimulation. Bladder training.
New modalities
OAB : Bladder denervation.
bladder desensitisation.
[Resiniferatoxin intravesically].
Latissimus dorsi muscle is harvested from the back and transplanted around the urinary bladder: nerves are coapted and blood vessels anastomosed
Thank you