This PPT is for educational purpose for neural control of bladder, along with various types of neurogenic bladder

1. Presented by: Dr. Pravin Kumar
Moderator :Prof. S.B. DEVI
NEURAL CONTROL OF BLADDER

2.  Bladder divided into
◦ Detrusor - consists of smooth muscle
◦ Base-trigone and bladder neck, intimately
connected to pelvic floor.
Bladder outlet-two urethral sphincters
◦ Internal (smooth muscle) sphincter-bladder neck
and proximal urethra
◦ External (striated muscle) sphincter-membranous
urethra.
◦ Capacity- 400 to 600 ml

4. Urethral Sphin

5. Bladder functions
• Storage - at low pressure until 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.

6. 4. Peripheral nerves
1. Cortical micturition centre
2. Pontine micturition centre
Sympathetic
3.Spinal micturition
centre
(T11 –L2)
Parasympathe
tic ( S2,3,4)
(S2,3,4)
Control of micturition

7. Cortical micturation centre(CMC)
Location: Paracentral lobule in the medial aspect of the
frontoparietal cotex
Function: Inhibitory to PMC– Sends inhibitory signals to the
detrusor muscle to prevent the bladder contaction
Dysfunction : loss of social control of bladder(infant bladder)

8. Pontine Micturition Centre (PMC)
Also called Barrington’s nucleus
(located in the locus ceruleus, pontomesencephalic gray matter,
and nucleus tegmentolateralis dorsalis)
•Lateral region
Function - continence, storage urine. Stimulation results in a
powerful contraction of the external urethral sphincter
•Medial region
Function - micturition center
Coordinates the urethral sphincter relaxation and detrusor
contraction to facilitate urination

9. Sacral micturation centre
 1)Parasymapathetic
 2)Sympathetic
 3)Somatic

10. PARASYMPATHETIC:
CENTRE: S2-S4 in intermediolateral column
SUPPLY THROUGH: pelvic splanchnic nerves
NEUROTRANSMITTER : ACh VIA M2, M3
FUNCTION: Postganglionic neurons release ach → M2 and
M3 → detrusor muscle Bladder contraction & Internal
sphincter relaxation facilitating micturation

12. • SYMPATHETIC:
CENTRE: T11-L2 intermediolateral column
SUPPLY : Sympathetic chain ganglia- hypogastric and
pelvic plexus
FUNCTION:
–Via β-adrenergic receptors -relaxation of the detrusor
muscle.
–Through alpha 1 receptors causes Contraction of
internal sphincter
–Facilitate bladder storage and continence

14. SOMATIC :
CENTRE: Onuf nucleus S2-S4
SUPPLY THROUGH: Pudendal nerve
NEUROTANSMITTER: Ach via nicotinic receptor
FUNCTION : Controls the external sphincter(cortical
control)

15. Efferent pathways for bladder control (SMC)
tract

17. NEUROGENIC BLADDER
Definition: Dysfunction of the urinary bladder due to
disease of the central nervous system or peripheral
nerves involved in the control of micturition

18. 1)Uninhibited
2)Reflex
3)Autonomous
4)Motor
5)Sensory

19. Uninhibited bladder (failure to store)
 loss of the cortical inhibition of reflex voiding
bladder tone and sensation remains normal.
 frequency, urgency, and incontinence(detruser hypereflexia)
Urodynamic testing- normal bladder sensation and filling
parameters, multiple unstable contractions
Causes:
Stroke,brain tumour,NPH,dementia,parkinsonism etc

20. UMN/Reflex/Automatic neurogenic bladder
 lesion above the level of the sacral bladder center and
below the level of the PMC.
 Loss of the normal inhibition from higher centers results
in detrusor contraction during bladder filling(detrusor
hyperactivity)
 Detrusor sphincter dyssynergia(DSD) –obstructed voiding,
incomplete emptying ↑ IV pressure→HDN, Obst. Uropathy
 Symptoms -Urgency, frequency, hesitancy, interupted
stream, urge incontinence (DSD+DH)
Causes: spinal cord injury, tranverse myelitis, MS, ALS,
Myeopathy etc

21. Autonomous neurogenic bladder(flaccid bladder)
 lesion in between the bladder and spinal cord
 both afferent and efferent fibres are involved
 loss of sensation and voluntary control of bladder
 Inability to initiate micturition
 overflow incontinence and increased residual urine
develop.
Causes: Cauda equina syndrome, conus medullaris spinal
shock, extrinsic tumor compression,pelvic trauma,spina
bifida etc

22. Motor paralytic bladder
• Motor nerve supply to the bladder is interrupted
• The bladder distends and decompensates,
but sensation is normal
• residual urine is markedly increased
• the bulbocavernosus and superficial anal reflexes are
usually absent but sacral and bladder sensation are present
Causes: lumbar spinal stenosis,lumbosacral
meningomyelocele, following radical hysterectomy or
abdominoperineal .Resection, herpes zoster infection

23. Sensory paralytic bladder
 sensory nv supply to the bladder is interrupted
 lesions that involve the posterior roots or posterior root
ganglia of the sacral nerves, or the posterior columns of
the spinal cord.
 distension, dribbling, and difficulty both in initiating
micturition and in emptying the bladder.
 Painless urinary retention, overflow incontinence,UTI
 Sensation is absent, and there is no desire to void, can
void voluntarily (motor intact)
causes: Tabes dorsalis, diabetes, syringomyelia,pernicious
anemia etc

24. Treatment:
Uninhibited neurogenic bladder:
• Drugs to block parasympathetic activation of bladder contraction
• Oxybutynin, tolterodine, trospium,darifenacin, and solifenacin
Reflex neurogenic bladder:
• Clean intermittent self-catheterisation (CISC) every 4-6 hr
• Anticholinergic medication oxybutynin hydrochloride (5mg
tds) Tolterodine (1-2mg bd) Solifenacin (5-10mg)
• Cystoscopic placement of an intraurethral stent

25. Motor , sensory and autonomous bladder:
• Clean intermittent catheterization
• Indwelling catheters
• Sacral nerve root neuromodulation.
• Long term use of indwelling urinary catheter to be avoided

26. THANK YOU


27.  References;
Campbell wash urology 11th ed
Davidson’s medicine 22nd ed
Adam’s Neurology 10th ed