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![Detrusor muscle
• Sympthetic (T11 - L2) [Hypogastric nerve] -Via β3-
adrenergic receptors - inhibition and relaxation of the
detrusor muscle
• Parasympathetic (S2,S3,S4) [Pelvic splanchnic nerve] - via
M2/M3 cholinergic receptors (NT - Ach) - contraction of the
detrusor muscle.](https://image.slidesharecdn.com/bladderpresentationreshma-240507184941-7f7492f4/75/Urinary-Bladder-neurology-presentation-pptx-3-2048.jpg)
![Internal Sphincter
• Smooth muscle
• Involuntary control
• Sympthetic (T11 - L2) [Hypogastric nerve] -Through alpha-1
receptors causes Contraction of internal sphincter](https://image.slidesharecdn.com/bladderpresentationreshma-240507184941-7f7492f4/75/Urinary-Bladder-neurology-presentation-pptx-4-2048.jpg)
![External Sphincter
• Skeletal muscle
• Voluntary control
• Innervated by Somatic nervous system (S2,S3,S4)
[Pudendal nerve] -Through Nicotinic receptors (NT - Ach)](https://image.slidesharecdn.com/bladderpresentationreshma-240507184941-7f7492f4/75/Urinary-Bladder-neurology-presentation-pptx-5-2048.jpg)
Urinary Bladder neurology presentation.pptx
- 1. Bladder Neurology Speaker :Dr. Reshma Moderator : Dr Enna Sondhi
- 2.
- 3. Detrusor muscle • Sympthetic(T11 - L2) [Hypogastric nerve] -Via β3- adrenergic receptors - inhibition and relaxation of the detrusor muscle • Parasympathetic (S2,S3,S4) [Pelvic splanchnic nerve] - via M2/M3 cholinergic receptors (NT - Ach) - contraction of the detrusor muscle.
- 4. Internal Sphincter • Smoothmuscle • Involuntary control • Sympthetic (T11 - L2) [Hypogastric nerve] -Through alpha-1 receptors causes Contraction of internal sphincter
- 5. External Sphincter • Skeletalmuscle • Voluntary control • Innervated by Somatic nervous system (S2,S3,S4) [Pudendal nerve] -Through Nicotinic receptors (NT - Ach)
- 6. Bradley’s Neurology inClinical Practice, 7th edition, page no. - 606
- 7.
- 8. Parasympathetic • CENTRE: S2-S4in intermediolateral column • SUPPLY THROUGH: Pelvic splanchnic nerves • NEUROTRANSMITTER : ACh via M3 • Bladder detrusor contraction • Internal sphincter relaxation
- 9. Sympathetic • CENTRE: T11-L2intermediolateral column • SUPPLY THROUGH: Hypogastric Nerve • β3- receptors -inhibition and relaxation of the detrusor muscle. • Alpha-1 receptors - Contraction of internal sphincter • Facilitate bladder storage and continence
- 10. Somatic • CENTRE: ONUF’SNucleus in the Ventral horn of S2-S4 • SUPPLY THROUGH: Pudendal Nerve • NT : Ach, Nicotinic Receptors • FUNCTION : Controls The External Sphincter
- 11. Spinal Reflex Arc •AFFERENT ARC :- Stretching of bladder wall - through the Pelvic nerve (Parasympathetic ) to the spinal micturition Center. • DETRUSOR CENTER :- Sacral segments S2-S4 of the spinal cord. • EFFERENT ARC :-Travels through the Pelvic nerve - contraction of detrusor muscle and relaxation of internal urethral sphincter.
- 12. Pontine Micturition Center •BARRINGTON'S NUCLEUS • From the pontomesencephalic micturition center, efferents to the spinal cord descend by way of the reticulospinal tracts ( located medially and anteriorly in the anterior funiculus) to the detrusor motor neurons in the intermediolateral cell columns of the sacral gray matter (S2– S4). • Pontine output is excitatory for voiding reflex.
- 13. Higher Center • Situatedin Prefrontal lobe, Paracentral lobule, Cingulate gyrus, •Insula. • Efferents from the cortical and subcortical micturition centers descend by way of the pyramidal tracts to the pudendal nuclei (Onuf’s nucleus) in the sacral spinal cord (S2–S4). • Cortical input is inhibitory on micturition reflexes. CORTICAL CENTERS:
- 14. SUBCORTICAL CENTERS : Thalamicnuclei, Limbic system, Red nucleus, Substantia nigra, Hypothalamus, Subthalamic nucleus. CEREBELLUM : Anterior vermis of the cerebellum, fastigial nucleus are concerned with micturition. Higher Center
- 15. Gaurding Reflex First impulsecomes at 150ml :- signal from spinal cord via posterior column -> PAG -> L region of PONS activates sympathetic and pudendal nerve, leads to relaxation of detrusor, constriction of internal urethral sphincter and constriction of external urethral sphincter.
- 16. Voiding Reflex Intense bladder(~450ml) afferent firing in the pelvic nerve activates spinobulbospinal reflex pathways that pass through the pontine micturition centre (BARRINGTON'S NUCLEUS) which is under continuous cortical inhibition.
- 17. Voiding Reflex If :- 1.afferentsignals from the bladder are sufficiently strong 2. voiding is safe 3. voiding socially appropriate Then cortical inhibition decreases.
- 18. Voiding Reflex • Stimulatesthe parasympathetic outflow to the bladder and to the urethral smooth muscle. • Inhibits pudendaloutflow to the urethral outlet. • Inhibits the sympathetic outflow to urethral outlet. And leads to voiding. This -
- 19.
- 20. Hald and Bradley •Supraspinal lesion • Suprasacral spinal lesion • Infrasacral lesion • Peripheral autonomic neuropathy • Muscular lesion On the basis of Neuroanatomy
- 21. Lancet Neurology Vol14 July 2015
- 22.
- 23. • LOSS OFSUPRASPINAL CONTROL • Results from injury to corticoregulatory tract exerting inhibitory control on PMC • Lesions above pons. • Frequency, urgency & urge incontinence. • Micturition is usually precipitous and complete. • Low or absent residual volume • Bladder behaves like infants • urine voided anytime anywhere without control • Causes: CVA, frontal tumors, parasagittal meningioma, ACA aneurysm, NPH, PD, Demyelinating disease Uninhibited Bladder
- 24. Reflex Neurogenic Bladder • SPINALCORD LESION ABOVE SACRAL LEVEL • Post–spinal shock second stage of recovery. • Hyperactive micturition reflex with loss of voluntary control • Small amount of urine collected in the bladder elicits the micturition reflex • Bladder tone increased, capacity reduced • No residual urine • Causes: spine cord injury, compressive myelopathy, myeilitis, syringomyelia
- 25. Autonomous Bladder • SPINALCORD LESION INVOLVING SACRAL LEVEL • Spinal cord injury that causes complete motor and sensory impairment of the bladder from the sacral cord. • Bladder tone flaccid, sensation absent. • Inability to initiate micturition. • Increased bladder capacity and residual urine. • Overflow incontinence, no urgency. • Voiding possible only by maneuver. • Causes: Cauda equina syndrome,Conus medullaris.
- 26. Sensory Neurogenic Bladder • LESIONINVOLVING AFFERENT SENSORY NEURONS • Selectively interrupt the sensory fibers from the bladder to spinal cord or from the afferent tract to the brain • Impaired bladder sensation, Painless distention • Initiation of micturition is possible. • If bladder not voided at timely basis l/t over distension of bladder • Bulbocavernosus & anal reflexes absent • Causes: Tabes dorsalis,Neuropathies mainly small fibers like DM, Amyloidosis
- 27. Motor Paralytic Bladder •LESION INVOLVING EFFERENT MOTOR NEURONS • Disease processes that affect motor innervation of the bladder. • Inability to initiate or maintain micturition, • Bladder sensations are intact. • c/o Painful retention of urine or impaired bladder emptying. • Increased Bladder capacity, residual urine, infection. • Bulbocavernosus & anal reflexes absent • Causes: Lumbosacral meningomyelocele, Extensive pelvic surgery or trauma , Lumber spinal stenosis, Herpes zoster
- 29. History • Patients withstorage dysfunction complain of frequency for micturition, nocturia, urgency and urgency incontinence. Urgency, frequency and nocturia, with or without incontinence, is called the overactive bladder syndrome, urge syndrome or urgency-frequency syndrome • Patients experiencing voiding dysfunction report hesitancy for micturition, a slow and interrupted urinary stream, the need to strain to pass urine, and double voiding. Patients may be in complete urinary retention • Drug history • Bladder diary-The bladder diary supplements the history taking and records the frequency for micturition, volumes voided, episodes of incontinence, and fluid intake over the course of a few days
- 30. Bradley’s Neurology inClinical Practice, 7th edition, page no. - 612
- 31. I Investigations- • Screening forUrinary Tract Infections-urine sample should be sent off to the lab for culture. • Bladder Scan- It is pertinent to estimate the post void residual urine by ultrasonography. • It evaluates for evidence of damage such as upper urinary tract dilatation or renal scarring. • Urodynamic Studies-measurements of urine flow rate and residual volume, cystometry during both filling and voiding, videocystometry, and urethral pressure profilometry • Investigations Requiring Catheterization-Cystometry evaluates the pressure-volume relationship during nonphysiological filling of the bladder and during voiding. The detrusor pressure is derived by subtraction of the abdominal pressure (measured using a catheter in the rectum) from the intravesical pressure (measured using a catheter in the bladder).
- 32. Bradley’s Neurology inClinical Practice, 7th edition, page no. - 608
- 33. Management- Bradley’s Neurology inClinical Practice, 7th edition, page no. - 617
- 34. Treatment approach to neurogenic bladderdysfunction Bradley’s Neurology in Clinical Practice, 7th edition, page no. - 620
- 35.