This document discusses bladder physiology, disorders, and treatment. It begins with the anatomy and nerve supply of the bladder. It then explains Bradley's loops, which describe the pathways controlling bladder function from the cortex to the bladder. Different types of bladder disorders are classified, including uninhibited cortical, automatic/reflex, autonomous, sensory paralytic, and motor paralytic bladders. Stress incontinence is also discussed. Treatment aims to protect the upper urinary tract, improve continence, and restore bladder function while improving quality of life. Conservative and medical therapies as well as external appliances are described.

1. BLADDER PHYSIOLOGY
AND DISORDERS.
DR SUHAIL RAFIK

2. ANATOMY

8. NERVE SUPPLY OF BLADDER

9. T11,
T12

10. NERVE SUPPLY

11. BRADLEY’S LOOPS : 1ST LOOP
 Also called the cerebral loop
 Connects the cortical areas with the pontine micturition centers “BARRINGTON
NUCLEUS”
 Cortex influences the pons and decides when to void and when to not.

12. BRADLEY’S LOOP

13. BRADLEY’S LOOP

14. LOOP 2
 Functions between the pons and the bladder
 Gets affected in any lesion involving the spinal cord above the sacral center

15. BRADLEY’S LOOP

16. LOOP 3
 Detrusor contraction sends
Afferent to Pudendal Nerve nucleus i.e.Onuff’s nucleus(somatic)
Inhibits external urethral sphincter
Hence the sphincter relaxes and allows voiding

17. LOOP 4
 “Urethral reflex”
 Flow of urine into the urethra stimulates the local plexuses and further helps in
relaxation of the external sphincter
 Helps in voiding

18. 5th LOOP
 Cortex influences the Onuff’s nucleus
 Which sends signals via somatic pudendal nerve
 Relaxes the external sphincter and helps voiding
 “Meaning everyone can voluntarily void even without a full bladder” because your
cortex decided so.

19. BLADDER CONTROL CENTERS

20. BARRINGTONS NUCLEUS
FIRST SIGNAL
AT 150 ML
STIMULATES A
FIBRES
SECOND SIGNAL
AT 400ML
STIMULATES BOTH
A FIBRES AND PAIN
FIBRES

23. BLADDER DISORDERS

24. EAU GUIDELINES ON NEURO-UROLOGY
PRE VOID :
frequency
Urgency
Urge incontinence
NORMAL VOIDING
NO POST VOID
RESIDUE
PREVOID:
UMN features
VOID:
Hesitancy
Cannot hold in between
Detrussor-sphincter
dysynergia
Double void
POST VOID:
Residual urine present
PRE VOID:
Normal
VOID:
Hesitancy
Poor or absent flow
Overflow
incontinence
POST VOID:
Increased residual
urine
1
2
3

25. LAPIDES CLASSIFICATION OF BLADDER DISORDERS

26. UNINHIBITED CORTICAL BLADDER
 Suprapontine lesion
 Bradley’s loop 1 affected
 Cortical pons pathway affected
 No social inhibiton
 Voids at wrong time, wrong place
 Small, spastic bladder
 Increased frequency

28.  Seen in :
 Cerebrovascular accidents
 Frontal tumors
 Parasaggital meningiomas
 Normal Pressure Hydrocephalus : gait disturbance, cognitive impairment, impaired bladder control.
 ACA aneurysm
 Parkinsons disease
 Demyelinating conditions

29. AUTOMATIC / REFLEX BLADDER
 Infrapontine lesions
 Sacral Reflex arc intact
 The Pons decision over switching between bladder filling and voiding- lost
 Frequent small voids
 Small bladder
 Seen in Multiple sclerosis / spinal cord tumours / spinal cord trauma.

30. AUTONOMOUS BLADDER
 Sacral or infrasacral lesion
 No nervous control over bladder
 Acts independently
 LMN bladder
 Large volume residual urine present
 Seen in conus medularis / cauda equine syndrome / peripheral neuropathy

31. SENSORY PARALYTIC BLADDER
 Isolated afferent denervation lesions
 No sensation of bladder filling
 Bladder overdistended
 Overflow incontinence
 Voluntary voiding needed
 Motor innervation intact
 Saddle anaesthesia present (s2,s3,s4 afferent lost)
 Seen In : multiple sclerosis / diabetes mellitus / tabes dorsalis

32. MOTOR PARALYTIC BLADDER
 LMN bladder
 Isolated motor denervation lesions
 Bladder sensation present
 Painful urine retention
 Bulbocavernous and anal reflex absent
 Has to void by Credes’ maneuver - pressure over distended bladder /lower abdomen
 Seen in lumbosacral meningomyelocoele / lumbar canal stenosis / extensive pelvic surgery / poliomyelitis /
polyradiculopathy

34. STRESS INCONTNENCE

35.  Normally during coughing/ sneezing intra abdominal pressure increases
 However urinary continence is maintained as the Nucleus retroambiguous sends signals to
ventrolateral medulla
 Stimulates the Onuff’s nucleus
 Contracts the external sphincter and pelvic floor muscles
 Multiple pregnancy and childbirth with instrumentation damages the pelvic integrity – stress
incontinence

36. TREATMENT
 The primary aims in treating neurourological disorders are:
 1. protection of the upper urinary tract;
 2. improvement of urinary continence;
 3. restoration of (parts of) the LUT function;
 4. improvement of the patient’s QoL.
 Further considerations are the patient’s disability, cost-effectiveness, technical
complexity, and possible complications

37.  Conservative treatment
 Assisted bladder emptying Triggered reflex voiding is not recommended as there
is a risk of pathologically elevated bladder pressures. Only in the case of absence,
or surgically reduced outlet obstruction it may be an option.
 Caution: bladder compression techniques to expel urine (Credé) and voiding by
abdominal straining (Valsalva manoeuvre) create high pressures and are
potentially hazardous, and their use should be discouraged

38.  Rehabilitation
 In selected patients, pelvic floor muscle exercises, pelvic floor electro-stimulation,
and biofeedback might be beneficial

39.  External appliances
 Social continence for the incontinent patient can be achieved using an appropriate
appropriate method of urine collection.
 Medical therapy
 A single, optimal, medical therapy for patients with neurourological symptoms is
not yet available. Muscarinic receptor antagonists are the first-line choice for
treating neurourological disorders.

40. REFERENCES
 EAU guidelines on neurourology
 DeJong’s The Neurologic Examination
 Localization in Clinical neurology

41. THANK YOU
 THANK YOU