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Neurogenic bladder UG & PG
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
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Neurogenic bladder UG & PG
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- 2. Outline of the presentation Introduction Applied physiology Symptomatology Typesaccording to levels of bladder dysfunction Investigations Treatment available
- 3. Why understanding of Bladder 15% ofall 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 - atlow 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 urethralsphincter :- 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 • Thebladder 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. Peripheralnerves 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: Paracentrallobule 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 calledBarrington’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 orSacral/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
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- 12. Stimulation Response Parasympathetic (S 2-4) Excitatoryto 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 Sensationof 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
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- 20. Resultant • Poorly sustainedhyperreflexic bladder contraction (DH) and(DSD) • Raised post voiding residual (PVR) Exacerbation of symptoms
- 21. Extrapyramidal diseases • Extrapyramidalfeatures • 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 • Signsof 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 historyof 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 thelevel 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 andsubsacral 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
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- 30. Causes of variouslevels of dysfunction a) Suprapontine and Pontine Causes • Stroke • Tumors • Dementia (AD,FTD)
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- 32. Sacral and Subsacralcauses
- 33. Management- Investigations • Noninvasive bladderinvestigations- • 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 – Reinnervationwith prolonged duration of MUAPs Neuroimaging –MRI Cauda equina & conus lesions, spinal, supra pontine and pontine lesions
- 36. Treatment - Detrusoroveractivity • 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
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- 38. Treatment Only Urinary Retention (Ifresidual 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 • • • • • • • Complaintsabout 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
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- 42. References • Harrisons’ Principlesof 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 …..