Neurogenic bladder

1. MODERATOR:- Dr.BALASUBRAMANYAM SIR
PRESENTER:- Dr.MOUNICA.K

2. ANATOMY OF BLADDER:
Bladder is a smooth muscle chamber
subperitoneal,hollow muscular organ that acts as
reservoir for urine.
LOCATION:
Situated posterior to pubic symphysis
Superior and posterior parts of bladder are covered by
peritoneum
Inferior and inferolateral covered by endopelvic fascia
Muscle is smooth muscle-DETRUSOR
TRIGONE is a small triangular area immediately above
the bladder neck on the posterior wall of bladder

3. Parts of bladder

4. The bladder neck is composed of detrusor muscle
interlaced with large amount of elastic tissue. Muscle
in this area is INTERNAL SPHINCTER
EXTERNAL URETHRAL SPHINCTER-voluntary
skeletal muscle and can be used to consciously prevent
urination
CAPACITY-300 up to a maximum capacity of 500 ml

5. INNERVATION OF BLADDER
Bladder receives innervation through a network of
parasympathetic, sympathetic and somatic nerve
fibres
AFFERENT INNERVATION;
INNERVATION NERVE ACTION FUNCTION
PARASYMPATHETIC
S2,3,4
PUDENDAL
NERVE
Sensation of pain
and distension
conveyed from
bladder wall
Carried normal
sensation
SYMPATHETIC
T9-L2
HYPOGASTRIC
PLEXUS
Sensation of painful
distension carried
from bladder wall
Carries painful
sensation

6. EFFERENT INNERVATION;
INNERVATION NERVE ACTION FUNCTION
PARASYMPATHETIC
S2,3,4
PELVIC NERVE
(NERVI
ERIGENTES)-
HYPOGASTRIC
PLEXUS
Detrusor muscle
contraction and
internal sphincter
relaxation
voiding
SYMPATHETIC
T11-L2
HYPOGASTRIC
NERVES
Detrusor muscle
relaxation and
internal sphincter
contraction
storage
SOMATIC-FROM
ANTERIOR HORN
CELLS S2,3,4
PUDENDAL
NERVE
Voluntary
innervations
initiate or inhibit
micturition
through cortical
control
Voluntary control

7. INNERVATION OF BLADDER:

8. RECEPTORS AND INNERVATION;
 DETRUSOR-
intermediolateral gray
column of s2,3,4-
parasympathetic pelvic
nerve (M2 receptors)
 EUS-Somatomotor S2,3,4
nucleus(onuf’s nucleus)-
pudendal nerve (nicotinic
receptors)
 TRIGONE and IUS-
Innervated by sympathetic
nervous system acts
through beta2 and alpha1
receptors

9. SPINAL REFLEX ARC
•
 Afferrent arc-Sensation of
stretch arising from bladder
wall travels through
parasympathetic nerves to
centres for micturition
 Detrusor centre or sacral
parasympathetic nucleus-
sacral segments s2,3,4 of
spinal cord
 Efferent arc-travels through
pelvic nerves to pelvis plexus
and short postganglionic
fibres travel from plexus to
detrusor muscle

10. HIGHER CENTRES
1.CORTICAL CENTRES
a.Medial frontal lobe
b.Cingulate gyrus
c.Corpus callosum
2.SUBCORTICAL CENTRES
a.Thalamic nucleus
b.Limbic system
c.Red nucleus
d.Substantia nigra
e.Hypothalamus
f.Subthalamic nucleus
3.CEREBELLUM
a.Anterior vermis
b.Fastigial nucleus

11. FRONTAL LOBE OF BRAIN
 Contains PRIMARY MICTURITION CENTRE
 It helps in voluntary urination
 It sends inhibitory impulses to detrusor muscle via
pons to prevent bladder emptying until socially
acceptable place is available
 Lesion results in loss of voluntary control to
normal micturition

12.  PONS
 Pons contains pontine mictutrition centre –
BARRINGTON NUCLEUS
• PONTOMESENCEPHALIC RETICULAR
FORMATION MICTURITION CENTER-Located in
locus ceruleus,pontomesencephalic gray matter and
nucleus tegmentolateralis dorsalis
• Collection of cell bodies located in rostral pons in
brainstem involved in supraspinal regulation of
micturition
• Connections with medial frontal cortex,insular
cortex,hypothalamus,periaqueductal gray

13.  PERIAQUEDUCTAL GRAY
 It is the relay station for ascending information from
spinal cord and incoming information from higher
brain areas

14.  SACRAL SPINAL CORD
 Terminal portion of spinalcord
 It has sacral spinal reflex centre
 It is a primitive micturition centre
 Upto 3-4 yrs of age micturition is controlled by
SRC

15. PHYSIOLOGY OF MICTURITION
Micturition is a spinobulbospinal reflex
 In response to stretch impulses afferent impulses are
carried to spinal cord
 From spinal cord information is carried to pontine
micturition centre(Barringtons nucleus)
 PMC sends descending fibres to preganglionic
parasympathetic motor neurons in spinal cord
innervating bladder
 PMC is under control of centres in forebrain

17. Neural regulation of storage phase and
voiding phase
STORAGE PHASE
 Storage reflexes. During filling,
there is low-level activity from
bladder afferent fiberssignaling
distension via the pelvic nerve,
which in turn stimulates
sympathetic outflow to the bladder
neck and wall via the hypogastric
nerve. This sympathetic
stimulation relaxes the detrusor
and contracts the bladder neck at
the internal sphincter. Afferent
pelvic nerve impulses also
stimulate the pudendal (somatic)
outflow to the external sphincter
causing contraction and
maintenance of continence.

18. VOIDING PHASE
Voiding reflexes. Upon initiation of
micturition, there is high-intensity
afferent activity signaling wall
tension, which activates the
brainstem pontine micturition
center. Spinobulbospinal reflex can
be seen as an ascending signal from
afferent pelvic nerve stimulation
(left side), which passes through the
periaqueductal gray matter before
reaching the pontine micturition
center and descending (right side)
to elicit parasympathetic
contraction of the detrusor, and
somatic relaxation via the pudendal
nerve.

19.  In infants bladder function is purely reflex but with
cortical maturation and completion of myelination
inhibitory control over this reflex develops as well as
voluntary regulation of external sphincter
 Normal micturition requires intact autonomic and
spinal pathways ,cerebral inhibition and control of
EUS must be normal

20. NEUROGENIC BLADDER
 Neurogenic bladder refers to dysfunction of urinary
bladder caused due to disease of central nervous
system or peripheral nerves involved in control of
micturition
 NEWER CLASSIFICATION OF BLADDER
DYSFUNCTION
1. SUPRAPONTINE
2. INFRAPONTINE/SUPRASACRAL
3. INFRASACRAL

22. SUPRAAPONTINE SUPRASACRAL/
INFRAPONTINE
INFRASACRAL
SYMPTOMS STORAGE PROBLEM
FREQUENCY
,URGENCY AND URGE
INCONTINENCE
MIXED OVERLAP
OF HESITANCY
,INTERRUPTED
STREAM,FREQUEN
CY ,URGENCY
VOIDING
PROBLEM,HESIT
ANCY,OVERFLO
W
INCONTINENCE
POSTVOIDAL
RESIDUAL URIE
NORMAL HIGH VERY HIGH
UROFLOWMETRY NORMAL INTERRUPTED
FLOW
POOR OR
ABSENT FLOW
URODYNAMICS DETRUSOR
OVERACTIVITY
DETRUSOR
SPHINCTER
DYSSYNERGIA
DETRUSOR
UNDERACTIVITY
,SPHINCTER
INSUFFICIENCY

23. NEUROGENIC BLADDER
 OLDER CLASSIFICATION-LIPIDES
CLASSIFICATION
 1.LOSS OF SUPRASPINAL CONTROL-UNINHIBITED
BLADDER
 2.SPINAL CORD LESION ABOVE SACRAL LEVEL-
REFLEX NEUROGENIC BLADDER –AUTOMATIC
 3.SPINAL CORD LESION INVOLVING SACRAL
LEVEL-AUTONOMOUS BLADDER
 4.LESIONS INVOLVING AFFERENT SENSORY
NEURONS-SENSORY NEUROGENIC BLADDER
 5.LESIONS INVOLVING EFFERENT MOTOR
NEURONS-MOTOR PARALYTIC BLADDER
 6.OTHERS-STROKE/DEMENTIA/SPINAL SHOCK

24. 1.UNINHIBITED/CORTICAL BLADDER
 Lesion of CNS involving area above pons.
 Uninhibited impulses to pontine micturition
centre/barrington nucleus leading to s2,3,4 and
micturition
 C/f-frequency,urgency and urge incontinence
 No or absent residual volume so called safe bladder
 Also called as social disinhibition bladder syndrome
 Seen in CVA, frontal tumors, parkinsons
disease,demyelinating disease

25. 2.REFLEX NEUROGENIC BLADDER/SPASTIC
 Spinalcord lesion above sacral level and below pons
 Occurs with severe myelopathy or extensive brain
lesions causing interruption of both the descending
autonomic tracts to the bladder and the ascending
sensory pathways above sacral segments of cord
 UMN CUT OFF BUT LMN IS INTACT
 Detrusor sphincter synergia is lost
 This results in obstructed voiding,interrupted urinary
stream,incomplete emptying and high intravesical
pressures because sphincter fails to relax correctly

26.  Loss of normal inhibition from higher centres results
in detrusor contraction during filling
 Detrusor becomes overactive so there is urinary
frequency,urgency,urge incontinene
 Inability to initiate micturition voluntarily
 Associated with quadriplegia or paraplegia and in
advanced cases of multiple sclerosis

27. 3.AUTONOMOUS BLADDER
 Spinal cord lesion lesion involving sacral level
 Denervation of both afferent and efferent supply to
bladder
 LMN type of bladder-large painless dribbling bladder
 Bladder tone flaccid ,sensation absent, inability to
initiate micturition
 Increased bladder capacity and residual urine
 Overflow incontinence, no urgency
 No bladder reflex activity, infection risk high
 Causes-neoplastic, traumatic lesions, cauda equina
,conus medullaris syndrome

28. 4.SENSORY NEUROGENIC BLADDER
 Impaired bladder sensation but motor control is intact
 Sensation is absent and there is no desire to void
 Initiation of micturition is possible
 c/o urinary retention or overflow incontinence
 More prone for urinary tract infections
 If bladder not voided at regular intervals over
distention of bladder
 Causes-Tabes dorsalis,Diabetic neuropathy

29. 5.MOTOR PARALYTIC BLADDER
 Motor supply to bladder is interrupted but sensation is
intact
 Bladder tone flaccid
 c/o painful retention of urine or impaired bladder
emptying
 Inability to initiate or maintain micturition
 Bladder capacity and residual urine markedly
increased.HIGH risk of UTI
 Causes-lumbosacral meningomyelocele,tethered cord
syndrome,lumbar spinal stenosis

30. UMN/LMN/SENSORY LESION
REFLEXIC-
SPASTIC/UNIHIBITED/
UMN
AREFLEXIC –
AUTONOMUS/Flaccid/
LMN
Sensory
Characteristics
No inhibitions influence
time & place of voiding
bladder empties in response
to stretching of bladder wall
Characteristics
Bladder acts as if there were
paralysis of all motor
functions
Characteristics
Lack of sensation of need to
urinate
Clinical manifestations
-Incontinence
-Frequency
-Urgency
-Voiding is unpredictable
and incomplete
Clinical manifestations
Fills without emptying
Retention
Dribbling incontinence
Clinical manifestations
Poor bladder sensation,
infrequent voiding of large
residual volume
Causes;
Corticospinal tract lesion
observed in
SCI/stroke/multiple
sclerosis/brain tumor/brain
trauma
Causes;
Lower motor neuron lesion
caused by trauma involving
S2-S4 lesions of cauda
equina/pelvic nerves
Causes;
Damage to sensory limb of
bladder spinal reflex arc seen
in multiple scierosis/diabetes
mellitus

31. URINARY INCONTINENCE AND TYPES
 LOSS OF BLADDER CONTROL
1. Stress – urine loss during activities such as
coughing, sneezing, laughing or lifting.
2. Urge – a sudden need to urinate, occasionally with
large volume urine loss. Can also exist without
incontinence(urgency).
3. Overflow – a frequent dribble of urine as a result of
inefficient bladder emptying symptoms are similar to
stress incontinence.
4. Mixed – stress + urge forms.
5. Functional – urine loss not associated with any
pathology or problem in the urine system.

33. EVALUATION
HISTORY
Urgency/hesistancy-storage or voiding
EXAMINATION
INVESTIGATIONS
1. Screening for urinary tract infections
2. Bladder scan-to measure post residual volume by usg
3. USG for upper urinary tract abnormalities or renal
scarring
4. Urodynamic studies-to study function of lower
urinary tract

34. Assessment of lower urinary tract
 Urodynamic studies are necessary to document type of
bladder dysfunction
 Measurement of urine flow rate
 Measurement of post void residual urine
 Cystometry during filling and voiding
 Video cystometry
 Urethral pressure profilometry

35. Complications of neurogenic
bladder dysfunction
 DETRUSOR OVERACTIVITY-raised intravesical
pressure that leads to structural changes in bladder
wall such as trabeculations and diverticulae
 Upper urinary tract also show changes such as
vesicoureteric reflex,hydronephrosis,renal
impairement and even end stage renal failure
 Also more prone to variety of genitourinary tract
infections such as cystitis,pyelonephritis,and
epididymoorchitis and also to bladder stones

36. MANAGEMENT
 GOALS-
1. Achieve urinary continence
2. Prevent uti
3. Preseve upper urinary tract function
A. GENERAL MEASURES
If symptoms are mild
Fluid resuscitation
Avoidance of caffeine

37.  B.VOIDING DYSFUNCTION
a) If residual urine is more than 100ml or more than
1/3rd of bladder capacity-STERILE INTERMITTENT
SELF CATHETERISATION is advised
b) Reflex voiding using trigger techniques and crede
manouvre are generally avoided
c) Alpha blockers-relaxes internal urethral sphincter
and this improves bladder emptying and reduce post
voidal residual urine

39.  C.STORAGE DYSFUNCTION
a) Antimuscarinic medications are used for detrusor
overactivity
b) DESMOPRESSIN –Synthetic analogue of arginine
vasopressin that decreases urine production and
increases reabsorption of water from DCT and CT
c) BOTULINUM TOXIN-blocks synaptic release of
acetylcholine from the parasympathetic nerve
endings and produces paralysis of detrusor muscle
d) PERIPHERAL NERVE STIMULATION

40. DRUGS USED
MUSCARINIC
ANTAGONIST
BETA 2 AGONIST ALPHA 1 ANTAGONIST
OXYBUTININ
DOREFENACIN
SOLEFANACIN
TOLTERODINE
MIRABEGRON TERAZOSOIN
DOXAZOSIN
USED IN TREATMENT
OF OVERACTIVE
BLADDE AND URGE
INCONTINEN CE
TRETMENT OF
OVERACTIVE BLADDER
USED IN TREATMENT
OF STRESS
INCONTINENCE AND
BPH

42.  UROLOGICAL PROCEDURES PERFORMED TO
TREAT VARIOUS CAUSES OF INCONTINENCE
STRESS INCONTINENCE-PELVIC
FLOOR WEAKNESS
BLADDER NECK SUSPENSION
TENSION FREE VAGINAL TAPE
TRANSOBTURATOR TAPE
STRESS INCONTINENCE-SPHINCTER
ABNORMALITY
ARTIFICIAL SPHINCTER
URGENCY INCONTINENCE-
DETRUSOR OVERACTIVITY
BOTULINUM TOXIN
SACRAL NEUROMODULATION
AUGMENTATION CYSTOPLASTY
INTRACTABLE INCONTINENCE URINARY DIVERSION WITH STOMA

43.  URINARY TRACT INFECTIONS IN
NEUROGENIC BLADDER
 Presence of asymptomatic bacteria alone in a
patient performing cisc should not be a indication
to start antibiotics
 Indication to start antibiotic-presence of
associated symptoms local or systemic features

44. THANK YOU