bladder anatomy and physiology and related disorders

This ppt is regarding bladder anatomy and physiology and related disorders

1. A clinical case 23 yr female with tuberculoma with recently developed hydrocephalous developed incontinence She could neither perceive any fullness of bladder nor could feel the passage of urine Patient had no evidence of seizure at the time

2. At 300 ml UB pressure= 13 cm water At 400 ml UB pressure= 12 cm water At 500 ml UB pressure= 14 cm water

3. What happened? Bed side tests reveal that on introduction of normal saline upto 500ml patient can maintain normal urinary bladder pressure i.e detrusor muscle tone is normal The cause of incontinence will be more evident in the next few slides

4. NEUROPHYSIOLOGY OF THE BALDDER

5. THE URINARY BLADDER

6. INNERVATION OF THE BLADDER Efferents (Motor) AUTONOMIC NERVOUS SYSTEM SYMPATHETIC (T10, T11, T12) PARASYMPATHETIC (S2, S3, S4) SOMATIC NERVOUS SYSTEM (S2, S3, S4) Afferents (Sensory) Cortical micturition center Pontine micturition center (PMC)

7. INNERVATION OF THE BLADDER T 10 T11 T12

8. INNERVATION OF THE BLADDER - ANS SYMPATHETIC: Interomediolateral column T10-12 Inferior splanchnic nerves Inferior mesentric ganglia Hypogastric nerve Pelvic plexus Bladder dome (beta-adrenergic receptors) Trigone & Internal sphincter (alpha-adrenergic)

9. INNERVATION OF THE BLADDER - ANS SYMPATHETIC (Contd.): Inhibitory influences Detrusor Relaxation Facilitatory influences Internal sphincter Constriction STORAGE OF URINE (“STORAGE MODE”) Concomitant inhibition of parasympathetic supply

10. INNERVATION OF THE BLADDER - ANS PARASYMPATHETIC: Intermediolateral column of S3 + S2,S4 (the “ detrusor center”) Pelvic nerves Pelvic plexus Parasympathetic ganglia in bladder wall Detrusor muscle ( Muscarinic AChR )

11. INNERVATION OF THE BLADDER - ANS PARASYMPATHETIC (Contd.): Facilitatory Detrusor muscle Contractions VOIDING OF URINE (“EMPTYING MODE”)

12. INNERVATION OF THE BLADDER

13. INNERVATION OF THE BLADDER SOMATIC: Anterior horn cells S2-4 ( Onuf’s nucleus- ventrolateral part) Pudendal nerve External urethral sphincter (Nicotinic AChR ) Constriction Storage of urine (Voluntary control)

14. INNERVATION OF THE BLADDER- AFFERENTS Two kinds of bladder sensations Proprioception Sensations of bladder filling Sense of fullness Urge to void Feeling that micturition is imminent Two types of receptors located in muscle layer Volume: stimulated by passive stretch Tension: stimulated by passive stretch & detrusor contractions

15. INNERVATION OF THE BLADDER- AFFERENTS From receptors in bladder wall Through parasympathetic pelvic nerves Enter spinal cord via posterior roots Some relay in detrusor center (S2, S3, S4) Most fibers ascend in posterior column tracts

16. INNERVATION OF THE BLADDER- AFFERENTS A PET study of cortical activation with bladder filling showed increased brain activity with incraesing bladder volume in the periaqueductal gray (PAG) matter in the midline pons It is proposed that PAG receives information about bladder fullness and relays this to areas involved in the control of bladder storage

17. INNERVATION OF THE BLADDER- AFFERENTS Exteroception: (Pain) Receptors in submucosa More densely located in bladder base (trigone) Impulses pass via hypogastric nerves Enter spinal cord via posterior root Ascend up through spinothalamic tract Afferent fibers from urethra & external sphincter pass via pudendal nerves to sacral segments (S2-4) of the spinal cord. Convey impulses for reflex activities

18. INNERVATION OF THE BLADDER- AFFERENTS

19. INNERVATION OF THE BLADDER- AFFERENTS Myelinated A delta sensory fibers respond predominantly to mechanical stretching of detrusor muscle cells during bladder filling In health, afferent arc of detrusor reflex is by A-delta fibers Unmyelinated C sensory fibers may help trigger the symptoms of overactive bladder in pathologic conditions. C fibers have receptors for a variety of neurotransmitters. These receptors include vanilloid receptors, which can be stimulated by capsaicin Capsaicin sensitive afferent neurons are usually quiescent in health, but in chronic spinal animal models, after spinal shock, new afferents of detrusor reflex formed by capsaicin sensitive C-fibers emerges

20. PONTINE MICTURITION CENTER (PMC) Holstege (1979-86): Medial (M) region in dorsal pons : Stimulation of Immediate increase in urethral pressure Silence of pelvic floor EMG signal Rise in detrusor pressure Same as “Barrington nucleus” Site of activation of micturition Lateral (L) region in dorsal pons : Stimulation leads to powerful contraction of urethral sphincter Important for continence

21. PMC M- REGION

22. PONTINE MICTURITION CENTER (PMC) Other view : PMC in dorsal pontomesencephalic tegmentum Located in or near locus ceruleus & pontomesencephalic gray matter Midbrain neurons= inhibitory Pontine neurons= facilitatory

23. PONTINE MICTURITION CENTER (PMC) Afferents from sacral segments Efferents descend via reticulospinal tracts in lateral funiculi of cord to Onuf’s nucleus & interomediolateral cell groups of sacral segments ( detrusor center) Receive descending fibers from anteromedial parts of frontal cortex (cortical micturition center), thalamus, hypothalamus and cerebellum Coordinates reciprocal relationship of detrusor and sphincter contraction & relaxation Act as switch between emptying & filling mode

24. CORTICAL MICTURITION CENTERS Located in Superomedial portion of frontal lobe ( paracentral lobule) Contributions from Anterior aspect of cingulate gyrus Genu of corpus callosum Thalamus Hypothalamus Subthalamus Red nucleus Substantia nigra

25. CORTICAL MICTURITION CENTER PCL Marginal sulcus Paracentral sulcus Cingulate gyrus

26. CORTICAL MICTURITION CENTER Efferents : To Onuf’s nucleus Descend by pyramidal tracts or anterior & medial to it near central canal in lateral funiculi To PMC Via corticopontine fibers Controls external urethral sphincter & PMC Has tonic influence on these structures Responsible for voluntary control over micturition Called “master of the bladder”

27. FUNCTIONS OF THE BLADDER STORAGE OF URINE VOIDING OF URINE

28. FUNCTIONS OF THE BLADDER Performs two mutually exclusive activities Storage of urine Voiding of urine Micturition frequency in a healthy adult with a normal bladder capacity (350-600 ml) is likely to be once every 3-4 hours Since the act of voiding lasts 2-3 min, for >98% of life the bladder is in storage mode In health & continence the decision when to void is determined by the perceived state of bladder fullness together with an assessment of the social appropriateness to do so

29. FUNCTIONS OF THE BLADDER STORAGE OF URINE Passive filling phase: Initial intravesical pressure increases minimally due to elastic property of smooth m. & connective tissue Proximal urethra pressure exceeds intravesical pressure Reflex activity: When intravesical pressure exceeds urethral pressure Impulses from cortical micturition center Enhanced sympathetic activity & external sphincter constriction Inhibition of detrusor contractions

30. FUNCTIONS OF THE BLADDER - STORAGE MEDIAL FRONTAL LOBES MOTOR CORTEX B.G. & CEREBELLUM PONTINE MICTURITION CENTER PARASYMPATHETIC SYMPATHETIC SOMATIC -- -- ++ ++ -- ++ ++ ++ -- --

31. FUNCTIONS OF THE BLADDER VOIDING OF URINE Bladder stretching (& increase in intravesical pressure) send signals to cortex & PMC Desire to void Voluntary relaxation of perineum Increase tension of abdominal wall Slow contraction of detrusor (PMC) Opening of internal sphincter (PMC) Relaxation of external sphincter

32. FUNCTIONS OF THE BLADDER - VOIDING MEDIAL FRONTAL LOBES MOTOR CORTEX B.G. & CEREBELLUM PONTINE MICTURITION CENTER PARASYMPATHETIC SYMPATHETIC SOMATIC ++ ++ -- ++ ++ -- ++ ++ -- --

33. DYSFUNCTIONS OF THE BLADER DUE TO NEUROLOGICAL CAUSE = “NEUROGENIC BLADDER”

34. CLASSIFICATION Most popular : given by Lapides (1976) Uninhibited Reflex Autonomous Sensory paralytic Motor paralytic

35. REFLEX BLADDER A/k/a UMN, spastic, automatic bladder Lesions above the sacral bladder center Causes : MS, trauma, myelitis , spondylosis , spinal AVM, TSP Loss of inhibition= overactive detrusor = contractions at small urine volumes = small volume bladder Preservation of sensations depend on completeness of lesion Symptoms: Urinary frequency & urgency Urge incontinence Inability to micturate voluntarily The bulbocavernous & superficial anal reflexes are preserved

36. REFLEX BLADDER Detrusor sphincter dyssynergia : Simultaneous contractions of sphincter & detrusor Seen with complete lesion b/w PMC and sacral cord Results in Obstructed voiding (straining & retention) Incomplete emptying High intravesical pressure= dilatation of upper urinary tract = kidney damage Residual urine = infections Coordinated sphincters : Lesion B/w cortex/ subcortical structures (B.G.) & PMC (Uninhibited bladder) Incomplete suprasacral spinal cord lesions No residual urine or back-pressure

37. REFLEX BALDDER FRONTAL LOBE LESIONS: Rt or Lt lesions involving posterior part of sup frontal gyrus , and cingulate gyrus result in loss of control of micturition & incontinence There is no warning of fullness of the bladder & imminence of urination Pt may suddenly void to his surprise Less complete lesions may lead to frequency & urgency Patient may be unable to initiate voiding when conditions are favourable An element of indifference is added when more anterior ( nonmotor ) parts of the lobe are involved

38. AUTONOMUS BLADDER A/k/a LMN, flaccid, atonic bladder Seen in Complete lesions below T12 Conus medullaris lesions Spinal shock Causes : trauma, myelitis , myelodysplasias , venous angiomas , tumours Inability to initiate micturition Completely paralyzed bladder, atonia of detrusor = enlargement of bladder as urine accumulates = large capacity bladder No awareness of fullness

39. AUTONOMUS BLADDER When intravesical pressure exceeds urethral pressure, passage of urine till pressure drops below threshold level (overflow incontinence) Large residual urine volume= infections Associated findings: Saddle anesthesia Loss of bulbocavernous & anal reflexes Loss of anal sphincter tone

40. MOTOR PARALYTIC BLADDER Lesions involving detrusor motor neurons or efferent motor fibers to detrusor Causes: lumbar canal stenosis , lumbosacral meningomyelocele , tethered cord syndrome, cauda-equina lesions Bladder sensations are intact Impaired bladder empting (straining) & painful retention of urine Residual urine + Bulbocavernous & anal reflexes absent Sacral sensations are intact

41. SENSORY PARALYTIC BLADDER Seen with Impairment of afferent pathways innervating bladder (sensory nerves, post. roots) Dysfunction of posterior columns & spinothalamic tract in spinal cord Causes : diabetes, tabes dorsalis Maintained voluntary initiation of micturition Painless urinary retention, overflow incontinence & UTI Bulbocavernous & anal reflexes -/+ Sacral sensations lost

42. MANAGEMENT OF BLADDER DYSFUNCTION CLINICAL INVESTIGATIONS TREATMENT

43. SYMPTOMS Dysfunction of storage Urgency Urge incontinence Frequency Initiation problems Hesitancy Dysfunction of voiding Sense of incomplete emptying Straining Poor stream Intermittent stream Painful or painless retention

44. CLINICAL EXAMINATION Spinal segments innervating bladder are caudal to those that innervate the legs, so cord diseases affecting bladder almost inevitably also produces lower limbs signs, so examination should concentrate on lower limbs Especially look for Saddle anesthesia Bulbocavernous & anal reflex Anal sphincter tone Evidence of peripheral neuropathy Dimpling in sacral region, hypertrichosis , nevus or sinus on inspection of lumbosacral spine Cerebellar signs & postural hypotension, in presence of extrapyramidal signs, for MSA Urogenital symptoms + Normal neurological examination = highly unlikely to be neurogenic bladder

45. INVESTIGATIONS VOIDING DIARY UROLOGICAL: Urodynamic studies (UDS) Noninvasive Urinary flowmetry ( Uroflowmetry ) Measurement of post-void residua (PVR) Invasive Measurement of PVR Cystometry (filling + voiding) Videocystometry Urethral pressure profile NEUROPHYSIOLOGICAL EMG : sphincter & pelvic floor muscles Others: Bulbocavernous reflex Pudendal n. evoked potentials Electric & magnetic stimulation of cortex & sacral roots SSR form genital region NEUROIMAGING MRI

46. INTAKE AND VOIDING DIARY

47. URODYNAMIC STUDIES (UDS) UROFLOWMETRY: Flow meter consist of a commode or urinal into which pt passes urine as naturally as possible In the base of collecting system is a spinning disc Urine flow tends to slow rotations of the disc A motor holds the rotation rate constant Urine flow is derived form measurement of power necessary to maintain disc rotation Parameters: time taken to reach maximal flow, max & average flow rate and voided volume Compared with nomograms

48. UROFLOWMETRY

49. URODYNAMIC STUDIES (UDS) MEASUREMENT OF PVR: Critical in planning treatment Patients symptom of “sense of incomplete emptying” is many times unreliable Non-invasively, by post-void ultrasound Invasively, by post-void catheterization Generally excepted figure for significant PVR is 100 ml

50. URODYNAMIC STUDIES (UDS) CYSTOMETRY: Measurement of intravesical pressure during filling of bladder by water or saline & voiding Simultaneous rectal pressure is also recorded & subtracted form intravesical pressure to give true detrusor pressure alone (to remove effect of abdominal pressure) In health, bladder expands to contain 400-600 ml of fluid without increase of pressure > 15 cm H 2 O Detrusor over activity (previously detrusor hyperreflexia ) is defined as a urodynamic observation characterized by involuntary detrusor contractions during the filling phase

51. URODYNAMIC STUDIES (UDS) CYSTOMETRY (contd.): When bladder filling is completed , patient voids into flow meter Urine flow rate & detrusor pressure measured The pressure for men should be < 50 cm H 2 O & for women < 30 cm H 2 O, with flow rates greater than 15 & 20 ml/sec respectively Abnormally increased detrusor pressure with low flow rates suggest outlet obstruction Real time computer analysis is available

52. URODYNAMIC STUDIES (UDS) VIDEOCYSTOMETRY: When cystometry is carried out using contrast filling medium & procedure is radiographically screened Bladder outline can be inspected during filling Any reflux in ureters can be seen Neurogenic bladder often produces characteristic changes with thickening of bladder wall & bladder diverticula

53. VIDEOCYSTOMETRY

54. ROLE OF UDS Relatively expensive and invasive It is recommended only to evaluate symptoms of overactive bladder in cases in which the findings will clearly influence treatment, such as after the failure of initial therapy Helpful to diagnose mixed type of bladder dysfunctions sphincter dyssynergia patients with prostatic enlargement

55. NEUROPHYSIOLOGICAL Ix. EMG: First introduced to assess extent of relaxation of urethral sphincter during voiding Now rarely used because Technically difficult Needle produces discomfort impairing required relaxation of pelvic floor muscles Surface electrodes rarely pick required signals Doubt about the value of information the procedure provides Used to demonstrate changes of deneravtion & reinnervation in anal or urethral sphincter or pelvic floor in several neurogenic disorders e.g. affecting cauda equina Changes of denervation & reinnervation in sphincter EMG in MSA, usually anal sphincter is studied

56. NEUROIMAGING MRI: Ix of choice in patients with suspected structural lesion causing neurogenic bladder Excellent visualization of conus-cauda region Helpful in diagnosing underlying disorder

57. TREATMENT MEDICAL Drugs Catheterization Indwelling Intermittent (CIC) Permanent ( perurethral or suprapubic ) External Sacral nerve stimulators Nerve root stimulators Others SURGICAL

58. DRUG TREATMENT - ANTICHOLINERGICS Oxybutinin ( Oxyspas , Tropan ) MECAHNISM OF ACTION Anticholinergics Blocks AChR (postganglionic) Relaxes detrusor Propantheline is the prototype drug Tolterodine & Darifenacin are more selective for bladder INDICATION Detrusor Overactivity  bladder irritability  frequency, urge  bladder capacity 2.5-5 mg BD/QDS, PO SIDE EFFECTS Visual Blurring Dry Mouth, Dry skin Nausea, Constipation, Heart Palpitation Urinary Retention Drowsiness & Confusion CONTRAINIDCATIONS Hypersensitivity Narrow- angle Glaucoma GI Obstruction Ulcerative Colitis Toxic Megacolon Urinary Retention Obstructive Uropathy Myasthenia Gravis Tolterodine ( Detrusitol , Roliten ) 2 mg BD, PO Trospium 20 mg BD, PO Propantheline 15 mg TID/QID, PO Darifenacin 7.5-15 mg OD, PO

59. DRUG TREATMENT TRICYCLICS (TCA): Exhibit anticholinergic and direct muscle relaxant effects on the urinary bladder Imipramine ( Depsonil )- Facilitates urine storage by decreasing bladder contractility and increasing outlet resistance Has alpha-adrenergic effect on the bladder neck and antispasmodic effect on detrusor muscle Used in detrusor overactivity Amitriptyline ( Tryptomer )– Ineffective for use in urge incontinence Extremely effective in decreasing urinary frequency in women with pelvic floor muscle dysfunction Well-tolerated and effective in most women with urinary frequency

60. DRUG TREATMENT DESMOPRESSIN SPRAY (D-Void): Used in detrusor overactivity To treat increased night-time frequency One or two nasal puffs (1 mcg/ml) before retiring reduces frequency for 6-8 hrs Adverse Effect: Hyponatremia BOTULINUM-A TOXIN: Recently introduced for detrusor overactivity Injection into detrusor smooth muscle by endoscopy Effect last for 6-12 months No long-term data available

61. DRUG TREATMENT INTRAVESICAL CAPSAICIN: Neurotoxic on vanilloid receptors (VR1) present on afferent C-fibers, & blocks them when used in sufficient high concentration Used to decrease detrusor overactivity in pts with intractable incontinence caused by spinal cord disease A 1-2 mmol soln in 30% alcohol % 70% saline was instilled into bladder using balloon catheter & left for 30 mins Benefit last for upto 6 months Disadvantages: pungency & nonpharmaceutical status Resiniferotoxin : Less irritating, selective neurotoxin CANNABIS-BASED MEDICINAL EXTRACT: Experimental use in detrusur overactivity Sublingual spray used in MS in an open label study Promising results

62. INTERMITTENT CATHETERIZATION INDICATION: Incomplete bladder emptying with significant PVR &/or urinary retention CONTRAINDICATIONS: Structural abnormality of urethra, severe urethritis & periurethral abscess COMPLICATIONS: Urethritis , urethral trauma & bleeding STERILE INTERMITTENT CATHETERIZATION: Every six hourly by trained personnel using all aseptic precautions Initially done every six hourly

63. INTERMITTENT CATHETERIZATION CLEAN INTERMITTENT CATHETERIZATION (CIC): Proposed by Lapides in 1970s Postulated that most cases of UTI are secondary to some underlying abnormality of urinary tract & in others clean catheterization may suffice as any bacteria introduced will be neutralized by host immunity Highly effective in patients with incomplete bladder emptying & significant residual urine Best performed by patient themselves at home Initially be done twice daily, &  as required Should be done regularly Proper hand & genitalia wash before the procedure Disposable catheters are used Bacteriuria is noted in 50% of the cases, but incidence of symptomatic UTI is low

64. PERMANENT INDWELLING CATHETERS INDICATIONS: Unmanageable urge incontinence & frequency with significant PVR Lack of manual dexterity Lack of patient cooperation Vesicoureteral reflux Upper urinary tract damage Perurethral or suprapubic (better) Complications: Recurrent & resistant UTI Recurrent urinary stones Pericatheter urine leak Hematuria EXTERNAL DEVICES (Condom Catheters): Available for men only When urge incontinence is the main problem

65. OTHER NONPHARMACOLOGICAL Rx BLADDER TRAINING" generally refers to a combination of patient education, scheduled voiding and urge-suppression techniques, and pelvic-muscle exercise Valsalva or Credé maneuver The Credé maneuver is manual compression of the bladder Used in patients with decreased bladder tone or areflexia and low outlet resistance. Initiation of reflex bladder contraction Pinching or stimulating the lumbar and sacral dermatomal levels is used to provoke reflex bladder contraction. Timed voiding A program of timed voiding is useful in patients with weak sphincters or in patients with hyperreflexic bladders. These patients are put on a schedule of frequent bladder emptying before actual bladder contraction. Timed voiding should be scheduled every 2-4 hours

66. DRUG Rx Bethanechol hydrochloride ( Duvoid , Urecholine ) Cholinergic action Used for stimulation of the bladder to produce contraction to initiate micturition and empty the bladder Found to be most useful in patients who have bladder hypocontractility , provided they have functional and coordinated sphincters Rarely used due to difficulty in timing effect and because of GI stimulation Adult Dose 10-50 mg PO tid / qid Contraindiacted in hypersensitivity; peptic ulcer disease, obstructive pulmonary disease, bradycardia , hypotension, atrioventricular conduction defects, epilepsy, and mechanically obstructed GI or GU tract. Postmenopausal women with symptoms of overactive bladder are commonly treated with oral or topical estrogen, but few data document the efficacy of these agents Alfa blockers like prazosin are used when overactive bladder is associated with prostatic hypertrophy, not proven role otherwise

67. SURGERY Highly successful in patients with incontinence, who are otherwise fit & healthy like patients with spinal cord injury Not so in patients with progressive neurological diseases When non-surgical therapeutic options are exhausted & the patient has significant symptoms Types of surgery: Detrusor overactivity = augmentation cystoplasty Sphincter failure= artificial sphincter Intractable incontinnece = urinary diversion

68. ALGORITHM FOR DETRUSOR OVERACTIVITY

69. NEUROGENIC BLADDER IN S.C. LESIONS SPINAL CORD INJURY During this spinal shock phase, urinary retention and constipation. Urodynamic findings are consistent with areflexic detrusor and rectum, the urinary bladder must be drained with CIC or indwelling urethral catheter. When the spinal shock phase wears off, bladder function returns but the detrusor activity increases “ detrusor hyperreflexia Suprasacral lesions exhibit detrusor areflexia at initial insult but progress to hyperreflexic state over time is important. Conversely, sacral cord lesions are associated with areflexic bladders that may become hypertonic overtime Combination of CIC and anticholinergics Early consideration of surgical therapy

70. NEUROGENIC BLADDER IN S.C. LESIONS Spinal cord lesions (above the sixth thoracic vertebrae) Most often will have urodynamic findings of detrusor hyperreflexia , striated sphincter dyssynergia , and smooth sphincter dyssynergia A unique complication of T6 injury is autonomic dysreflexia Autonomic dysreflexia is an exaggerated sympathetic response to any stimuli below the level of the lesion. This occurs most commonly with lesions of the cervical cord. Often, the inciting event is instrumentation of the urinary bladder or the rectum, causing visceral distention Spinal cord lesions (below T6) Urodynamic findings of detrusor hyperreflexia , striated sphincter dyssynergia , and smooth sphincter dyssynergia but no autonomic dysreflexia These individuals will experience incomplete bladder emptying secondary to detrusor sphincter dyssynergia , or loss of facilitatory input from higher centers. Cornerstone of treatment involves CIC and anticholinergic medications

71. NEUROGENIC BLADDER IN S.C. LESIONS MS: Usually, poor correlation exists between the clinical symptoms and urodynamic findings. Thus, using urodynamic studies to evaluate patients with MS is critical. The most common urodynamic finding is detrusor hyperreflexia , occurring in as many as 50-90% of patients with MS. As many as 50% of patients will demonstrate DSD-DH. Detrusor areflexia occurs in 20-30% of cases. The optimum therapy for a patient with MS and incontinence must be individualized and based on the urodynamic findings

72. THANK YOU

73. The micturition reflex Sensation of bladder fullness via pelvic and pudendal nerves to S 2,3,4 Periaqueductal gray matter Medial Pontine micturition center Frontal lobe decides social appropriateness Onuf’s nucleus to pudendal nerves Detrussor center (S 2,3,4) to pelvic nerves RECIPROCAL ACTIVITY BETWEEN SPHINCTER & DETRUSSOR Micturition