This document provides an overview of neurogenic bladder including: 1. Neurogenic bladder affects 15% of the population and symptoms increase with age. Bladder dysfunction can negatively impact quality of life. 2. The bladder has storage and voiding functions controlled by the brain and spinal cord. Detrusor overactivity, detrusor-sphincter dyssynergia, and detrusor areflexia are types of neurogenic bladder dysfunction. 3. Investigations include post-void residual volume, uroflowmetry, and cystometry to evaluate the bladder and determine appropriate treatment which may include anticholinergics, botulinum toxin injections, clean intermittent catheterization, or surgery

1. NEUROGENIC
BLADDER
Dr Ashutosh Ojha
Mob-
9719713786(WhatsApp)
ashutosh8116@gmail.com

2. Outline of
the
presentation
Introduction
Applied physiology
Symptomatology
Types according to levels of
bladder dysfunction
Investigations
Treatment available

3. Why
understanding
of Bladder
15% of all population have some bladder dysfunction if
thoroughly investigated and worked upon.
People above 60 years have …50% bladder symptoms
Bladder dysfunction ..makes a patients ..smelling
…even untouchable …
Most of the dysfunction are treatable
Even good history and clinical examination can lead to
Diagnosis
Very few patients require sophisticated investigation
Hence..I PLEAD your valuable ATTENTION

4. 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.

5. ANATOMY-UB
• External urethral sphincter :-
Voluntary skeletal muscle (
Other entirely smooth muscle).
The external sphincter muscle is
under voluntary control of the
nervous system and can be used
to consciously prevent urination
even when involuntary controls
are attempting to empty the
bladder.
• Capacity:- Is about 300 ml with
a maximum capacity of 500 ml

6. ANATOMY..BL Neck
• The bladder neck is 2 to 3
cm long, and its wall is
composed of detrusor muscle
interlaced with a large amount
of elastic tissue.
• Muscle in this area is called
Internal sphincter.
• Its natural tone normally
keeps the bladder neck and
posterior urethra empty of
urine
• Posterior urethra- lower
part of the bladder neck
• ( because of its relation to the urethra)

7. 3.Spinal micturition
centre
4. Peripheral nerves
1.Cortical micturition centre
2.Pontine micturition centre(PMC)
Sympathetic
(T11 –L2)
Parasympathetic
( S2,3,4)
(S2,3,4)
Control of micturition

8. Cortical
micturation
centre(CMC)
• Location: Paracentral lobule in the
medial aspect of the frontoparietal cortex
• 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

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

10. 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 nuclei
Collection of external urethral
sphinter motoneurones
3. Levator Ani Motoneurones

11. Peripheral innervation

12. Stimulation Response
Parasympathetic
(S 2-4)
Excitatory to
detrusor, relaxes
sphincter -Helps void
Sympathetic
(T11- L2)
Inhibitory to detrusor,
↑trigone & Urethral
tone
Somatic ( S2 - 4) Excitatory to the
external sphincter

13. Micturition reflex
Internal sphincter –
no important role in micturition,
prevents leakage during filling and
prevents reflux of semen into bladder during
ejaculation
Sympathetic nerves –
no part in micturition

14. 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
Detrussor center (S 2,3,4) to pelvic nerves Onuf’s nucleus to pudendal nerves
RECIPROCAL ACTIVITY BETWEEN SPHINCTER & DETRUSOR
Micturition

16. On-off switch
Relay
center
Primitive
voiding
Cerebral
PMC
SMC

17. Symptomatology

18. Detrusor Hypereflexia

19. Detrusor Sphincter Dyssynergia

20. Resultant
• Poorly sustained hyperreflexic bladder
contraction (DH) and(DSD)
• Raised post voiding residual (PVR)
Exacerbation of symptoms

21. 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

22. 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

23. 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
• 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
Cauda equina

24. Types according to
the level of bladder
dysfunction

26. 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.

27. b) Pontine lesion –
“ Reflex / Automatic bladder”
DH,
Arreflexia in pts with INO
c) Spinal (subpontine/suprasacral)
“ Spastic Bladder”
Disorders of storage and emptying
DSD (true only if above T6 level), DH

28. d) Sacral and subsacral lesions
I) Afferent fibres involved only –
“Atonic /Areflexic bladder”
Overflow incontinence
Straining for micturition
No DSD, no DH
II) Both afferent and efferent involved –
“Autonomous bladder”
Small capacity , acting of its own. No DSD/DH

29. UMN-
SPASTIC
LMN-
FLACCID
AREFLEXIC
Cerebral
PMC
SMC

30. Causes of various levels of dysfunction
a) Suprapontine and Pontine Causes
• Stroke
• Tumors
• Dementia (AD,FTD)

31. Spinal causes (subpontine/suprasacral)

32. Sacral and Subsacral causes

33. Management-
Investigations
• Noninvasive bladder investigations-
• Post void residual volume –
• In without catheterization,Ultrasound (
N is <100ml)
• Uroflowmetry-
• Voided volume ( >100ml)
• Maximal flow, maximal and average flow
rate (M > 20ml/sec and F > 15ml/sec)

34. Cystometry-
• Measure detrusor
pressure (Intravesical
pressure & Rectal
pressure)
• Bladder infused till 400 to 600ml –
Pressure shouldnot rise to >15cm water
(Stable bladder)
• Neurogenic detrusor overactivity –
Involutary detrusor contraction during
filling phase
• Voiding phase – Detrusor pressure
• M<50cm of
water
F < 30cm water

35. Sphincter EMG –
Reinnervation with prolonged duration of
MUAPs
Neuroimaging –MRI
Cauda equina & conus lesions, spinal,
supra pontine and pontine lesions

36. 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

37. Neurogenic Detrusor overactivity

38. Treatment
Only Urinary Retention
(If residual volume > 100ml)
• Clean intermittent self
catheterisation (CISC)
• Permanent indwelling
catheter
Detrusor overactivity &
Retention
• Anticholinergic drugs
• CISC

39. 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

40. TAKE MY MESSAGE
•
•
•
•
•
•
•
Complaints about bladder function are common in
patients with neurological disease
Neurological evaluation is important to diagnose type of
neurogenic bladder.
Urodynamic studies are important to diagnose detrusor
hyperreflexia (DH), detrusor sphincter dyssynergia
(DSD), detrusor areflexia and organic outlet obstruction
For DH, anticholinergics are primary T/t.
For DSD, anticholinergics with α - blocker may be tried
along with CIC
For detrusor areflexia best therapy is CIC
Long term use of indwelling catheters should be
avoided

41. •Thank you

42. References
• Harrisons’ Principles of Internal Medicine
• Victor Adam Neurology
• Adam Atlas of Anatomy
• The whole presentation made to help PG Intenal
Med/ Surgery / Neurology and UG students …

43. Comments requested at
• Mob-+919719713786(WhatsApp Only)
• Email- ashutosh8116@gmail.com
• Reader ,Internal Medicine …..