The document provides a comprehensive overview of neurogenic bladder, including its anatomy, nerve supply, and various types of neurogenic bladder dysfunctions. It covers the physiological mechanisms, common causes of different bladder types, and the management of urinary incontinence and retention. Additionally, it outlines treatment options like catheterization, drug therapy, and surgical interventions for affected individuals.

1. NEUROGENIC BLADDER

2. Contents
1. ANATOMICAL INTRODUCTION
2. NERVE SUPPLY
3. PHYSIOLOGICAL REFLEX
4. NEUROGENIC BLADDER
5. INCONTINENCE
6. MANAGEMENT

5. URINARY BLADDER

6. URINARY BLADDER ANATOMICAL
INTRODUCTION
Urinary bladder is the temporary store
house of urine which gets emptied
through the urethra.
The male urethra subserving the
functions of urination and ejaculation.
Female urethra is for urination only.

7. CAPACITY OF THE BLADDER
Capacity in an adult male 120 to 320 ml.
Filling beyond 220 ml causes micturition,
emptied when filled to about 250 to 300
ml.
Filling up to 500 ml may be tolerated, but
beyond this it becomes painful.

8. • Detrusor - innervated by S2,3,4
parasympathetic (muscarinic M2
receptors) intermediolateral gray
column –pelvic n
• External urethral sphincter -
innervated by somatomotor
S2,3,4 nucleus (Onuf’s Nucleus)-
pudendal n
• Trigone and internal sphincter
innervated by Sympathetic
T10,11,12 (less important)
• Afferent sensation through pelvic
n and pudendal n, hypogastric n
(Aδ and C fibers) to
Periaqueductal gray matter
pontine micturition center
S 2,3,4
S 2,3,4
Innervation of male lower urinary tract

9. NERVE SUPPLY
Its contains both sympathetic and
parasympathetic components.
Parasympathetic efferent fibers S2,S3,
S4 are motor to the detrusor muscle and
inhibitory to the sphincter vesicae.
 If these are destroyed, normal
micturition is not possible.

10. NERVE SUPPLY CONTI….
 Sympathetic efferent fibers (T11 to L2):
- inhibitory to the detrusor
-motor to the sphincter vesicae
 The pudendal nerve (S2, S3, S4)
-supplies the sphincter urethrae which
is voluntary
 Sensory nerves:
• pain sensations,
causes:
- spasm of bladder wall
- carried by parasympathetic nerves and
partly by sympathetic nerves
NERVE SUPPLY CONTI….

11. HIGHER CENTER
 Higher centers for micturition
1) Inhibitory centers : midbrain
-cerebral cortex
2) Facilitatory centers : Pons
- cerebral cortex

12. FUNCTIONS OF NERVES
Nerve On
detrusor
muscle
On
internal
sphincter
On
external
sphincter
Function
Sympathetic
nerve
Relaxation Constriction Not supplied Filling of urinary
bladder
Parasympathetic
nerve
Constriction Relaxation Not supplied Emptying of
urinary bladder
Somatic nerve Not supplied Not supplied Constriction Voluntary control
of micturition

13. MICTURITION REFLEX
.
Filling of urinary bladder
Stimulation of stretch receptor
Afferent impulses pass via pelvic nerve
Efferent impulses via pelvic nerve
Contraction of detrusor muscle & relaxation of internal sphincter
Sacral segments of spinal cord

14. MICTURITION REFLEX CONTI…
Flow of urine into urethra and stimulation of stretch receptors
Afferent impulses via pelvic nerve
Inhibition of pudendal nerve
Relaxation of external sphincter
Voiding of urine

15. NEUROGENIC BLADDER
BY: P.J.MEHTA
There are five types of neurogenic bladder:
TYPE LESION
1. Uninhibited bladder ..cortico regulatory tract
2. Reflex bladder ..spinal cord above S2
3. Autonomous bladder ..at S2, S3 and S4 level
4. Motor atonic bladder ..motor efferents
5. Sensory atonic bladder ..sensory afferents

16. 1. UNINHIBITED BLADDER
CAUSES:
-cerebrovascular accidents,
-head injuries,
-brain tumors, etc.
Voluntary control of micturition is lost.
Lesion :
- the midbrain
- superior frontal gyrus

17. 2.REFLEX BLADDER
ETIOLOGY:
Transverses myelitis
Trauma
Neoplasms
Meningitis
Disseminated sclerosis
Lesion :
complete transection of spinal cord
above sacral segments

18. REFLEX BLADDER CONTI…
PATHOGENESIS:
Acute transaction of the cord causes
retention of urine during the stage of spinal
shock.
Leads to retention of residual urine.
During recovery stage, reflex activity begins
and automatic evacuation of bladder results.

19. 3. AUTONOMOUS BLADDER
ETOLOGY:
Congenital : spina bifida,
meningomyelocele
Trauma: gunshot, auto accidents
Infective: arachnoiditis, radiculitis
Neoplasms of the cord
Surgery: combined perineal and abdominal
resection.
LESION:
sacral segment of spinal nerve.

20. AUTONOMOUS BLADDER CONTI…
CLINICAL FEATURES:
Loss of bladder sensation
Inability to initiate micturition
normally
paralysis of pariurethral striated
muscles
associated with anesthesia and
absent bulbocavernous reflex.

21. 4. SENSORY PARALYTIC BLADDER
ETIOLOGY:
Tabes dorsalis
Pernicious anemia
Diabetes
Disseminated sclerosis
Syringomyelia
Lesion :
afferent fibers from the bladder

22. SENSORY PARALYTIC BLADDER
CONTI..
PATHOGENESIS:
Loss of bladder sensation, which leads
to overdistension of bladder.
Initially there is normal capacity
increases and residual urine appears.
CLINICAL FEATURES:
Initially these patients are
asymptomatic.
Gradually there is terminal dribbling
and later overflow incontinence.

23. 5. MOTOR PARALYTIC BLADDER
ETIOLOGY:
Poliomyelitis
Polyradiculopathy
Congenital anomalies
Tumor
Trauma
Lesion :
Efferent fibers of the bladder

24. MOTOR PARALYTIC BLADDER CONTI..
PATHOGENESIS:
Since the sensory nerves are intact,
bladder if left alone, distends and
decompensates.
CLINICAL FEATURES:
Painful distention of the bladder and
inability to initiate micturition.
Decrease in size and force of steam
and interrupted stream.
Recurrent episodes of urinary
infections.

25. INCONTINENCE OF URINE
The term ‘continence’ is used to
describe the normal ability of a person
to store urine and faeces temporarily,
with conscious control over the time
and place of micturition and
defaecation.
‘Incontinence’ has been defined as
the involuntary or inappropriate passing
of urine or faeces, or both, that has an
impact on social functioning or
hygiene(DoH 2000).

26. INCONTINENCE OF URINE
Types:
1. Extra urethral incontinence
2.Detrusor over activity incontinence
3.Urodynamic stress incontinence
4.Nocturnal enuresis
5.Giggle incontinence
6.Functional incontinence

27. 1.Extraurethral incontinence
Loss of urine through channels
other than the urethra
CAUSES
congenital abnormality.
trauma at pelvic surgery such as
hysterectomy
endometriosis,
infection or carcinoma.
Child birth(Wall 1999)

28. 2. Detrusor overactivity
incontinence
-present as a symptom, a sign and as
a condition
The symptoms:
complains of urge incontinence,
immediately preceded by urgency,
that is a strong desire to void.

29. Detrusor overactivity
incontinence
The sign:
conformed as a sign observed
at urodynamic assessment
The condition:
May be further qualified as
neurogenic, in neurological condition

30. 3.URODYNAMIC STRESS INCONTINENCE
Symptom:
during increased intra-abdominal
pressure, such as during coughing,
laughing, sneezing and lifting
Sign:
An involuntary spurt dribble or
droplet of urine is observed to leave
urethra immediately on an increase
in intra-abdominal pressure

31. 4.NOCTURNAL ENURISIS
During sleep, or “bed wetting”
15-20% of 5 year old children and
up to 2% of young adults(Glazener
&Evans 2003)

32. 5.GIGGLE INCONTINENCE
In girls around puberty
Caused by detrusor overactivity
induced by laughter(chandra et al
2002)

33. 6.FUNCTIONAL INCONTINENCE
involuntary loss of urine
in ability to perform toileting
functions secondary to physical or
mental limitation

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

35. 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