Neural control of bladder

This PPT is for educational purpose for neural control of bladder, along with various types of neurogenic bladder

1. Presented by: Dr. Pravin Kumar Moderator :Prof. S.B. DEVI NEURAL CONTROL OF BLADDER

2.  Bla dd e r d ivide d in t o Detrusor - consists of smooth muscle Base- trigone and bladder neck, intimately connected to pelvic floor . Bladder outlet-two urethral sphincters Internal (smooth muscle) sphincter-bladder neck and proximal urethra External (striated muscle) sphincter-membranous urethra. Capacity- 400 to 600 ml

3. U r e th r al S p h i n

4. Bladder funct i ons Storage - at low pressure until 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. 4. P eri phe r al ne r v es Cortical micturition centre Pontine micturition centre Sympathetic 3.Spinal micturition centre (T11 – L 2) Parasympathetic ( S2,3,4) (S2,3,4) C o n t r o l o f micturiti on

6. Cor t i c al mictu r a tion ce n t r e(CMC) Loc a ti o n: P a r ace n t r al l o b u le in the med i al aspect o f the f r o n t opar i e t al c o t e x Functi o n : Inh i b i t o r y t o P M C – Sends inhibitory signals to the detrusor muscle to prevent the bladder contaction D y s fun c tion : l os s o f s ocial c o n t r o l o f b ladder (infant bladder)

7. P o n tine Micturition Ce n t r e ( PMC ) Also called Barrington’s nucleus (located in the locus ceruleus , pontomesencephalic gray matter, and nucleus tegmentolateralis dorsalis ) Lateral region Function - continence, storage urine. S timulation results in a powerful contraction of the external urethral sphincter Medial region Function - micturition center C oordinates the urethral sphincter relaxation and detrusor contraction to facilitate urination

8. Sacral micturation centre 1) Parasymapathetic 2)Sympathetic 3)Somatic

9. P ARA S YM P A T H ET I C: CENTRE: S2-S4 in intermediolateral column SUPPLY THROUGH : pelvic splanchnic nerves NEUROTRANSMITTER : ACh VIA M2, M3 FUNCTION: Postganglionic neurons r elease ach → M2 and M3 → detrusor muscle Bladder contraction & Internal sphincter relaxation facilitating micturation

10. S YM P A TH E TIC: CENTRE : T11-L2 intermediolateral column SUPPLY : Sympathetic chain ganglia- hypogastric and pelvic plexus FUNCTION: Via β-adrenergic receptors - relaxation of the detrusor muscle. Through alpha 1 receptors causes Contraction of internal sphincter Facilitate bladder storage and continence

11. SOMATIC : CENTRE : Onuf nucleus S2-S4 SUPPLY THROUGH : Pudendal nerve NEUROTANSMITTER: Ach via nicotinic receptor FUNCTION : Controls the external sphincter(cortical control)

12. E f fere n t p at h w ay s for bladder control (SMC) t r ac t

13. NEUROGENIC BLADDER Definition: D ysfunction of the urinary bladder due to disease of the central nervous system or peripheral nerves involved in the control of micturition

14. 1)Uninhibited 2)Reflex 3)Autonomous 4)Motor 5)Sensory

15. Uninhibited bladder (failure to store) loss of the cortical inhibition of reflex voiding bladder tone and sensation remains normal. frequency, urgency, and incontinence( detruser hypereflexia ) Urodynamic testing- normal bladder sensation and filling parameters, multiple unstable contractions Causes: Stroke,brain tumour,NPH,dementia,parkinsonism etc

16. UMN/Reflex/Automatic neurogenic bladder lesion above the level of the sacral bladder center and below the level of the PMC. Loss of the normal inhibition from higher centers results in detrusor contraction during bladder filling( detrusor hyperactivity) Detrusor sphincter dyssynergia (DSD) –obstructed voiding, incomplete emptying ↑ IV pressure→HDN , Obst . Uropathy Sy mptom s - Urgenc y , fre q ue n c y, he s ita n c y, interu p ted stre a m, ur g e i ncontin e nce (DSD +DH) Causes: spinal cord injury, tranverse myelitis , MS, ALS, Myeopathy etc

17. Autonomous neurogenic bladder(flaccid bladder) lesion in between the bladder and spinal cord both afferent and efferent fibres are involved loss of sensation and voluntary control of bladder Inability to initiate micturition overflow incontinence and increased residual urine develop . Causes: Cauda equina syndrome, conus medullaris spinal shock, extrinsic tumor compression,pelvic trauma,spina bifida etc

18. Mo t or pa r al y tic bladder Motor nerve supply to the bladder is interrupted The bladder distends and decompensates , but sensation is normal residual urine is markedly increased th e bu l bo c a v ernos u s and sup erficial ana l r e f l e x es a r e u su a ll y ab sent b u t s ac r al and b l add e r sens a ti o n a r e p r ese n t Causes: lumbar spinal stenosis,lumbosacral meningomyelocele , following radical hysterectomy or abdominoperineal .Resection, herpes zoster infection

19. Sensory pa r al y tic bladder sensory nv supply to the bladder is interrupted lesions that involve the posterior roots or posterior root ganglia of the sacral nerves, or the posterior columns of the spinal cord. distension, dribbling, and difficulty both in initiating micturition and in emptying the bladder. Painless urinary retention, overflow incontinence,UTI Sensation is absent, and there is no desire to void, can void voluntarily (motor intact) causes: Tabes dorsalis , diabetes, syringomyelia,pernicious anemia etc

20. Treatment: Uninhibited neurogenic bladder: Drug s t o b l oc k p a r a s ymp a th e tic acti v a ti o n of b ladder c o n t r acti on O x y butyn i n , t o l t e r od i n e , t r osp i u m , dar i f enac i n , and so l i f enac i n Reflex neurogenic bladder: Clean intermittent self- catheterisation (CISC) every 4-6 hr Anticholinergic medication oxybutynin hydrochloride (5mg tds ) Tolterodine (1-2mg bd ) Solifenacin (5-10mg ) Cystoscopic placement of an intraurethral stent

21. Motor , sensory and autonomous bladder: C lean i n t ermi t t e n t c a th e t eri z a ti on Ind w ell i n g c a th e t e r s S a c r al ne r v e r o o t neu r omodu l a t i o n . Long term use of indwelling urinary catheter to be avoided

22. THANK YOU

23. References; Campbell wash urology 11 th ed Davidson’s medicine 22 nd ed Adam’s Neurology 10 th ed