neurogenic bladder

1. Neurogenic Bladder
Presenter
Dr. Mohibullah
Moderator
Dr. Abbas Jaffri

2. Objectives
• History and Clinical Examination
• Etiology
• Diagnosis
• Conservative Treatment
• Bowel Management
• Physiotherapy
• Continence devices (Pads etc.)
• Bladder Drainage
• CISC
• Drugs

3. Introduction
• Urinary bladder is a smooth muscle organ, but is
under voluntary control from the cerebral cortex.
• Normal bladder function requires coordinated
interaction of afferent and efferent components
of both the somatic and autonomic nervous
systems.
• Many levels of nervous system are involved in
regulation of voiding function therefore
neurologic disease can cause changes in bladder
function.

4. Introduction
• Normal adult bladder is able to distend
gradually to a capacity of 400-500ml without
appreciable increase in intravesical pressure.
• When the sensation of fullness is transmitted
to the sacral cord, motor arc of the reflex
causes a powerful and sustained detrusor
contraction and urination if voluntary control
is lacking (infants).

5. Sympathetic : Contracts internal sphincter
Parasympathetic: Relax Internal Sphincter, Contracts Detrusor
Pudendal: Relaxes External Sphincter

6. Neurogenic bladder
• If these nerves are harmed by illness or injury,
the muscles may not be able to tighten or relax at
the right time.
• Several muscles and nerves must work together.
• for bladder to hold urine &
• to empty the bladder.

7. Pathophysiology
• Neurogenic urinary tract dysfunction is common among
individuals with
• Multiple Sclerosis (MS),
• Parkinson’s disease,
• spina bifida,
• spinal cord injuries (SCIs),
• stroke,
• major pelvic surgery,
• diabetes or other illnesses
• may lead to common complications
• renal insufficiency,
• incontinence,
• urinary tract infections.
• Bladder dysfunction also decreases psychological and social
well-being

8. Pathophysiology
• Neurogenic bladder is when bladder control is
affected due to
• the brain,
• spinal cord, or
• nerve complications.
• The 3 areas of the Central Nervous System that
control bladder function are;
• Cerebral Cortex,
• Pontine Micturition Centre, and
• Sacral Micturition Centre.

9. Pathophysiology
• Neurogenic Bladder can be classified according to different
types of conditions involving the detrusor and sphincter
activity.
• Hyperreflexia with an involuntary contraction: leads to
• sphincter dysfunction,
• reflex incontinence,
• residual urine.
• Arefelxia of both the Detrusor and Sphincter Muscles:
 This is due to sacral injury
• leads to stress incontinence and
• residual urine.

10. Pathophysiology
• Areflexia of the detrusor muscle and Hyperreflexia of the
sphincter:
• leads to
• urinary retention and
• overflow incontinence.
• Areflexia of the sphincter and Hyperreflexia of the Detrusor
muscle:
• leads to
• reflex incontinence.

11. Pathophysiology
• Other classifications are based on the level of injury in the
Suprasacral, Sacral, or Infrasacral segments.
• Suprasacral Neurogenic Bladder Injury:
• between the brainstem and sacral center.
• leads to disinhibited sacral reflexes,
• Overactivity of the detrusor,
• Overactivity of the external and/or internal sphincters, and
• Impaired coordination between these two muscles.

12. • Sacral Neurogenic Bladder Injury
• occurs due to injury to the sacral spinal cord.
• Infrasacral Neurogenic Bladder injury
• occurs due to injury to the Cauda Equina.
• Both the Sacral and Infrasacral Neurogenic Bladder are
classified as Lower Motor Neuron Lesions (LMNL)

14. Patient History
• History taking should include past and present
symptoms and disorder.
• A voiding-diary and history should be taken in
the first assessment.
• In non-traumatic neuro-urological patients with
insidious onset, a detailed history may find that
the condition started in childhood or adolesnce.
• History consists of both
• urinary storage and
• voiding symptoms.

15. Patient History
• Urological history inquires about
– onset of symptoms
– relief after voiding; to detect extent of lesion in the
absence of obstructive uropathy
– bladder sensation
– initiation of micturition
– straining
– intermittency
– history of catheterization, CISC, frequency, voided
volume
– incontinence and urgency episodes.

16. Patient History
• Bowel history is important as the patients
may have associated neurogenic bowel
dysfunction.
– Frequency
– fecal incontinence/soiling
– desire to defecate
– defecation pattern
– rectal sensation

20. Patient History
• Sexual function may be impaired. Inquire
about
– sensation in genital area
– lack of erection
– orgasm
– ejaculation
– dyspareunia in females

21. Patient History
• Neurological History includes inquiry of
– acquired or congenital neurological condition,
– mental status, comprehension,
– somatic and sensory symptoms,
– spasticity or autonomic dysreflexia (lesions above
T6),
– hand function and mobility.

22. Past history
• Hereditary or familial risk factors,
• age of menarche,
• obstetric history,
• history of diabetes,
• neurological diseases,
• accidents and
• surgeries involving CNS and Spine.

23. Patient History
Drug History:
– current medication
Personal History:
– Lifestyle (smoking, drugs, alcohol),
– Sexual,
– Bowel function and
– Quality of life.

24. Physical Examination
• Neuro-urological status should be described
as completely as possible.
• All sensations and reflexes in urogenital area
must be tested, including
• the anal sphincter,
• Pelvic floor muscles,
• Motor Level of spinal cord injury and
• Extremities tone.

25. EAU Recommendations

26. Diagnosis
• When diagnosing neuro-urological symptoms,
the aim is to describe the type of dysfunction
involved.
• extensive medical history,
• physical examination and
• Bladder diary are mandatory.
• before any additional diagnostic
investigations can be planned.

27. Diagnosis
• Early diagnosis and treatment are essential in
both congenital and acquired neurological
disorders to prevent irreversible changes
within the lower urinary tract.
• Early intervention can prevent irreversible
deterioration of LUT and UUT.

28. Bladder Diary
• Bladder diaries provide data on
• the number of voids,
• voided volume,
• pad weight,
• Incontinence,
• Leakage,
• urgency episodes.
• A 24 hour bladder diary (3 consecutive days) is
reliable.

30. Management
• Primary aims for treatment of neuro-
urological symptoms are:-
• Protection of Upper Tract
• Achievement (maintenance) of Continence
• Restoration of LUT function
• Improvement of patient’s QOL

31. Conservative Management
• Timed Voiding:
• Timed-voiding is behavioral exercise to practice bladder
control as generally done in combination with fluid-intake
diaries.
• Limit fluid-intake at night.
• Routine bladder emptying, between every 4 to 6 hours.
• Limit caffeinated and carbonated beverage use.

32. Conservative Management
• Double voiding:
• Delayed voiding:
• If have OAB symptoms,
• start by delaying urination a few minutes.
• Slowly increase the time to a few hours.
• This helps to learn how to put off voiding,
even when you feel an urge.

33. Conservative Management
• Pelvic floor exercises:
• These may help relax bladder muscle when it
starts squeezing.
• Increase the strength of sphincter muscles.

34. Conservative Management
– Bladder Expression: Downwards movement of the
lower abdomen by supra pubic compression (Crede
manoeuvre) or by abdominal straining (Valsalva) leads
to an increase in intravesical pressure and also causes
reflex sphincter contraction.
– There use should be discouraged unless UDS show
that the intra-vesical pressure remains within safe
limits.
– In long-term, pelvic floor weakness may increase
further causing/exacerbating stress incontinence.

35. Credé Manoeuvre

36. Conservative Management
• Triggered Reflex Voiding:
• Stimulating the sacral or lumbar dermatomes in
patients with upper motor neuron lesion can
elicit a reflex detrusor contraction.
• Risk of high pressure voiding is present.

37. Conservative Management
– External Appliances:
• Social continence may be achieved by
• collecting urine during incontinence, using pads.
• Condom Catheters with urine bag are a practical
method for men.
– Penile clamp is contraindicated in case of low
bladder compliance because of risk of developing
high intravesical pressure and pressure sores/
necrosis in case of altered / absent sensation.

39. Management
Drugs: A single, optimal therapy for neuro-urological
patients is not always available.
– Therapies include
– anti-muscarinic and
– intermittent catheterization.
– Aim is to prevent upper tract damage and improve
long term outcomes.

40. Management
• Conservative Management
– Antimuscranics are first line choice for treating
Neurogenic Detrusor Overactivity, by inhibiting the
parasympathetic pathways, they cause increase in
bladder volume and reduce episodes of UI.
– Oxybutynin, trospium, tolterodine and propiverine are
established, effective and well tolerated even in long
term.
– Darifenacin and solifenacin have shown similar results
in patients with NDO secondary to SCI and MS.

41. Management
• Conservative Management
– Beta-3 Adrenergic Agonists such as mirabegron
• In SCI and MS patients has not demonstrated any
significant effect on detrusor pressure or
cystometric capacity in short term, however
improvement in LUTS has been reported.
– Significant improvement in OAB symptoms with
lower dose of mirabegron have been reported.

42. Management
• Conservative Management
– Alpha blockers such as tamsulosin, naftopidil, and
silodosin seem to be effective in decreasing
bladder outlet resistance & PVR.
– For increasing bladder outlet resistance, there are
no high level evidence studies in neurological
patients.

43. Management

44. Management
• Catheterization
– Patients who cannot empty their bladder
effectively, preferably need Intermittent self or
third party catheterization.
– Sterile IC significantly reduces risk of UTI and
bacteriuria as compared with clean IC.
– The average frequency of catheterization is four to
six times.

45. Management
• Catheterization
– Catheter size most often used is between 12-16Fr.
– Bladder volume at catheterization should not
more than 400-500ml.

46. Management

47. Surgical Management
• Augmentation cystoplasty.
• Abdominal Slings
• Botulinum Toxin injection in the detrusor.
• Artificial Urinary Sphincter.
• Sacral neuromodulation (SNS) therapy
• Percutaneous tibial nerve stimulation (PTNS)
• Urinary diversion surgery.

48. Thank you