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NEUROGENIC BLADDER
Dr. sh. Alaie
Neurologist
NEUROGENIC BLADDER
Definition
Is a malfunctioning bladder due to any type
of neurologic disorder.
NEUROGENIC BLADDER
Voiding:
1)Filling = storage :bladder acts as low
pressure receptacle
Sphincter high resistance
2)Voiding = Emptying :Bladder contracts
Sphincter opens
Both Should be done in Normal Pressure
Normal Voiding:1)Normal Detrusor
4-8 /day
2)Normal Sphincter
3)Synergy
4)Voluntrily
Normal Pressure
Anatomy
BRAIN
Master control of the entire Urinary system
Medial aspect of Precentral gyrus
Inhibitory signal to detrussor until a suitable
time &place
Injury :1)Unawareness to entire voiding
process
2) Spastic bladder
ANATOMY
PONS
PMC:coordinating Bladder &Urethral
Sphincter =Synergy
Facilitate Urination 1)detrussur contraction
2)sphincter relaxation
Ingury :1)Spastic bladder
2)DSD
ANATOMY
SPINAL CORD
Supra sacral:intermediary between PMC
&Sacral cord
Lat.CorticoSpinal &ReticuluSpinal
Injury: 1)Spastic Bladder
2)DSD
ANATOMY
Sacral cord
Primitive Voiding Center for Reflex Arc
S2,S3,S4
Injury :Detrusor Areflexia
ANATOMY
Peripheral nerves
1)Sympathetic :bladder & internal sphincter
2)parasympathetic: bladder
3)Somatic:Onuf neucleus: Ex.sphincter
Injury:Areflexic bladder:sensory /motor
Physiology
1)Filling
accumulation of urine while the pressure is low
If Pv >Pu : Urine Leackage
Reflux
Sympathetic :1)inhibit parasympathetic
2)relaxation &expansion of detrussor
3)close the bladder neck
Pudendal : contraction of the Ex.Sphincter
Pu>Pv
NEUROGENIC BLADDER
Physiology
2)Emptying:
Bladder filling to capacity: stretch receptors:pelvic
nerve
& Hypogastric nerve
Sacral cord:voiding
After 3-4 Yr old:sympathetic : relaxes in. sphincter
Ps: detrusor contraction
Pudendal: relaxation of ex.sphincter
Pv>Pu: voiding
TYPES of NEUROGENIC BLADDER
1)Detrusor :Overactive:Impaired filling
Underactive:Impaired Emptying
2)Sphincter:Overavtive:Impaired Emptying
Underactive:Leackage
3)Loss of coordination:Impaired Emptying
Types of Bladder Dysfunction
1- Failure of Storage (Detrusor Hyperreflexia)
2- Failure of Emptying
a) Detrusor Hypoactivity
b) Detrusor –Sphincter dyssynergia=DSD
3- Mixed type
All can be dangerous to upper tract
SYMPTOMS
Storage Failure
a) frequency / nocturia
Urination>8 times a day
or
> 2 times over night
b) urgency: extreme desire to void
c) Incontinency : urge in continence
d) hesitancy,intermittency,straining to
void,terminal dribbling.
SYMPTOMS
Emptying Failure
a) feeling of incomplete emptying
b) frequency , urgency
c) incontinency (overflow)
d) hesitancy,intermittency,straining to
void,terminal dribbling.
Symptoms are the same in all
types!
70% mismanagement based
on history alone!
COMPLICATIONS
1)rise in
Pv:REFLUX:Hydroureter/Hydronephrosis
2)Retention:Frequent UTI
(+reflux:Pyelonephritis)
3)Urinary stones
4)Impaired social & personal life
NEUROGENIC BLADDER
NEUROLOGIC DISEASES
Voiding dysfunction is important in
multiple sclerosis
Because of:
1- Frequency (up to 90% of patients)
2- Serious complications: 55% → 5%
3- Impairment of social &personal life &
sexual activity
4- Could be successfully managed
5- Social & cultural aspects
MS
SYMTOMS
- Voiding dysfunction may be the sole initial
complaint ( 2.3% ).
- Or part of the presenting symptoms
( 10% )
NEUROLOGIC DISEASES
CVA
Cerebral Shock:Det.Areflexia:Retention
Afew weeks/months later:Det.Hyperreflexia
NEUROLOGIC DISEASES
MSA
Urinary symptoms are common
Come early (60% before or associated with
other symptoms
Even 4yr before diagnosis
AUTONOMIC DYSREFLEXIA
Is a lethal emergency
Acute massive disorderd autonomic(S)
response to specific stimuli in SC injury
above T6- T8
More common in cervical
After shock period but up to yrs after injury
Stimuli below level of the lesion
AUTONOMIC DYSREFLEXIA
Headache/HTN(even ICH or sezure)
Flashing of face,body above the lesion
Sweating
Usually bradycardia,maybe
tachycardia/arrhytmia
Stimulus from: bladder/rectum:
distention,manipulation
GI/bone FX /sexual activity /bed sore
AUTONOMIC DYSREFLEXIA
Endoscopic procedure: spinal/ general
anesthesia
SL niphedipin/ oral niphedipin/ trazocin
Significant rise in BP without other
symptoms
Diagnosis
1- History: ask strictly about voiding
symptoms and feeling of
incomplete emptying
2- exam: pelvic exam
Sacral reflex exam
Signs of spinal cord involvment
3- Lab : U/A, U/C, BUN, Cr
Diagnosis
4- Imaging : sonography
a) Anatomy
b) Residue ( up to 100CC)
Diagnosis
5- In – out catheter method:
a) Well hydrated for 48 hr
b) Drink 2 glasses of water, before exam
c) First desire to void = capacity(300 – 500cc)
d) Measure residue after voiding
Diagnosis
Urodynamic study
A general term for the study of the storage
and voiding function
Diagnosis
Urodynamic study
a) Bladder eapacity (300 – 500cc)
b) Detrussor pressure, Max 10 Cm H2o
c) DSD
d) Detressor instability
e) L.P.P (leak point pressure)
Diagnosis
Urodynamic study
Indication
- urologic problems: Contraversy
- Neurologic problems:
All with neurogenic bladder
should undergo urodynamic study to
characterize the nature of the problem
and to determine prognosis and
management .
MANAGEMENT
GOALS
1234567-
upper tract preservation
absence or control of infection
adequate storage at low I.V.P
adequate emptying at low I.V.P
adequate control
no catheter
social acceptability
MANAGEMENT
STORAGE FAILURE
1) Non surgical:
a) Non pharmacologic
b) Pharmacologic
2) surgical
MANAGEMENT
STORAGE FAILURE
NON PHARMACOLOGIC
1- voiding diary: 3-5 days
a) Total 24hr urinary output
b) Number of voids
c) Voiding interval
d) Diurnal distribution
e) Timing and triggers for incontinence
MANAGEMENT
STORAGE FAILURE
Bladder training program :
1- lengthen the amount of time between
voiding.
2- increase the amount of urine the bladder
can hold .
3- improves the control over the urge.
4- patient gives voiding program to his
bladder.
MANAGEMENT
STORAGE FAILURE
BLADDER TRAINING PROGRAM
1- Kegel exercise.
2- delaying urination,5 min → 10 min
Walk instead of running at urge
Relaxation techniques
3- sheduled bathroom trips:
Every 1hr initially.
4- irritating factors: Alcohol, caffeine, acidic foods
(tomatoes, grapefruit)
5- change of temperature.
6- bio feedback and acupuncture.
MANAGEMENT
STORAGE FAILURE
pharmacologic
1- anti cholinergics:
a) Tolterodine 1-2 mg/bid
b) Oxybutinine 5 mg/TDS
2- TCA: imipramin 25 mg/day
3- desmopressin , spray, 1-2 puff
4- Ca antagonists/potassium channel
openers/prostaglandin inhibitors…??
MANAGEMENT
STORAGE FAILURE
pharmacologic
Warning!!!
Anticholinergic:
1- check for residue before
2- check for pharmacologic retention after
MANAGEMENT
STORAGE FAILURE
SURGICAL
1- intravesical injection of botolinum toxin
oxybutinin
capsaicin?
2- electrical stimualtion
3- denervation techniques
4- augmentation cystoplasty
MANAGEMENT
EMPTYING FAILURE
1- Non surgical
a) Non pharmacologic
b) Pharmacologic
2- surgical
MANAGEMENT
EMPTYING FAILURE
NON PHARMACOLOGIC
1- Valsalva – crede manuver:
Increase I.V.P
2- trigger void
3- clean intermittent catheterization( CIC )
MANAGEMENT
EMPTYING FAILURE
NON PHARMACOLOGIC
CIC
1- safe
2- extremely effective
3- most practical means of attaining catheter free state
4- preserves the independence
5- protects the kidneys
6- prevents incontinence
7- decrease infections
8- non expensive
MANAGEMENT
EMPTYING FAILURE
NON PHARMACOLOGIC
CIC
9- can be used in all types of dysfunction
10- decrease residue after a while
- If the patient can eat or write can do CIC
Cornerstone of treatment
MANAGEMENT
EMPTYING FAILURE
PHARMACOLOGIC
1- bethanechol?
2- baclofen
3- prosteglandin??
MANAGEMENT
EMPTYING FAILURE
SURGICAL
1- electrical stimulation
2- bladder myoplsty
3- reduction cytoplasty