NEUROGENIC BLADDER

INTRODUCTION
The normal function of the urinary bladder is to store and expel urine in a coordinated, controlled fashion.
This coordinated activity is regulated by the central and peripheral nervous systems. Neurogenic bladder is a term applied to a malfunctioning urinary bladder due to neurologic dysfunction or insult emanating from internal or external trauma, disease, or injury.

URINARY BLADDER AND SPHINCTER

1. The detrusor muscle

2. Internal urethral sphincter

3. External urethral sphincter

 Normal voiding essentially is a spinal reflex that is modulated by the central nervous system (brain and spinal cord)which coordinates the functions of the bladder and urethra.

COMPONENTS OF MICTURITION REFLEX a) Brain b) Pons c) Spinal cord d) Peripheral nerves 1. Autonomic nervous system 2. somatic nervous system

Detrusor frontal centre Limbic centre Pons centre

Striated sphincter frontal centre Hypothalamic centre

Hypo gastric nerve

Bladder Pudendal nerve Pelvic nerve Sacral centre

1. BRAIN - Master control of the entire urinary system. - Micturition control centre is located in the frontal lobe and diffusively in the premotrice area (paracentral lobule). - Tonically inhibitory signals to the detrusor muscle to prevent the bladder from emptying.

2. BRAIN STEM
- The pons is responsible for coordinating the activities of the urinary sphincters and the bladder so that they work in synergy. - The mechanical process of urination is coordinated by the pons in the area known as the pontine micturition centre (PMC).

 PMC Excitatory in nature. Stimulation of PMC urethral sphincters to open & detrusor to contract expel the urine. PMC affected by emotions.

SPINAL CORD
Spinal cord acts as an important intermediary between the pons and the sacral cord. An intact spinal cord is critical for normal micturition. Sacral spinal cord - Specialized area known as the sacral reflex centre. It is responsible for bladder contractions. The sacral reflex centre is the primitive voiding centre.

 PERIPHERAL NERVES 1. SOMATIC NEURONS:Onuf nucleus (ant horn cell S2-S4) Pudendal N. sleletal muscles of ext. uretheral sphincter. - Acetylcholine excitatory stimulation. - Filling phase contraction of ext. sphincter maintain continence.

2. AUTONOMIC NEURONS a) PARASYMPATHETIC Excitatory. S2-S4 Pelvic nerve detrusor muscles contraction. - acetylcholine.

B) SYMPATHETIC NERVOUS SYSTEM- Inhibitory T10-L2 Inferior mesenteric ganglion

Hypogastric N. (mainly L2)

Fundus of bladder
Relaxation of bladder Beta 2 receptor

Trigone, bladder outlet

increases bladder outlet resistance Alpha1 receptor

FILLING PHASE
Sympathetic nerves facilitate urine storage in the following ways: Sympathetic nerves inhibit the parasympathetic nerves from triggering bladder contractions.

Sympathetic nerves directly cause relaxation and expansion of the detrusor muscle.

Sympathetic nerves close the bladder neck by constricting the internal urethral sphincter.

Emptying phase
Inhibition of somatic neurons relaxation of external sphincter.

The sympathetic nerves send a message to the internal sphincter to relax and open. The parasympathetic nerves trigger contraction of the detrusor.

PATHOPHYSIOLOGY
1. BRAIN LESION Lesions of the brain above the pons destroy the master control centre, causing a complete loss of voiding control. Primitive voiding reflexremain intact. Signs of urge incontinence or spastic bladder (Detrusor hyperreflexia or overactivity). The bladder empties too quickly and too often, with relatively low quantities, and storing urine in the bladder is difficult.

 Example:1. 2. 3. 4. 5. Stroke Hydrocephalus Brain tumor Cerebral palsy Encephalitis

SPINAL CORD LESION

Spinal cord injury - initial response - spinal shock.

Spinal shock phase, flaccid paralysis below the level of injury. Somatic reflex activity is either depressed or absent.
The autonomic activity is depressed - urinary retention. Urodynamic findings are consistent with areflexic detrusor.

 Spinal shock phase wears off, bladder function returns but the detrusor activity increases in reflex excitability to an overactive statedetrusor hyperreflexia.

The voiding disorder is similar to that of the brain lesion except that the external sphincter may have paradoxical contractions as well. If both the bladder and external sphincter become spastic at the same time:
Detrusor-sphincter dyssynergia because the bladder and the external sphincter are not in synergy

 Spinal cord lesion (above T6) - Urodynamic findings of detrusor hyperreflexia, striated sphincter dyssynergia and smooth sphincter dyssynergia . & a unique complication of autonomic dysreflexia.

Spinal cord lesions (below T6) -no autonomic dysreflexia.

SACRAL CORD INJURY & PERIPHERAL N. INJURY Detrusor areflexia. Selected injuries of the sacral cord and the corresponding nerve roots arising from the sacral cord may prevent the bladder from emptying.

If a sensory neurogenic bladder not able to sense when the bladder is full. In the case of a motor neurogenic bladder, the individual will sense the bladder is full and the detrusor may not contract, a condition known as detrusor areflexia.

 Incomplete bladder emptying,

Urinary retention,
Overflow incontinence (painless, flaccid, distended, constantly leaking bladder).

 Example:-

Sacral cord tumor Herniated disc Myelodysplasias Injuries that crush the pelvis. Diabetes mellitus AIDS Poliomyelitis Guillain-Barr syndrome Severe herpes in the genitoanal area

APPROACH
1. 2. 3. 4. 5. a) b) c) d) e) f) History & physical examination Lab studies- Urine routine & culture. Blood urea nitrogen and creatinine. USG & MRI. Other test- voiding diary & pad test. Diagnostic procedures Postvoid residual urine Uroflow rate Filling cystometrogram Voiding cystometrogram (pressure-flow study) Cystogram Electromyography

MANAGMENT
1. Stress incontinence may be treated with surgical and nonsurgical means. 2. Urge incontinence may be treated with behavioral modification or with bladder-relaxing agents. 3. Mixed incontinence may require medications as well as surgery. 4. Overflow incontinence may be treated with some type of catheter regimen. 5. Functional incontinence may be resolved by treating the underlying cause (eg, urinary tract infection, constipation) or by simply changing a few medications.

1. Absorbent products Pads or garments designed to absorb urine to protect the skin and clothing. Disposable and reusable forms. They are a temporary means of keeping the patient dry. 2. Urethral occlusive devices

Urethral occlusive devices are artificial devices that may be inserted into the urethra or placed over the urethral meatus to prevent urinary leakage.

Catheters
Bladder catheterization may be a temporary measure or a permanent solution for urinary incontinence.

1. Indwelling urethral catheters

2. Suprapubic catheters 3. Intermittent catheterization

Drugs
The 3 main categories of drugs used to treat urge incontinence include Anticholinergic drugs, Antispasmodics and Tricyclic antidepressant agents.

Stress incontinence results from a weak urinary sphincter. The internal sphincter contains high concentrations of alpha-adrenergic receptors. Sympathomimetic drugs and tricyclic agents increase bladder outlet resistance to improve symptoms of stress urinary incontinence.

 1.Anticholinergic drugs:- They are effective in treating urge incontinence because they inhibit involuntary bladder contractions. Propantheline Dicyclomine Hyoscyamine sulfate 2. Antispasmodic drugs:- These relax the smooth muscles of the urinary bladder. By exerting a direct spasmolytic action on the smooth muscle of the bladder, antispasmodic drugs have been reported to increase bladder capacity and effectively decrease or eliminate urge incontinence. Oxybutynin Tolterodine Flavoxate Drotaverine

 3. Tricyclic antidepressant drugs:- They function to increase norepinephrine and serotonin levels. In addition, they exhibit anticholinergic and direct muscle relaxant effects on the urinary bladder. Imipramine hydrochloride Amitriptyline hydrochloride

Surgical Care
Stress incontinence - procedures that increase urethral outlet resistance i)bladder neck suspension ii)periurethral bulking therapy iii)sling procedures iv)artificial urinary sphincter. Urge incontinence - procedures that improve bladder compliance or bladder capacity i)sacral neuromodulation ii)botulinum toxin injections iii)detrusor myomectomy iv) bladder augmentation

COMPLICATIONS OF T/T
Prolonged contact of urine- contact dermatitis and skin breakdown. If left untreated,these skin disorders may lead to pressure sores and ulcers. Decompensated bladder that does not empty well, the postvoid residual urine can lead to overgrowth of bacteria and subsequent urinary tract infection. Chronic indwelling catheters - recurrent bladder infection, bladder stones, ascending pyelonephritis, and urethral erosion. The use of intermittent catheterization may result in bladder infections or urethral injury.

 Chronic suprapubic tubes may result in bladder spasms, bladder stone formation, and bladder infection. Potential problems unique to suprapubic catheters include skin infection, hematoma, bowel injury, and problems with catheter reinsertion. Untreated urinary tract infections may lead to urosepsis and death.

COMPLICATION
1. 2. 3. 4. 5. Infection Hydronephrosis Calculus Renal amyloidosis Sexual dysfunction