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Urinary bladder

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BLADDER PATHOLOGY PLAYS AN IMPORTANT ROLE IN A SPINAL CORD LESION..MUST FOR A MEDICINE POST GRADUATE...

BLADDER PATHOLOGY PLAYS AN IMPORTANT ROLE IN A SPINAL CORD LESION..MUST FOR A MEDICINE POST GRADUATE...


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  • 1. URINARY BLADDER
    BY Dr.NAGULA PRAVEEN
    6/3/2010
    1
  • 2. Case scenarios
    1. A 45 year old male came to ED few hours after sustaining a fall from the steps and injured his spine—MRI spine showed the cord compression at T11, T12,L1—on examination the patient had paraplegia, areflexia,hypotonia.incontinence of bowel and bladder.
    6/3/2010
    2
  • 3. 2. A 35 yr old female k/c/o multiple sclerosis came with bladder complaints—cystometrogram showed uninhibited contractions of the bladder,detrusor is hyperactive,dysynergia present--?
    3.A 55 yr old female,hadprolapse of uterus and incontinence of urine while coughing and sneezing.she had h/o vaginal deliveries at home and perineal injury due to delivery.no treatment taken.
    6/3/2010
    3
  • 4. 4. a 45 yr old ,grossly pallor,k/c/ TB,cachetic patient was found to be incontinent before he could reach the toilets.cystometrogram revealed normal bladder function.
    5.A 43 yr old female suffering from frequent UTI presented with incontinence of urine before reaching the toilet.nocturnal wetting present.
    6/3/2010
    4
  • 5. 6. a 65 yr old case of BOO came with complaints of frequent passage of urine,patient giving history of pressure over the abdominal muscles while voiding but voiding is incomplete—USG showed high residual volume.
    6/3/2010
    5
  • 6. Review of cases
    1.overflow incontinence---spinal shock ,UMN lesion
    2.reflex neurogenicbladder,spastic as sacral nerves are intact.cortical inhibition is lost.UMN
    3.stress incontinence.
    4.functional incontinence.
    5.urge incontinence.
    6. atonic bladder due to BOO.
    6/3/2010
    6
  • 7. Anatomy
    immediately behind the pelvic bones
    Empty bladder within pelvis.
    pyramidal in shape when empty.
    Ovoid when filled with urine.
    Parts—apex, base,neck,superior surface ,two inferolateral surfaces.
    Epithelium-transitional---plastic
    6/3/2010
    7
  • 8. Apex connected to the umbilicus by median umbilical ligament—remnant of urachus.
    Superolateral angle joined by ureters.
    Inferior angle gives rise to urethra.
    Base or posterior surface is triangular.
    Vas deferens on the posterior surface of bladder..
    Peritoneal covering is peeled off the lower part of anterior abdominal wall,as the bladder fills,lies in direct contact with anterior abdominal wall.
    6/3/2010
    8
  • 9. held in position by puboprostatic ligaments.
    Mucous membrane -rugae –disappear when filled.
    Trigone-smooth,firmly adherent to the underlying muscular wall.
    Between ureters is called as interureteric ridge.
    Ureters enter obliquely.
    Muscle of the bladder-smooth muscle-detrusor.
    Sphincter vesicae at neck of bladder.
    6/3/2010
    9
  • 10. 6/3/2010
    10
  • 11. 6/3/2010
    11
  • 12. 6/3/2010
    12
  • 13. 6/3/2010
    13
  • 14. Blood supply,lymphaticdrianage
    Superior and inferior vesical arteries----internal iliac arteries
    Vesical venous plexus---prostatic plexus –internal iliac vein
    Internal and external iliac lymph nodes
    6/3/2010
    14
  • 15. sphincters
    Assure continence
    In male ,internal sphincter prevents the reflux of semen from urethra during ejaculation.
    to relax during micturition.
    Int. sphincter-sphincter vesicae-sym-adrenergic
    Ext,sphincter –sphincter urethrae-int.pudendal nerve
    6/3/2010
    15
  • 16. Nerve supply
    Inferior hypogastric plexuses.
    Sympathetic post ganglionicfibresfrom L1,L2 via hypogasrtic plexuses
    Parsympatheticpreganglionic fibers from S2,S3,S4---inferior hypogastric plexuses—bladder wall—synapse with post ganglionicfibres
    Afferent sensory fibres---pelvic sphlanchnic nerves—CNS
    Some afferent—sympathetic—hypogastric plexus—L1,L2
    6/3/2010
    16
  • 17. 6/3/2010
    17
  • 18. 6/3/2010
    18
  • 19. 6/3/2010
    19
  • 20. BLADDER FUNCTION
    Storage and intermittent evacuation of urine are served by three structural components –bladder itself,detrusor ,functional internal sphincter composed of smooth muscle,striated external sphincter or urogenital diaphragm .
    6/3/2010
    20
  • 21. Detrusor muscle innervation
    DETRUSOR CENTER S2,S3,S4 ofspinal cord intermediolateral columns of gray matter pre ganglionic fibers synapse in parasympathetic ganglia within the bladder wall short post ganglionic fibers end on ----muscarnic acetylcholine receptors of muscle fibers.
    Cause contraction of bladder.
    Antagonised by atropine—5mg
    6/3/2010
    21
  • 22. Sympathetic fibersinteromediolateral nerve cells of T10,T11,T12 preganglionic fibers pass via inferior sphlanchnicnerves,inferior mesenteric ganglia-----hypogastric nerve---beta adrenergic receptors in dome of bladder,alpha adrenergic to internal sphincter and trigone
    Filling phase of urine.
    Causes relaxation of bladder.
    Relaxation of sphincter.
    6/3/2010
    22
  • 23. Anterolateral horns of S2,S3,S4----densely packed group of somatomotor neurons—(nucleus of onuf)—pudendal nerves---External urethral and anal sphincter are composed of striated muscle fibers.
    Ventrolateral part —innervate external urethral sphincter
    Mediodorsal part--- anal sphincter
    Respond to nicotinic effects of Ach.
    6/3/2010
    23
  • 24. Urethra,external sphincter –afferent fibers---pudendal nerves—sacral segments of spinal cord---higher centers
    Impulses for reflex activities
    Sensation of bladder fullness
    Some go through hypogastric plexus---transverse lesions of the cord as high as T 12 report vague discomfort of urethra.
    6/3/2010
    24
  • 25. Special feature of Detrusor muscle
    Unlike striated muscle ,detrusor muscle is capable of some contractions,imperfect at best due to its postganglionic system—after complete transection of the sacral segments of spinal cord.
    Do not empty the bladder completely.
    Dysynergia of detrusor and external sphincter muscles---as coordination occur at supraspinal levels.
    6/3/2010
    25
  • 26. Micturition center
    lies in locus cereleus.
    Medial region—triggers micturition.
    Lateral region—continence.
    Afferents from sacral segments
    Efferents ---reticulospinal tracts in the lateral funiculi of the spinal cord ---cells of onuf—sacral segments.
    Fibers from motor cortex—corticospinal tracts—AHC-external sphincter.
    Mid brain tegmentum are inhibitory
    Pontine tegmentum are facilitatory
    From cortico spinal tract is inhibitory.
    6/3/2010
    26
  • 27. Normal micturition
    Possible only when the spinal segments.,together with their afferent and efferent nerve fibers,are connected with so called micturition centers in the pontomesencephalictegmentum.
    6/3/2010
    27
  • 28. The act of micturition is both reflex and voluntary.
    Normal person on voiding
    1.voluntary relaxation of the perineum
    2.increased tension of the abdominal wall
    3.slow contraction of the detrusor
    4.opening the internal sphincter
    5.relaxation of the external sphincter.
    Detrusor contraction is spinal stretch reflex
    6/3/2010
    28
  • 29. Assisted by abdominal muscle contraction –raises intrabdominal pressure—external pressure on bladder
    It is a simple reflex in young children,inhibited by crebral cortex in adults—corticospinal tracts –S2,S3,S4
    Voluntary control of micturition –sphincter urethrae contraction—2-3 yr of life.
    6/3/2010
    29
  • 30. The abdominal muscles have no power to initiate micturition except when the detrusor muscle is not functioning normally.
    The voluntary restraint of micturition is a cerebral affair—arise from frontal lobes
    Integration of detrusor and external sphincteric function depends mainly on the descending pathway from the dorsolateralpontinetegmentum.
    6/3/2010
    30
  • 31. Increased blood flow was detected in the right pontinetegmentum,periaqueductalregion,hypothalamus,and right inferior frontal cortex
    Subjects prevented from voiding with full bladder-right ventral pontinetegmentum
    Pontine centers involved in in voiding.
    6/3/2010
    31
  • 32. 6/3/2010
    32
    LESIONS—BLADDER FUNCTION
  • 33. 6/3/2010
    33
    1.Loss of complete cord below T12
  • 34. Trauma,myelodysplasias,tumor,venousangioma,necrotizingmyelitis.
    Bladder is paralysed
    No awareness of fullness of bladder.
    Overflow incontinence
    Voiding by credemanuevre—lower abdominal compression and straining
    Saddle anesthesia.
    Anal sphincter and colon are affected.
    Abolition of bulbocavernousreflexes,anal reflex
    Cystometrogram low pressure and no emptying contractions.
    6/3/2010
    34
  • 35. 2.disease of the sacral motor neurons in the spinal gray matter,the anterior roots ,peripheral nerves
    6/3/2010
    35
  • 36. Ex—lumbar meningomyelocele,tethered cord syndrome.
    LMN paralysis of the bladder
    Paralyzed bladder.—tone is lost.
    Voluntary intiation of micturition is lost.—loss of cortical fibres
    Bladder distends as urine accumulates until there is overflow in continence.
    Sacral and bladder sensation are intact.
    It is ATONIC bladder.
    6/3/2010
    36
  • 37. 6/3/2010
    37
  • 38. 3.interupption of sensory afferents from the bladder
    in diabetes and tabesdorsalis
    motor fibers are unaltered.
    primary sensory bladder paralysis
    both afferents and efferents are affected
    small fibers-diabetes.
    Guillainbarre syndrome..
    6/3/2010
    38
  • 39. 4.upper spinal cord lesions:
    Reflex neurogenic bladder (spastic)
    Multiple sclerosis,traumaticmyelopathy
    Syringomyelia,myelitis,spondylosis,AVM,tropical spastic paraperesis.
    Sudden onset—spinal shock
    Urine accumulates—distended—overflows
    As spinal shock resolves—unable to inhibit the bladder—urgency,precipitantmicturition,incontinence result.
    6/3/2010
    39
  • 40. 6/3/2010
    40
  • 41. Intiationof voluntary micturition is impaired and bladder capacity is reduced
    Bladder sensation upon sensory tracts
    Preservation of bulbocavernous and anal reflexes
    Uninhibited contractions of bladder in relation to low volume of urine
    If the lesion develops slowly—no flaccid stage,incontinence worsen with time
    In case of cervical cord injury there is persistent hypotonicity.
    6/3/2010
    41
  • 42. 5.mixed type of neurogenic bladder
    Multiple sclerosis
    Tethered cord syndrome,
    Multiple level lesions
    Combination of sensory motor,spastic bladder paralysis
    6.stretch injury of the bladder
    Anatomic obstruction of bladder neck
    Repeated voluntary retention of urine
    Repeated overdistention leads to decompensation—atonia,hypotonia
    Emptying contractions are inadequate.
    Large residual volume even after the credemanuevre
    6/3/2010
    42
  • 43. 7.frontal lobe incontinence
    Confused mental state
    Ignores the desire to void
    Subsequent incontinence
    Supranuclear type of hyperactivity and precipitant evacuation
    Posterior part of superior frontal gyrus,anteriorcingulategyrus
    No warning signs of fullness—suddenly wet
    Waking hours.
    8. nocturnal incontinence enuresis-
    Delay in acquiring inhibition of micturition
    6/3/2010
    43
  • 44. Urge incontinence
    6/3/2010
    44
  • 45. URGE INCONTINENCE
    Reduced bladder capacity
    Excessive and inappropriate detrusor contraction.
    Decreased cortical inhibition –cerebral infarction,alzheimersdisease,braintumor,parkinsons disease.
    Bladder irritation—trigonitis,post radiation fibrosis.
    Outflow tract obstruction . Frequent episodes of urgency
    Moderate to large volumes
    Nocturnal wetting
    6/3/2010
    45
  • 46. Sphincter /pelvic incompetence
    MC form of urinary incontinence
    Pelvic floor laxity-ageing,vaginaldeliveries,directperineal injury cystocele prostatic surgery
    Partial denervation.
    Incontinence at times of straining –coughing,laughing,sneezing.lifting
    Small to moderate volume of urine
    Very infrequent night time leakage
    Little post voidal residual .
    6/3/2010
    46
  • 47. 6/3/2010
    47
  • 48. 6/3/2010
    48
  • 49. Reflex incontinence
    Spinal cord damage above sacral cord level
    Detrusor spasticity
    Functional outflow obstruction
    Unable to sense the need to void
    Spinal cord injury is most common
    Day and night time with equal frequency
    Without warning or precipitating stress
    Moderate volumes
    Frequent voiding
    Perineal sensation reduced
    Sacral reflexes intact
    6/3/2010
    49
  • 50. Functional incontinence
    Physical and mental disabilty
    Urinary tract is intact
    Sedatives may exacerbate the condition
    Frontal lobe dysfunction
    6/3/2010
    50
  • 51. WORK UP
    History—precipitants
    Timing
    Frequency
    Volume of urine loss
    Warning symptoms
    Intactness of perineal and bladder sensations
    Diary of events and contributing factors
    Medications—anticholinergics,alphaadrenergics,b blockers
    6/3/2010
    51
  • 52. Physical examination
    Gen examination
    Suprapubic palpation
    Percussion of bladder after voiding
    Per rectal-prostate enlargement
    Valsalvamanuevre
    Stress incontinence when bladder is full
    Vaginal atrophy
    Bulbocavernous reflex’
    Anal sphincter tone
    6/3/2010
    52
  • 53. Lab analysis
    Urinalyiss
    BUN
    Creatinine
    Glucose
    USG
    Cystometrogram
    Stress tests2gm of wetting
    Cotton swab test
    Marshall and bonney test
    Urethroscopy
    6/3/2010
    53
  • 54. 6/3/2010
    54
  • 55. CYSTOMETROGRAM
    6/3/2010
    55
  • 56. Therapy
    Flaccid paralysis—bethanechol
    Spastic paralysis—propantheline,oxybutinin
    Intermittent self catheterisation
    Chronic antibiotic therapy
    Vitamin C 1000mg/day
    Sacral stimulator
    6/3/2010
    56
  • 57. summary
    6/3/2010
    57
  • 58. TAKE HOME MESSAGE
    Stress incontinence is a feature of elderly.
    Urge Incontinence in case of chronic trigonitis
    Functional incontinence in case of severel ill patients.
    Cystometrogram is important for evaluation.
    Self catheterisation by the patient to be encouraged.
    USG showing residual volume over 20 ml—neurogenic bladder.
    Every case of incontinence check for sacral area for sensations,bulbocavernousreflex,anal sphincter tone by PR
    6/3/2010
    58
  • 59. REFERENCES
    SNELLS ANATOMY
    PRIMARY CARE MEDICINE
    HARRISONS 17 TH ED
    ADAM AND VICTORS’ PRICIPLES OF NEUROLOGY SEVENTH ED.
    6/3/2010
    59
  • 60. Thank you
    6/3/2010
    60