Neurogenic Bladder part 1 By Dr Arman Hossain, MD Physical Medicine , Dhaka Medical College Hospital, Dhaka, Bangladesh.

1. Neurogenic Bladder -1
Dr. SM Arman Hossain
MD Resident (Phase-B)
Physical Medicine And Rehabilitation
Dhaka Medical College Hospital

2. Introduction
The primary functions of the urinary bladder are storage of urine
and coordinated emptying
Incontinence and urinary retention are common presenting
symptoms of bladder dysfunction in patients with neurologic
disorders
The management of neurogenic bladder dysfunction is too
important to be left as a matter for occasional consultation

3. Neuroanatomy of Urinary Bladder

4. Neuroanatomy of Urinary Bladder..Cont’d
BD Chaurasia’s Human Anatomy

5. Neurophysiology
Central pathways
• Cortical Micturition centre( paracentral lobule of the
frontoparietal cortex)
- Inhibits parasympathetic sacral micturition center
- Inhibitory to pons
- Allows bladder storage
• Pontine Micturition center(PMC)
- Lateral Region: storage urine
- Medial Region: Micturition center
- Coordinates bladder contraction and sphincter relaxation
(Physical Medicine and Rehabilitation Board Review)

6. Cont’d..
Peripheral pathways
Coordinated by interactions between the autonomic nervous
system (sympathetic and parasympathetic) and somatic nervous
System
• Sympathetic nervous system- urine storage
• Parasympathetic nervous system- urine release.
*Sympathetic for “S”torage & Parasympathetic for “P”ee

7. Cont’d..
Parasympathetic
Origin: intermediolateral gray matter at S2–S4 levels
Course: Travel through pelvic nerves to parasympathetic
receptors of detrusor muscle
Function: Stimulation of cholinergic receptors
Result: Bladder contraction & emptying

8. Cont’d..
• Sympathetic
Origin: Intermediolateral gray matter from T11–L2
Course: Travel through hypogastric nerves to α-1 and ß-2
adrenergic receptors within the bladder and urethra
Function: Stimulation of ß-3 adrenergic receptors within the
body of the bladder causes smooth muscle relaxation
(compliance)
stimulation of α-1 adrenergic receptors within the base of the
bladder/prostatic urethra causes smooth muscle contraction
(increase outlet resistance)
Result: urine storage

9. Cont’d..
• Somatic efferents fibers
o Origin: Pudendal nucleus of sacral segments (S2–S4)
o Course: Travel through pudendal nerve to innervate striated
muscle of external urethral sphincter.
o Function: Voluntary contraction of external urethral sphincter
o Result: prevents leakage or emptying

10. Cont’d..
• Somatic afferent fibers:
o Origin: Detrusor muscle stretch receptors, external anal and
urethral sphincters, perineum, genitalia.
o Course: Travel through the pelvic and pudendal nerves to the
sacral cord.
o Function:
- Myelinated A-delta fibers respond to bladder distention
stimulating parasympathetic emptying of bladder.
- Unmyelinated C-fibers are silent and not essential for normal
Voiding
o Result : Voiding of the bladder

11. Cont’d..
Urethral sphincters
• Internal sphincter:
- Mostly innervated by T11–L2 hypogastric nerve (sympathetic)
- Under control of autonomic system; large number of alpha-
adrenergic receptors
- Contracts sphincter for storage
- Smooth muscle, involuntary
• External sphincter:
- Innervated by pudendal nerve (S2–S4)
- Prevents leakage or emptying
- Skeletal muscle, voluntary

12. Neuropharmacology
Receptors of urinary bladder
Cholinergic muscarinic receptors (M3)
Located within the bladder wall, trigone, bladder neck, and
urethra. Ach binds to M3 receptors to cause contraction
• Beta-3 adrenergic receptors:
Concentrated in the body of the bladder, also some in bladder
neck.Norepinephrine (NE) binds to beta-adrenergic receptors to
cause relaxation
• Alpha-1 adrenergic receptors:
Located within the base of the bladder and prostatic urethra
NE binds to alpha-1 adrenergic receptors to cause contraction

13. Cont’d….
krusen's handbook of physical medicine and rehabilitation

14. cont’d..
(Vishram Singh Textbook of Anatomy)

15. Micturation reflex
Micturation reflex: It is a spinal reflex facilitated & inhibited by higher brain canters to
void urine from urinary bladder.(Guyton & Hall). Pathways-
Filling of urinary bladder
Stimulation of stretch receptor
Afferent impulses pass via pelvic nerve
Sacral segment of spinal cord
Efferent impulses via pelvic nerve
Contraction of detrusor muscle & relaxation of internal sphincter

16. Cont’d…
Flow of urine into urethrae & stimulation of stretch receptor
Afferent impulses via pelvic narve
Inhibition of pudendal nerve
Relaxation of external sphincter
Voiding of urine
(Ref: Sembulingam 7th edition)

17. Normal Voiding
• First sensation- 100 ml to 200ml of urine
• Sensation of fullness- 300 to 400 ml
• sphincter remains contracted through a primitive reflex known
as the holding reflex
• Sensation of Urgency- 400 to 500ml
• Normal Bladder capacity- 400 to 700 ml
krusen's handbook of physical medicine and rehabilitation

18. Cont’d..
• During emptying: The periurethral striated sphincter is
relaxed, At the same time, the bladder neck will relax
• The detrusor muscle of the dome of the bladder contracts
• voiding takes place
• This extraordinarily well-coordinated process requires perfect
synergy between the sympathetic, parasympathetic, and
somatic nerve supplies

19. Neurogenic bladder
• Neurogenic bladder is defined as bladder dysfunction resulting
from a central or peripheral neurologic insult
• Possible symptoms include urinary incontinence, urgency,
nocturia, straining, incomplete voiding, and urinary retention
https://now.aapmr.org/

20. Anatomical Classification
Anatomical Classification of Neurogenic bladder
1. Supraspinal
2. Suprasacral
3. Infrasacral
Braddom's physical medicine and rehabilitation

21. Cont’d…
1. Supraspinal lesion
- Uninhibited bladder
- Lesion of CNS involving area above Pons
- Micturition is usually precipitous & complete
- Absent Post void residual (PVR) urine
- Normal Sensation of bladder filling
- Cause: CVA, frontal tumors, parasagital meningioma,PD
*Local reflex ঠিক থাকবে। signal---- cerebral cortex পর্যন্ত র্াবে।
ককন্তু pons এর micturition center কক inhibit করবে পাবর না।*
Braddom+krusen+Board review+queen’s neurology

22. Cont’d…
2. Suprasacral lesion
- Automatic Bladder/Reflex neurogenic bladder
- Inability to initiate voluntary micturition
- Detrusor-sphincter dyssynergia is a rule
- Bladder tone increased, capacity reduced
- Small residual volume
- Cause: Compressive myelopathy, Spinal cord trauma
syringomyelia
*Local reflex ঠিক থাকবে। ককন্তু brain এর সাবথ communication নাই। োই local reflex এর মাধ্যবম micturition
হবে*

23. Cont’d…
3. Infrasacral Lesion
- Atonic Bladder/Autonomous bladder
- Denervation of both afferent & efferent supply to bladder
- Bladder tone flaccid
- Increased bladder capacity & PVR urine
- No bladder reflex acitvity
- Infection rate is high
- Overflow incontinence, no urgency
- Cause: Cauda equina syndrome, conus medularis, spinal shock
*কারন bladder এর সাবথ অনয কাবরা সম্পকয নাই*

24. Cont’d…
Neurology: A Queen Square Textbook

25. Functional Classification
1. Failure to store:
- Overactive bladder(OAB)
- UMN bladder
- Voiding is unpredictable & incomplete
- Symptoms: Urgency, Frequency, Urgency incontinence,
nocturia
Braddom+Board review

26. Cont’d…
2. Failure to empty:
- Urinary retention
- LMN bladder
- Fills without emptying
- Symptoms: Hesitancy, feeling of incomplete voiding,
straining, double voiding

27. Cont’d…

28. Cont’d…

29. Cont’d…
Lesion involving afferent sensory neurons:
• Sensory neurogenic bladder
• Impaired bladder sensation
• Initiation of micturition is possible
• If bladder not voided at timely basis--- overdistended bladder
• Bulbocavernosus & anal reflexes are absent
• Cause: tabes dorsalis, neuropathies mainly small fibers-DM,
amyloidosis

30. Cont’d…
Lesion involving efferent motor neurons:
• Motor paralytic bladder
• Bladder tone flaccid, sensory intact
• C/O painful retention of urine
• Inability to initiate or maintain micturition
• Bulbocavernosus & anal reflexes are absent
• Cause: Extensive pelvic surgery or trauma, Lumbosacral
meningomyelocele

31. NLUTD symptoms
Voiding Symptoms:
- Hesitancy
- Slow Stream
- Straining to void
- Terminal dribbling
- Feeling of incomplete emptying
Storage symptoms:
- Frequency
- Urgency
- Urge incontinence
- Nocturia

32. Urodynamic terminology
Frequency: Failure bladder storage function leads to frequency
of micturition
Urgency: Sudden, strong desire to void urine
Urge incontinence: Sudden & involuntary loss of urine
Nocturia: Interruption of sleep by urge to void
Braddom+Baily& Love

33. Cont’d…
Hesitency: Difficulty to initiate micturation
Urinary retention: It is the inability of the urinary bladder to
empty. cause may be neurogenic or non neurogenic
Hesitancy: Difficulty in initiating voiding

34. Cont’d…

35. Cont’d…
Detrusor–Sphincter Dyssynergia(DSD)
• Loss of the coordinating control of the pontine micturition center
• Lesion in suprasacral Spinal cord injury (SCI)
• Detrusor contraction and sphincter relaxation are not coordinated
• Spastic bladder will often try to empty against a closed sphincter
• This manifests as both urgency and an inability to pass urine
• Resultant incomplete bladder emptying predisposes to urinary
infection
Davidson's Principles and Practice of Medicine+ Braddom

36. Diagnostic testing for Neurogenic Bladder
dysfunction

37. Upper Tract Tests
1. Ultrasonography
2. Plain radiography of the urinary tract: KUB
3. Computed tomography
4. Excretory Urography or CT Urogram
5. Creatinine clearance Time
6. Isotope studies

38. Lower Tract Tests
1. Urinalysis, culture and sensitivity testing
2. Postvoid Residual(PVR)
3. Cystography
4. Urodynamics
5. Urethral Pressure profiles
6. Sphincter Electromyography
7. Videourodynamics/ Flurourodynamics
8. Cystoscopy

39. Ultrasonography
• low-risk and relatively low-cost test for routine evaluation and
easy for the patient. It is not
• Sensitive enough to evaluate acute ureteral obstruction
• Adequate for imaging chronic obstruction and dilation,
scarring, renal masses (both cystic and solid), and renal
stones
• The bladder, unless empty, can be evaluated for wall thickness,
irregularity

40. Plain radiography of the urinary tract: KUB
• A kidneys, ureters, and bladder (KUB) study is often
combined with US to identify any possible radiopaque calculi
in the ureter or bladder stones not seen on US

41. Computed tomography
• Performed without contrast enhancement
• Replaced KUB, US, and excretory urography in the evaluation
of the upper tracts when acute obstruction from stones is a
possibility.
• Most sensitive study for detecting small bladder stones in
patients with an indwelling catheter in whom the bladder is
collapsed around the catheter

42. Excretory Urography or CT Urogram
• With a delayed phase, A CT without/with contrast, has
replaced the excretory urogram now called a “CT-urogram” or
CTU.
• The “gold standard” for the work-up of patients with
asymptomatic microscopic hematuria
• Imaging choices should be made in the context of results of a
formal microscopic urine analysis

43. Cont;d…
Alternative studies include US, radioisotope renography, and
possibly cystoscopy should be done if there is –
• serum creatinine conc. is > 1.5 mg/dL
• The patient has insulin-dependent diabetes
• intravenous contrast agent administration increases the risk of
contrast-related nephropathy

44. Creatinine clearance Time
• Gold standard for assessing renal function and is said to
approximate GFR
• Accuracy depends on meticulous urine collection
• Because of such limitations, more endogenous markers of
GFR are being increasingly studied. e.g. serum cystatin C

45. Isotope studies
• Technetium-99m dimercaptosuccinic acid (DMSA) scan is
still the best study for both differential function and evaluation of
the functioning areas of the renal cortex.
• The renogram obtained with technetium-99m mertiatide (MAG-3) also
gives information on urinary tract drainage, as well as a good assessment of
differential function

46. Lower Tract Tests

47. Urinalysis, culture and sensitivity testing
• Done routinely for all patients with NLUTD and should be repeated as
often as necessary or at the very least at routine follow-up annually.
• Recommended before invasive procedures in cases of suspected UTI or
with new lower urinary tract symptoms such as incontinence, frequency
• Recommended In persons with SCI who lack sensation, UTI symptoms
may also include increased spasticity or autonomic dysreflexia (AD).

48. Postvoid Residual(PVR)
• The PVR is simple to determine and clinically useful
• PVRs can vary throughout the day
• A catheter insertion has been used for PVR in the past, but
there are now simple US machines that noninvasively obtain
the PVR.
• A low (<20% of bladder capacity) PVR is not by itself
indicative of a safe bladder because high intravesical
pressures can be present despite low PVR values.

49. Cystography
• Usually performed to test for the presence or absence of
ureteral reflux, and it also shows the outline and shape of the
bladder.
• Findings suggestive of increased bladder pressure, such as
diverticuli or an irregular bladder contour due to trabeculation
can be observed.
• It does not provide information about bladder pressure
corresponding to reflux; for this, urodynamic testing is needed

50. Urodynamic Evaluation/Study
• Pressure-flow study of lower urinary tract function with or
without the use of fluoroscopy (video urodynamics)
• Gold standard for the evaluation of lower urinary tract function
• Evaluates two phases of bladder function: filling (storage) and
voiding (emptying)

51. Cont’d…
Procedure requires-
- Insertion of a catheter into the bladder
- Second catheter to measure abdominal pressures into the
rectum
- Needle electrode for sphincter EMG
- Uroflowmeter
- Video fluroscopy (+/-)

52. Cont’d…

53. Cont’d…

54. Cont’d…
Filling phase metrics with Urdodynamic testing-
- Bladder capacity
- Bladder sensation:
- Bladder wall complience:
- Presence of involuntary contraction
Voiding phase provides information about-
- Bladder contractility
- Urinary flow rate
- Urethral sphincter activity,
- Characterization of possible bladder outlet obstruction.

55. Sphincter Electromyography
• Sphincter EMG can be combined with the cystometrogram (CMG) or
preferably with a full multichannel videourodynamic study
• Recordings have been made with a variety of electrodes (monopolar,
coaxial needle, and surface electrodes) from the levator, perianal, or
periurethral muscles
• Normally, EMG activity gradually increases as bladder capacity is reached
during bladder filling and then becomes silent just before voiding
• Low levels of EMG activity with no recruitment during filling are a
common pattern in complete SCI

56. Cont’d…

57. Cystoscopy
• Routine indication for cystoscopy is the presence of along-term indwelling
suprapubic or urethral catheter because the presence of the catheter
increases the risk for bladder tumor
• Often a noncontrast CT is the only study that will pick up small bladder
stones, especially if the bladder is collapsed around an indwelling catheter.
• Repeated lower tract infections can be an indication for cystoscopy and can
reveal nonopaque foreign bodies, such as hairs, that have been introduced
by catheterization

58. References
1. Braddom's physical medicine and rehabilitation 6th edition
2. Physical Medicine and Rehabilitation Board Review, 4th Edition
3. krusen's handbook of physical medicine and rehabilitation, 4th Edition
4. Davidson's Principles and Practice of Medicine,23rd Edition
5. BD Chaurasia's Human Anatomy. Vol -2
6. Vishram Singh Textbook of Anatomy, 2nd edition
7. Neurology: A Queen Square Textbook, 2nd Edition
8. Bailey and Love’s Practice of Surgery 27th edition
9. https://now.aapmr.org/

59. Thanks for your patience listening