NEUROGENIC BLADDER

1. ANATOMY,PHYSIOLOGY AND
APPROACH TO A PATIENT OF
NEUROGENIC BLADDER
BY SARBABHAUM TRIPATHY

2. ANATOMY
CONSISTS OF
• STORAGE ORGAN (MEMBRANOUS SAC COVERED BY
DETRUSSOR MUSCLE)
• OUTLET ( URETHRA AND SPHINCTERS)
DETRUSSOR MUSCLE -
• SMOOTH MUSCLE FIBRES ARRANGED IN SPIRAL,
LONGITUDINAL, AND CIRCULAR BUNDLES

3. URETHRAL SPHINCTERS
• EXTERNAL SPHINCTER (SPHINCTER URETHRAE): –
LOCATION –
• DISTAL INFERIOR END OF BLADDER IN FEMALES
• INFERIOR TO THE PROSTATE (AT THE LEVEL OF THE
MEMBRANOUS URETHRA) IN MALES
• SECONDARY SPHINCTER TO CONTROL FLOW OF URINE
THROUGH THE URETHRA
• SKELETAL MUSCLE
• VOLUNTARY CONTROL OF THE SOMATIC NERVOUS
SYSTEM.
• INNERVATED BY PUDENDAL NERVES

4. INTERNAL SPHINCTER MUSCLE OF URETHRA: –
LOCATION-
• JUNCTION OF PROXIMAL END OF URETHRA WITH
INFERIOR END OF BLADDER
• CONTINUATION OF DETRUSSOR MUSCLE
• SMOOTH MUSCLE
• UNDER AUTONOMIC CONTROL
• PRIMARY MUSCLE FOR PROHIBITING URINE
RELEASE

5. URINARY BLADDER

6. URETHRA CONSISTS OF
• INNER BAND OF LONGITUDINAL SMOOTH
MUSCLE
• MIDDLE BAND OF CIRCULAR SMOOTH
MUSCLE
• EXTERNAL BAND OF STRIATED MUSCLE

7. • PARASYMPATHETIC:
• CENTRE: S2-S4 IN INTERMEDIOLATERAL COLUMN
• SUPPLY THROUGH: PELVIC SPLANCHNIC NERVES
• END IN : GANGLIA IN BLADDER WALL
• NEUROTRANSMITTER : ACH VIA M2, M3
• FUNCTION: CHOLINERGIC TRANSMISSION IS THE
MAJOR EXCITATORY MECHANISM
• M2 AND M3 ON DETRUSSOR SMOOTH MUSCLE
INITIATES BLADDER DETRUSSOR CONTRACTION
AND INTERNAL SPHINCTER RELAXATION

8. • NON ADRENERGIC, NON-CHOLINERGIC
TRANSMITTERS-
• NON-CHOLINERGIC EXCITATORY
TRANSMISSION MEDIATED BY ATP ON P2X
PURINERGIC RECEPTORS IN DETRUSSOR
MUSCLE.
• INHIBITORY INPUT MEDIATED BY NITRIC
OXIDE (NO) ON URETHRAL MUSCLES

10. • SYMPATHETIC:
• CENTRE: T11-L2 INTERMEDIOLATERAL COLUMN
• SUPPLY THROUGH:
• SYMPATHETIC CHAIN GANGLIA-PREVERTEBRAL
GANGLIA-HYPOGASTRIC AND PELVIC PLEXUS –
INFERIOR MESENTRIC GANGLION –POST
GANGLIONIC FIBRES
FUNCTION:
• VIA Β3-ADRENERGIC RECEPTORS -INHIBITION AND
RELAXATION OF THE DETRUSSOR MUSCLE.
• VIA ALPHA1 RECEPTORS CAUSES CONTRACTION
OF INTERNAL SPHINCTER
• FACILITATE BLADDER STORAGE AND CONTINENCE

12. • SOMATIC :
• CENTRE: ONUF’S NUCLEUS S2-S4
• SUPPLY THROUGH: PUDENDAL NERVES
• FUNCTION : CONTROLS THE EXTERNAL
SPHINCTER

15. AFFERENT PATHWAY-
DETRUSSOR SENSATIONS-
• PELVIC AND HYPOGASTRIC NERVES
BLADDER NECK AND THE URETHRA
• PUDENDAL AND HYPOGASTRIC NERVES
• MYELINATED (AΔ) AND UNMYELINATED (C) AXONS.
• INFORMATION ABOUT BLADDER FILLING.
• AΔ-FIBRES - PASSIVE DISTENSION AND ACTIVE
CONTRACTION

16. • C-FIBRES(‘SILENT’ C-FIBRES) -NOXIOUS STIMULI
SUCH AS CHEMICAL IRRITATION OR COOLING
• CELL BODIES LOCATED IN DORSAL ROOT
GANGLIA (DRG) AT THE LEVEL OF S2–S4 AND
T11–L2 SPINAL SEGMENTS.
• SYNAPSE WITH INTERNEURONS MEDIATING
SPINAL REFLEX AND SPINAL-TRACT NEURONS
PROJECTING TO HIGHER BRAIN CENTRES
INVOLVED IN BLADDER CONTROL

17. SENSORY ROLE OF NON NEURONAL CELLS -
• THE UROTHELIUM ENGAGES IN RECIPROCAL
CHEMICAL COMMUNICATION WITH NERVES
IN BLADDER WALL
• EXPRESSION OF NICOTINIC,MUSCARINIC
,ADRENERGIC AND TRANSIENT RECEPTOR
POTENTIAL VANILLOID RECEPTORS(TRPV1)

18. • THE SUBUROTHELIAL LAYER OF
MYOFIBROBLASTS ( INTERSTITIAL CELLS) LIE
IN CLOSE PROXIMITY TO NERVES LINKED BY
GAP JUNCTIONS
• TOGETHER WITH AFFERENT NERVES, THE
UROTHELIUM AND SMOOTH MUSCLE,
COLLECTIVELY HAVE THE PROPERTIES TO ACT
AS A STRETCH-RECEPTOR ORGAN

22. CNS CONTROL
• PREGANGLIONIC NEURONS(PGNS) PRESENT IN
INTERMEDIATE GREY MATTER (LAMINAE V-
VII) OF SPINAL CORD
SACRAL(PARASYMPATHETIC) AND LUMBAR
SEGMENTS(SYMPATHETIC)

23. • THE SOMATIC MOTOR NEURONS LOCATED IN
THE VENTRAL HORN ( LAMINA IX ) IN ONUF’S
NUCLEUS,
• EXTENSIVE SYSTEM OF LONGITUDINAL
DENDRITES THAT TRAVEL WITHIN ONUF’S
NUCLEUS CONTROL THE EXTERNAL URETHRAL
SPHINCTER .

25. HIGHER CENTRES
SPECIFIC FOR MICTURITION-
• BARRINGTON’S NUCLEUS (PONTINE
MICTURITION CENTRE /M REGION ) LOCATED
IN DORSOMEDIAL PONS
• PERIAQUEDUCTAL GREY ( PAG )
• CELL GROUPS IN CAUDAL AND PREOPTIC
HYPOTHALAMUS
• MEDIAL FRONTAL CORTEX

26. • NON SPECIFIC ( LEVEL SETTING MECHANISM)
WITH DIFFUSE SPINAL PROJECTIONS-
• SEROTONERGIC NEURONS OF MEDULLARY
RAPHE NUCLEI
• NORADRENERGIC NEURONS OF LOCUS
COERULUS
• NORADRENERGIC A5 CELL GROUP IN BRAIN
STEM

28. • INTERNEURONS IN SPINAL CORD PROJECT TO
THE PAG
• NEURONS IN PMC RECEIVE INPUTS FROM
THE PAG AND ANTERIOR AND CAUDAL HYPO-
THALAMUS.
• PMC SENDS DESCENDING SIGNALS TO
PARASYMPATHETIC NUCLEUS OF SPINAL CORD
( EXCITATORY)

29. REGULATION OF FILLING AND VOIDING
• SIMPLE ON – OFF SWITCHING CIRCUITS
BLADDER FILLING AND GUARDING REFLEX-
• PARASYMPATHETIC INNERVATION OF DETRUSSOR IS
INHIBITED
• URETHRA- ACTIVATED, PREVENTING INVOLUNTARY
BLADDER EMPTYING- “GUARDING REFLEX”

30. • ORGANIZED BY INTERNEURONAL CIRCUITRY IN THE
SPINAL CORD
• INPUT FROM LATERAL PONS,ALSO KNOWN AS THE ‘L-
REGION’ OR ‘PONTINE STORAGE CENTRE’, ROLE IN
INVOLUNTARY SPHINCTER CONTROL

31. • SPINOBULBOSPINAL VOIDING-REFLEX PATHWAY
FUNCTIONS AS A SWITCH EITHER IN COMPLETELY ‘OFF’
MODE (STORAGE) OR MAXIMALLY ‘ON’ MODE (VOIDING)
• BLADDER FILLING --PARASYMPATHETIC TURNED OFF BUT
AT CRITICAL LEVEL OF BLADDER DISTENSION THE
AFFERENT ACTIVITY --SWITCHES THE PATHWAY TO
MAXIMAL ACTIVITY

33. Voluntary control of bladder and urethra has
two important aspects
1-registration of bladder filling sensations and
2-manipulation of the firing of the voiding reflex
PAG has pivotal role in both.Acts as relay station

34. • Sends and receives projection from higher
brain centres
• controls the primary input to the PMC
• higher brain centres (particularly the
prefrontal cortex- tonic suppression of
voiding) suppresses excitatory signal to PMC --
prevent voiding or incontinence

35. • Anterior cingulate cortex – determines
attention to signals coming from bladder
afferents and reaction to it by deciding to
void or by recruiting mechanisms that allow
voiding to be postponed
• Frontal lobes -determine the
appropriateness of micturition

36. NEUROTRANSMITTERS
• Glutamic acid, acting on NMDA (N-methyl-D-
Aspartate) (excitatory)
• Inhibitory amino acids (GABA,glycine and
enkephalins) exert tonic inhibitory control in
the PMC

39. NEUROGENIC BLADDER
• BLADDER DYSFUNCTION CAUSED AS A RESULT OF
NEUROLOGICAL DISORDER IS REFERRED TO AS
NEUROGENIC BLADDER
TYPES ARE-
1-UNINHIBITED BLADDER
2-REFLEX BLADDER
3-AUTONOMOUS BLADDER
4-MOTOR PARALYTIC BLADDER
5-SENSORY PARALYTIC BLADDER

40. NEUROGENIC BLADDER
TYPES-
• UNINHIBITED BLADDER –
• LOSS OF CORTICAL INHIBITION OF REFLEX
VOIDING
• BLADDER TONE REMAINS NORMAL
• BLADDER DISTENSION CAUSES CONTRACTION IN
RESPONSE TO STRETCH REFLEX
• FREQUENCY ,URGENCY ,AND INCONTINENCE
THAT ARE NOT ASSOCIATED WITH DYSURIA
• BLADDER SENSATION USUALLY NORMAL
• NO RESIDUAL URINE

41. UNINHIBITED BLADDER FOUND IN –
• CEREBROVASCULAR ACCIDENT( FRONTAL
LOBE)
• BRAIN TUMORS
• HEAD INJURY
• MULTIPLE SCLEROSIS
• PARKINSON’S DISEASE

42. • REFLEX NEUROGENIC BLADDER
• ALSO CALLED SPASTIC OR HYPERREFLEXIC BLADDER
• LESIONS ABOVE SACRAL CORD AND BELOW PONTINE
MICTURITION CENTRE
• UMN CUT OFF LMN INTACT
• DETRUSOR SPHINCTER SYNERGIA LOST RESULTS IN
OBSTRUCTED VOIDING,INTERRUPTED URINARY
STREAM,INCOMPLETE BLADDER EMPTYING
• BLADDER CAPACITY SMALL AND MICTURITION REFLEX
AND INVOLUNTARY
• RESIDUAL URINE VOLUME VARIABLE

43. • CONTRACTIONS OCCUR SPONTANEOUSLY OR
PROVOKED BY COUGHING/CHANGING
POSTURE ( STRESS INCONTINENCE)
• DETRUSOR OVERACTIVITY- URINARY
FREQUENCY ,URINARY URGENCY,URGE
INCONTINENCE

44. FOUND IN -
• SEVERE MYELOPATHY
• EXTENSIVE BRAIN LESIONS
• ASSOCIATED WITH QUADRIPLEGIA/PARAPLEGIA
AND ADVANCED CASES OF MULTIPLE SCLEROSIS
• INTERRUPTION OF BOTH DESCENDING
AUTONOMIC TRACTS AND ASCENDING SENSORY
PATHWAYS ABOVE THE SACRAL SEGMENTS OF
THE CORD

45. AUTONOMOUS BLADDER/FLACCID BLADDER –
• NO EXTERNAL INNERVATION
• DESTRUCTION OF PARASYMPATHETIC SUPPLY
• ABSENCE OF SENSATION
• NO REFLEX OR VOLUNTARY CONTROL OF
BLADDER
• CONTRACTION AS A RESULT OF STIMULATION OF
INTRINSIC NEURAL PLEXUSES WITHIN BLADDER
WALL
• LARGE AMOUNT OF RESIDUAL URINE

46. • URINARY RETENTION
• OVERFLOW INCONTINENCE
• INCREASED RESIDUAL URINE
• SADDLE ANESTHESIA
• LOSS OF BULBOCAVERNOUS AND
SUPERFICIAL ANAL REFLEX

47. CAUSED BY
• NEOPLASTIC,TRAUMATIC ,INFLAMMATORY
LESIONS OF SPINAL CORD BELOW T12 LEVEL
• CONGENITAL ANOMALIES LIKE SPINA BIFIDA
• SACRAL MYELOMENINGOCELE AND TUMORS
OF CONUS MEDULLARIS ,CAUDA EQUINA

48. MOTOR PARALYTIC BLADDER –
• MOTOR NERVE SUPPLY IS INTERRUPTED
• BLADDER DISTENDS AND DECOMPENSATES
• SENSATION NORMAL
• RESIDUAL URINE AND BLADDER CAPACITY
VARIES
• PAINFUL URINARY RETENTION /INCOMPLETE
BLADDER EMPTYING

49. CAUSED BY-
• LUMBAR SPINAL STENOSIS
• ABDOMINO-PERINEAL RESECTION SURGERY
• RADICAL HYSTERECTOMY

50. SENSORY PARALYTIC BLADDER –
• SENSATION IS ABSENT AND NO DESIRE TO VOID
• DISTENTION,DRIBBLING,AND DIFFICULTY BOTH IN
INITIATING MICTURITION AND IN EMPTYING
BLADDER
• LARGE AMOUNT OF RESIDUAL URINE
• URINARY RETENTION,OVERFLOW
INCONTINENCE,UTI
• PATIENT CAN VOID ( MOTOR INTACT) BUT NO
DESIRE TO VOID

51. CAUSED BY –
• INVOLVEMENT OF POSTERIOR
ROOTS/POSTERIOR ROOT GANGLIA OF THE
SACRAL NERVES /THE POSTERIOR COLUMNS
OF SPINAL CORD
• OCCURS IN TABES
DORSALIS,SYRINGOMYELIA,AND DIABETES
MELLITUS

52. SPINAL CORD INJURY (SCI)
• INITIALLY AREFLEXIC BLADDER AND COMPLETE
URINARY RETENTION THEN
• AUTOMATIC MICTURITION AND NEUROGENIC
DETRUSOR OVERACTIVITY (NDO) MEDIATED BY
SPINAL REFLEX PATHWAYS.
• INEFFICIENT VOIDING OWING TO
SIMULTANEOUS CONTRACTIONS OF THE
BLADDER AND THE URETHRAL SPHINCTER
(DETRUSOR–SPHINCTER DYSSYNERGIA)

55. APPROACH TO THE PATIENT
PRESENTING SYMPTOMS-
• URGENCY(SUDDEN, COMPELLING URGE TO URINATE)
• HESITANCY( DECREASED FORCE OF URINE STREAM,
WITH DIFFICULTY IN BEGINNING THE FLOW)
• FREQUENCY OF MICTURITION
• STRESS INCONTINENCE(UNINTENTIONAL LOSS OF
URINE ON PHYSICAL ACTIVITY)
• URGE INCONTINENCE(INVOLUNTARY LOSS WHEN
PERSON HAS DESIRE TO URINATE)
• URINARY RETENTION(INABILITY TO EMPTY THE
BLADDER COMPLETELY)

56. RELEVANT HISTORY
• H/O CONVULSIONS (FRONTAL LOBE TUMORS)
• H/O FOCAL NEUROLOGICAL DEFECT
• H/O HEMIPARESIS(FRONTAL LOBE
INFARCT/HEMORRHAGE)
• H/O PARAPARESIS (TRANSVERSE
MYELITIS/MULTIPLE SCLEROSIS)
• H/O TREMORS/REDUCED
MOVEMENT(PARKINSONS DISEASES)
• H/O HEAD TRAUMA
• H/O TRAUMA TO SPINAL CORD

57. • H/O LOSS OF SENSATION i.e. SADDLE ANESTHESIA(CAUDA
EQUINA SYNDROME)
• H/O BEHAVIOURAL DISTURBANCE(FRONTAL LOBE INFARCT-
INCONTINENCE)
• H/O DYSPHAGIA/DYSARTHRIA( BRAIN STEM INVOLVEMENT)
• H/O BURNING MICTURITION( URINARY TRACT INFECTION)
• H/O BIRTH TRAUMA/CONGENITAL BIRTH DEFECTS( SPINA
BIFIDA/MYELOMENINGOCELE)
• H/O SURGERY
• PAST H/O – DIABETES MELLITUS , SYPHILIS (SENSORY
INVOLVEMENT)

58. EXAMINATION
• DETAILED GENERAL AND NEUROLOGICAL
EXAMINATION
• WHETHER PATIENT IS CATHETERISED /
UNCATHETERISED
• ASSESSMENT OF HIGHER MENTAL FUNCTION
• ASSESSMENT OF MOTOR FUNCTION
• ASSESSMENT OF SENSORY SYSTEM
• CHARACTERISATION INTO UPPER MOTOR
NEURON INVOLVEMENT VS LOWER MOTOR
NEURON INVOLVEMENT

59. • WHEN PATIENT PRESENTS WITH
URGENCY/FREQUENCY/INCONTINENCE –
SIGNS OF UMN BLADDER – LOOK FOR BRISK
REFLEXES - SPASTICITY- EXAGERRATED DEEP
TENDON REFLEXES – PLANTARS EXTENSOR-
CAN BE DUE TO CORTICAL LESION ( WITH
HEMIPARESIS/BEHAVIOURAL SYMPTOMS) OR
LESIONS OF SPINAL CORD ABOVE S2-S4–
FURTHER BRAIN AND CORD IMAGING STUDIES

60. • WHEN PATIENT PRESENTS WITH
DISTENTION/RETENTION – SIGNS OF LMN
BLADDER – LOOK FOR REDUCED DEEP
TENDON REFLEXES- FLACCIDITY –OTHER
SENSORY INVOLVEMENT – CAN BE LESION OF
SPINAL CORD AT LEVEL OF S2-S4 – IMAGING
STUDIES AND FURTHER WORK UP

61. WORK UP
LABORATORY STUDIES-
• URINALYSIS AND URINE CULTURE – URINARY
TRACT INFECTION - IRRITATIVE VOIDING
SYMPTOMS AND URGE INCONTINENCE.
• URINE CYTOLOGY – IRRITATIVE VOIDING
SYMPTOMS OUT OF PROPORTION TO THE
OVERALL CLINICAL PICTURE AND/OR HEMATURIA
• RENAL FUNCTION STUDIES – BLOOD UREA
NITROGEN (BUN) AND CREATININE

62. • VOIDING DIARY-DAILY RECORD OF PATIENT'S
BLADDER ACTIVITY
• OBJECTIVE DOCUMENTATION OF PATIENT'S
VOIDING PATTERN, INCONTINENT
EPISODES,INCITING EVENTS ASSOCIATED
WITH URINARY INCONTINENCE.

63. DIAGNOSTIC PROCEDURES
• POSTVOID RESIDUAL BLADDER VOLUME
• UROFLOW RATE
• FILLING CYSTOMETROGRAM
• VOIDING CYSTOMETROGRAM (PRESSURE-FLOW
STUDY)
• CYSTOGRAM
• ELECTROMYOGRAPHY (EMG)
• CYSTOSCOPY
• VIDEOURODYNAMICS
• CT SCAN BRAIN AND SPINAL CORD
• MRI SCAN BRAIN AND SPINAL CORD

64. POSTVOID RESIDUAL BLADDER VOLUME
• POSTVOID RESIDUAL URINE (PVR)
• IF THE PVR IS HIGH- POORLY CONTRACTILE
BLADDER / BLADDER OUTLET OBSTRUCTION.

65. UROFLOW RATE (volume of urine voided per
unit time)
• Useful in Bladder outlet obstruction,detrusor
weakness
• Alone cannot distinguish an obstruction from
detrusor weakness

66. Filling cystometrogram
• A filling cystometrogram (CMG) assesses the
bladder capacity, compliance, and the
presence of phasic contractions (detrusor
instability). Most commonly, liquid filling
medium is used.
• An average adult bladder holds approximately
50-500 mL of urine. Provocative manoeuvres
help to unveil bladder instability.

68. Voiding cystometrogram
• Pressure-flow study simultaneously records
the voiding detrussor pressure and the rate of
urinary flow. This is the only test able to
assess bladder contractility and the extent of
a bladder outlet obstruction.
• Pressure-flow studies can be combined with
voiding cystogram and videourodynamic study
for complicated cases of incontinence.

69. Cystogram
• A static cystogram - confirm the presence of
cystocele, .The presence of a vesicovaginal fistula
or bladder diverticulum also may be noted.
• A voiding cystogram can assess bladder neck and
urethral function (internal and external
sphincter) during filling and voiding phases. A
voiding cystogram can identify a urethral
diverticulum, urethral obstruction, and
vesicoureteral reflux.

71. Electromyography
• EMG – determines if voiding is coordinated or
uncoordinate
• EMG allows accurate diagnosis of the detrusor
sphincter dyssynergia that is common in
spinal cord injuries.

72. Cystoscopy
• bladder lesions (eg, bladder cancer, bladder
stone) that would remain undiagnosed by
urodynamics alone.
• Cystoscopy is indicated for patients
complaining of persistent irritative voiding
symptoms or hematuria. (cystitis, stone, and
tumor)

74. Videourodynamics
• Videourodynamics is the criterion standard for
evaluation of a patient with incontinence.
Videourodynamics combines the radiographic
findings of voiding cystourethrogram (VCUG) and
multichannel urodynamics.
• Videourodynamics enables documentation of
lower urinary tract anatomy, such as
vesicoureteral reflux and bladder diverticulum, as
well as the functional pressure-flow relationship
between the bladder and the urethra.

76. TREATMENT AND MANAGEMENT
• Overflow incontinence -emptying the bladder
with a catheter
• Stress incontinence –procedures increasing
urethral outlet resistance, include:
• Periurethral bulking therapy
• Sling procedures
• Artificial urinary sphincter

77. Urge incontinence- behavioral modification
Surgical care for urge incontinence include the
following:
• Sacral neuromodulation
• Botulinum toxin injections

78. Urinary retention-
• Indwelling urethral catheters( Foley catheter)
• Suprapubic catheters
• Intermittent catheterization

79. • Anticholinergic drugs are the first-line
pharmacologic therapy in urge incontinence.
They are effective in treating urge
incontinence because they inhibit involuntary
bladder contractions.

80. • Solifenacin succinate
• Darifenacin
• Tolterodine L-tartrate for overactive bladder
• Beta-3 adrenergic receptor - Mirabegron was
approved in 2012 by the US Food and Drug
Administration (FDA) for the treatment of
overactive bladder.

81. Treatment contd.
• Vanilloids - The use of intravesical vanilloids in
human NDO is aimed at desensitizing bladder
afferents; prior instillation of a local
anaesthetic reduced the capsaicin-induced
irritation without blocking its effect(action on
TRPV1) not approved
• Botulinum neurotoxin A is effective in patients
of intractable NDO with spinal aetiology

82. BIBLIOGRAPHY
• The neural control of micturition by Clare J.
Fowler, Derek Griffiths, and William C. de
Groat, Nat Rev Neurosci. 2008 June ; 9(6):
453–466. doi:10.1038/nrn2401
• 7th edition DEJONG’S THE Neurological
Examination
• GUYTON AND HALLS textbook of physiology
11th edition

83. •THANK YOU ….