Neurogenic Bladder 1.pptx

Neurogenic Bladder part 1 By Dr Arman Hossain, MD Physical Medicine , Dhaka Medical College Hospital, Dhaka, Bangladesh.

1. Neurogenic Bladder -1 Dr. SM Arman Hossain MD Resident ( Phase-B) Physical Medicine And Rehabilitation Dhaka Medical College Hospital

2. Introduction The primary functions of the urinary bladder are storage of urine and coordinated emptying Incontinence and urinary retention are common presenting symptoms of bladder dysfunction in patients with neurologic disorders The management of neurogenic bladder dysfunction is too important to be left as a matter for occasional consultation

3. Neuroanatomy of Urinary Bladder

4. Neuroanatomy of Urinary Bladder..Cont’d BD Chaurasia’s Human Anatomy

5. Neurophysiology Central pathways • Cortical Micturition centre ( paracentral lobule of the frontoparietal cortex) - Inhibits parasympathetic sacral micturition center - Inhibitory to pons - Allows bladder storage • Pontine Micturition center(PMC) - Lateral Region: storage urine - Medial Region: Micturition center - Coordinates bladder contraction and sphincter relaxation (Physical Medicine and Rehabilitation Board Review)

6. Cont’d.. Peripheral pathways C oordinated by interactions between the autonomic nervous system (sympathetic and parasympathetic) and somatic nervous System Sympathetic nervous system- urine storage Parasympathetic nervous system- urine release. * S ympathetic for “ S”torage & P arasympathetic for “ P”ee

7. Cont’d.. Parasympathetic Origin : intermediolateral gray matter at S2–S4 levels Course : Travel through pelvic nerves to parasympathetic receptors of detrusor muscle Function : Stimulation of cholinergic receptors Result: Bladder contraction & emptying

8. Cont’d.. • Sympathetic Origin: Intermediolateral gray matter from T11–L2 Course: Travel through hypogastric nerves to α -1 and ß -2 adrenergic receptors within the bladder and urethra Function: Stimulation of ß -3 adrenergic receptors within the body of the bladder causes smooth muscle relaxation (compliance) stimulation of α -1 adrenergic receptors within the base of the bladder/prostatic urethra causes smooth muscle contraction (increase outlet resistance) Result: urine storage

9. Cont’d.. • Somatic efferents fibers Origin : Pudendal nucleus of sacral segments (S2–S4 ) Course : Travel through pudendal nerve to innervate striated muscle of external urethral sphincter . Function : Voluntary contraction of external urethral sphincter Result : prevents leakage or emptying

10. Cont’d.. • Somatic afferent fibers: Origin: Detrusor muscle stretch receptors , external anal and urethral sphincters, perineum, genitalia. Course: Travel through the pelvic and pudendal nerves to the sacral cord. Function : Myelinated A-delta fibers respond to bladder distention stimulating parasympathetic emptying of bladder. Unmyelinated C-fibers are silent and not essential for normal Voiding Result : Voiding of the bladder

11. Cont’d.. Urethral sphincters • Internal sphincter: - Mostly innervated by T11–L2 hypogastric nerve (sympathetic) - Under control of autonomic system; large number of alpha-adrenergic receptors - Contracts sphincter for storage - Smooth muscle, involuntary • External sphincter: - Innervated by pudendal nerve (S2–S4) - Prevents leakage or emptying - Skeletal muscle, voluntary

12. Neuropharmacology Receptors of urinary bladder Cholinergic muscarinic receptors ( M3) Located within the bladder wall, trigone , bladder neck, and urethra. Ach binds to M3 receptors to cause contraction • Beta-3 adrenergic receptors: Concentrated in the body of the bladder, also some in bladder neck.Norepinephrine (NE) binds to beta-adrenergic receptors to cause relaxation • Alpha-1 adrenergic receptors : Located within the base of the bladder and prostatic urethra NE binds to alpha-1 adrenergic receptors to cause contraction

13. Cont’d…. krusen's handbook of physical medicine and rehabilitation

14. cont’d.. ( Vishram Singh Textbook of Anatomy)

15. Micturation reflex Micturation reflex: It is a spinal reflex facilitated & inhibited by higher brain canters to void urine from urinary bladder.(Guyton & Hall). Pathways- Filling of urinary bladder Stimulation of stretch receptor Afferent impulses pass via pelvic nerve Sacral segment of spinal cord Efferent impulses via pelvic nerve Contraction of detrusor muscle & relaxation of internal sphincter

16. Cont’d… Flow of urine into urethrae & stimulation of stretch receptor Afferent impulses via pelvic narve Inhibition of pudendal nerve Relaxation of external sphincter Voiding of urine (Ref: Sembulingam 7 th edition)

17. Normal Voiding First sensation- 100 ml to 200ml of urine Sensation of fullness- 300 to 400 ml sphincter remains contracted through a primitive reflex known as the holding reflex Sensation of Urgency- 400 to 500ml Normal Bladder capacity- 400 to 700 ml krusen's handbook of physical medicine and rehabilitation

18. Cont’d.. During emptying: The periurethral striated sphincter is relaxed, At the same time, the bladder neck will relax The detrusor muscle of the dome of the bladder contracts voiding takes place This extraordinarily well-coordinated process requires perfect synergy between the sympathetic, parasympathetic , and somatic nerve supplies

19. Neurogenic bladder Neurogenic bladder is defined as bladder dysfunction resulting from a central or peripheral neurologic insult Possible symptoms include urinary incontinence, urgency, nocturia , straining, incomplete voiding, and urinary retention https://now.aapmr.org/

20. Anatomical Classification Anatomical Classification of Neurogenic bladder Supraspinal Suprasacral Infrasacral Braddom's physical medicine and rehabilitation

21. Cont’d… Supraspinal lesion - Uninhibited bladder Lesion of CNS involving area above Pons Micturition is usually precipitous & complete Absent Post void residual (PVR) urine Normal Sensation of bladder filling Cause: CVA, frontal tumors, parasagital meningioma,PD *Local reflex ঠিক থাকবে। signal---- cerebral cortex পর্যন্ত যাবে। কিন্তু pons এর micturition center কে inhibit করতে পারে না।* Braddom+krusen+Board review+queen’s neurology

22. Cont’d… Suprasacral lesion Automatic Bladder/Reflex neurogenic bladder Inability to initiate voluntary micturition - Detrusor-sphincter dyssynergia is a rule - Bladder tone increased, capacity reduced - Small residual volume - Cause: Compressive myelopathy, Spinal cord trauma syringomyelia * Local reflex ঠিক থাকবে । কিন্তু brain এর সাথে communication নাই। তাই local reflex এর মাধ্যমে micturition হবে*

23. Cont’d… Infrasacral Lesion Atonic Bladder / Autonomous bladder Denervation of both afferent & efferent supply to bladder Bladder tone flaccid Increased bladder capacity & PVR urine No bladder reflex acitvity Infection rate is high Overflow incontinence, no urgency Cause: Cauda equina syndrome, conus medularis , spinal shock *কারন bladder এর সাথে অন্য কারো সম্পর্ক নাই*

24. Cont’d… Neurology: A Queen Square Textbook

25. Functional Classification Failure to store: Overactive bladder(OAB) UMN bladder Voiding is unpredictable & incomplete Symptoms: Urgency, Frequency, Urgency incontinence, nocturia Braddom+Board review

26. Cont’d… Failure to empty: Urinary retention LMN bladder Fills without emptying Symptoms: Hesitancy, feeling of incomplete voiding, straining, double voiding

27. Cont’d…

28. Cont’d…

29. Cont’d… Lesion involving afferent sensory neurons: Sensory neurogenic bladder Impaired bladder sensation Initiation of micturition is possible If bladder not voided at timely basis--- overdistended bladder Bulbocavernosus & anal reflexes are absent Cause: tabes dorsalis , neuropathies mainly small fibers-DM, amyloidosis

30. Cont’d… Lesion involving efferent motor neurons : Motor paralytic bladder Bladder tone flaccid, sensory intact C/O painful retention of urine Inability to initiate or maintain micturition Bulbocavernosus & anal reflexes are absent Cause: Extensive pelvic surgery or trauma, Lumbosacral meningomyelocele

31. NLUTD symptoms Voiding Symptoms : Hesitancy Slow Stream Straining to void Terminal dribbling Feeling of incomplete emptying Storage symptoms: Frequency Urgency Urge incontinence Nocturia

32. Urodynamic terminology Frequency : Failure bladder storage function leads to frequency of micturition Urgency : Sudden, strong desire to void urine Urge incontinence : Sudden & involuntary loss of urine Nocturia : Interruption of sleep by urge to void Braddom+Baily & Love

33. Cont’d… Hesitency : Difficulty to initiate micturation Urinary retention : It is the inability of the urinary bladder to empty . cause may be neurogenic or non neurogenic Hesitancy: Difficulty in initiating voiding

34. Cont’d…

35. Cont’d… Detrusor–Sphincter Dyssynergia (DSD) Loss of the coordinating control of the pontine micturition center Lesion in suprasacral Spinal cord injury (SCI) Detrusor contraction and sphincter relaxation are not coordinated Spastic bladder will often try to empty against a closed sphincter This manifests as both urgency and an inability to pass urine R esultant incomplete bladder emptying predisposes to urinary infection Davidson's Principles and Practice of Medicine+ Braddom

36. Diagnostic testing for Neurogenic Bladder dysfunction

37. Upper Tract Tests Ultrasonography Plain radiography of the urinary tract: KUB Computed tomography Excretory Urography or CT Urogram Creatinine clearance Time Isotope studies

38. Lower Tract Tests Urinalysis , culture and sensitivity testing Postvoid Residual(PVR) Cystography Urodynamics Urethral Pressure profiles Sphincter Electromyography Videourodynamics / Flurourodynamics Cystoscopy

39. Ultrasonography low-risk and relatively low-cost test for routine evaluation and easy for the patient. It is not S ensitive enough to evaluate acute ureteral obstruction A dequate for imaging chronic obstruction and dilation, scarring, renal masses (both cystic and solid ), and renal stones The bladder, unless empty, can be evaluated for wall thickness, irregularity

40. Plain radiography of the urinary tract: KUB A kidneys, ureters, and bladder (KUB) study is often combined with US to identify any possible radiopaque calculi in the ureter or bladder stones not seen on US

41. Computed tomography Performed without contrast enhancement Replaced KUB, US, and excretory urography in the evaluation of the upper tracts when acute obstruction from stones is a possibility. M ost sensitive study for detecting small bladder stones in patients with an indwelling catheter in whom the bladder is collapsed around the catheter

42. Excretory Urography or CT Urogram With a delayed phase , A CT without/with contrast , has replaced the excretory urogram now called a “CT- urogram ” or CTU. The “gold standard” for the work-up of patients with asymptomatic microscopic hematuria Imaging choices should be made in the context of results of a formal microscopic urine analysis

43. Cont;d … Alternative studies include US, radioisotope renography , and possibly cystoscopy should be done if there is – serum creatinine conc. is > 1.5 mg/ dL The patient has insulin-dependent diabetes intravenous contrast agent administration increases the risk of contrast-related nephropathy

44. Creatinine clearance Time Gold standard for assessing renal function and is said to approximate GFR A ccuracy depends on meticulous urine collection Because of such limitations, more endogenous markers of GFR are being increasingly studied. e.g. serum cystatin C

45. Isotope studies T echnetium-99m dimercaptosuccinic acid (DMSA) scan is still the best study for both differential function and evaluation of the functioning areas of the renal cortex. The renogram obtained with technetium-99m mertiatide (MAG-3) also gives information on urinary tract drainage, as well as a good assessment of differential function

46. Lower Tract Tests

47. Urinalysis, culture and sensitivity testing Done routinely for all patients with NLUTD and should be repeated as often as necessary or at the very least at routine follow-up annually. Recommended before invasive procedures in cases of suspected UTI or with new lower urinary tract symptoms such as incontinence, frequency Recommended In persons with SCI who lack sensation , UTI symptoms may also include increased spasticity or autonomic dysreflexia (AD).

48. Postvoid Residual(PVR ) The PVR is simple to determine and clinically useful PVRs can vary throughout the day A catheter insertion has been used for PVR in the past, but there are now simple US machines that noninvasively obtain the PVR. A low (<20% of bladder capacity) PVR is not by itself indicative of a safe bladder because high intravesical pressures can be present despite low PVR values.

49. Cystography U sually performed to test for the presence or absence of ureteral reflux , and it also shows the outline and shape of the bladder . Findings suggestive of increased bladder pressure, such as diverticuli or an irregular bladder contour due to trabeculation can be observed. I t does not provide information about bladder pressure corresponding to reflux; for this, urodynamic testing is needed

50. Urodynamic Evaluation/Study P ressure-flow study of lower urinary tract function with or without the use of fluoroscopy (video urodynamics ) G old standard for the evaluation of lower urinary tract function Evaluates two phases of bladder function: filling (storage) and voiding (emptying )

51. Cont’d… Procedure requires- Insertion of a catheter into the bladder S econd catheter to measure abdominal pressures into the rectum Needle electrode for sphincter EMG Uroflowmeter Video fluroscopy (+/-)

52. Cont’d…

53. Cont’d…

54. Cont’d… Filling phase metrics with Urdodynamic testing- Bladder capacity Bladder sensation: Bladder wall complience : Presence of involuntary contraction Voiding phase provides information about- Bladder contractility U rinary flow rate U rethral sphincter activity, Characterization of possible bladder outlet obstruction.

55. Sphincter Electromyography Sphincter EMG can be combined with the cystometrogram (CMG ) or preferably with a full multichannel videourodynamic study Recordings have been made with a variety of electrodes ( monopolar , coaxial needle, and surface electrodes) from the levator , perianal , or periurethral muscles Normally , EMG activity gradually increases as bladder capacity is reached during bladder filling and then becomes silent just before voiding Low levels of EMG activity with no recruitment during filling are a common pattern in complete SCI

56. Cont’d…

57. Cystoscopy Routine indication for cystoscopy is the presence of along-term indwelling suprapubic or urethral catheter because the presence of the catheter increases the risk for bladder tumor Often a noncontrast CT is the only study that will pick up small bladder stones , especially if the bladder is collapsed around an indwelling catheter. Repeated lower tract infections can be an indication for cystoscopy and can reveal nonopaque foreign bodies , such as hairs, that have been introduced by catheterization

58. References Braddom's physical medicine and rehabilitation 6 th edition Physical Medicine and Rehabilitation Board Review, 4 th Edition krusen's handbook of physical medicine and rehabilitation, 4 th Edition Davidson's Principles and Practice of Medicine,23rd Edition BD Chaurasia's Human Anatomy. Vol -2 Vishram Singh Textbook of Anatomy, 2 nd edition Neurology: A Queen Square Textbook, 2 nd Edition Bailey and Love’s Practice of Surgery 27 th edition https://now.aapmr.org /

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