NEUROGENIC BLADDER

Outline of the presentation

• Applied physiology • Symptomatology• Types according to levels of bladder

dysfunction• Investigations• Treatment available

Bladder functions

• Storage - at low pressure until such time as it is convenient and socially acceptable to void

• Voiding - initiated by inhibition of the striated sphincter and pelvic floor, followed some seconds later by a contraction of the detrusor muscle.

1.Cortical micturition centre

2.Pontine micturition centre

3.Spinal micturition centre

4. Peripheral nerves

Sympathetic

(T11 –L2)

Parasympathetic

( S2,3,4)

(S2,3,4)

Control of micturition

Cortical micturation centre(CMC)

Location: Paracentral lobule in the medial aspect of the frontoparietal cotex

Function: Inhibitory to PMC

Dysfunction – loss of social control of bladder

The brain’s control of the PMC is part of the social training that children experience at age 2 - 4 years

Pontine Micturition Centre (PMC)Also called Barrington’s nucleus • Lateral regionFunction - continence, storage urine stimulation results in a powerful contraction of the urethral sphincter• Medial regionFunction - micturition center stimulation results in decrease in urethral pressure and silence of pelvic floor EMG signal, followed by a rise in detrusor pressure.

Sacral reflex or Sacral/Primitive micturition centre (SMC/PMC)

1. Sacral parasympathetic nucleus (SPN): S234- pelvic splanchnic nerves (nervi erigentes) arise from

2. Somatic – Onufoid nucleiCollection of external urethral sphinter motoneurones

3. Levator Ani Motoneurones

Peripheral innervation

Stimulation Response

Parasympathetic(S 2-4)

Excitatory to detrusor, relaxes sphincter - void

Sympathetic(T11- L2)

Inhibitory to detrusor, ↑trigone & Urethral tone

Somatic ( S2 - 4) Excitatory to the external sphincter

Micturition reflex

Internal sphincter – no important role in micturition, prevents leakage during filling andprevents reflux of semen into bladder during ejaculation

Sympathetic nerves – no part in micturition

The Micturition Reflex

Sensation of bladder fullness via pelvic and pudendal nerves to S 2,3,4

Periaqueductal gray matter

Medial Pontine micturition center

Frontal lobe decides social appropriateness

Onuf’s nucleus to pudendal nervesDetrussor center (S 2,3,4) to pelvic nerves

RECIPROCAL ACTIVITY BETWEEN SPHINCTER & DETRUSOR

Micturition

On-off switch

Relay center

Primitive voiding

CerebralPMC

SMC

Symptomatology

Detrusor Hypereflexia

Detrusor Sphincter Dyssynergia

Resultant

Poorly sustained hyperreflexic bladder contraction (DH) and (DSD)

Raised post voiding residual (PVR)

Exacerbation of urgency

Neuropathy• Long history of

neuropathic symptoms, • Stocking glove

anesthesia• Absent knee and ankle

jerks will be absent • Small fiber sensory

impairment demonstrable to the level of the ankles

• Other features of autonomic involvement

• Sexual dysfunction

Cauda equina• Bladder, sexual & bowel

dysfunction• S 2, 3, 4 sensory loss• Lax anal sphincter • Bulbocavernosus (sacral

reflexes) reflex lost• +/- Foot deformities, lower limb abnormalities• Cutaneous markers over the

back & sacrum

Spinal Cord• Signs of upper motor

neuron lesion in the lower limbs (unless the lesion is central intramedullary and small)

• Erectile dysfunction in men

• +/- Paraparesis

Brainstem• Marked neurological

deficits dorsal and discreet lesion defect of bladder function

• MLF lesion Internuclear ophthalmoplegia

Extrapyramidal diseases• Extrapyramidal features • MSA, Parkinsons disease• Autonomic dysfunction• Cerebellar signs

Suprapontine• Frontal lobe disorders• Dementia, personality change• Aware about incontinence

unless extensive lesions• Severe urgency, frequency &

urge incontinence without dementia, socially aware and embarrassed by

incontinence• Urinary retention

Types according to the level of bladder

dysfunction

a) Suprapontine/cortical lesion –

“Uninhibited /Cortical bladder”

Severe urgency, frequency & urge incontinence

with dementia – incontinent and inappropriate voiding

without dementia- socially aware & embarrassed by their incontinence.

b) Pontine lesion – “ Reflex / Automatic bladder”

DH, Arreflexia in pts with INO

c) Spinal (subpontine/suprasacral)“ Spastic Bladder”

Disorders of storage and emptyingDSD (true only if above T6 level), DH

d) Sacral and subsacral lesionsI) Afferent fibres involved only – “Atonic /Areflexic bladder”Overflow incontinenceStraining for micturition No DSD, no DH

II) Both afferent and efferent involved –“Autonomous bladder” Small capacity , acting of its own. No DSD/DH

UMN-SPASTIC

LMN- FLACCID AREFLEXIC

CerebralPMC

SMC

Causes of various levels of dysfunction

a) Suprapontine and Pontine Causes• Stroke• Tumors• Dementia (AD,FTD)

Spinal causes (subpontine/suprasacral)

Sacral and Subsacral causes

Management- Investigations Noninvasive bladder investigations- Post void residual volume –• In out catheterization,• Ultrasound ( N is <100ml)

Uroflowmetry- • Voided volume ( >100ml)• Maximal flow, maximal and average flow rate (M > 20ml/sec and F > 15ml/sec)

Cystometry-

• Measure detrusor pressure (Intravesical presure – Rectal pressure)

• Bladder infused till 400 to 600ml – Pressure should not rise to >15cm water (Stable bladder)

• Neurogenic detrusor overactivity – Involutary detrusor contraction during filling phase

• Voiding phase – Detrusor pressure M < 50cm water F < 30cm water

Sphincter EMG – Reinnervation with prolonged duration of MUAPs

Neuroimaging – Cauda equina & conus lesions,spinal, supra pontine and pontine lesions

Treatment - Detrusor overactivity• Anticholinergics - Oxybutynin, tolterodine - M3 blockers- darifenacin

• Tricyclic antidepressants - Imipramine

• Desmopressin intranasally – once in 24 hrs

• Botulinum toxin A

• Intravesical capsaicin – instilled with a balloon catheter

Neurogenic Detrusor overactivity

Treatment

Only Urinary Retention

(If residual volume > 100ml) • Clean intermittent self

catheterisation (CISC)• Permanent indwelling

catheter

Detrusor overactivity &Retention

• Anticholinergic drugs• CISC

Treatment

• External device – condom catheter• Sacral nerve stimulators – for DI• Nerve root stimulators – S 2,3,4 for voiding assisting defecation• Surgery – Augmentation cystoplasty, artificial

sphincter, urinary diversion with stoma collection bag