Neurogenic bladder

kathmandu medical college, department of surgery

1. NEUROGENIC BLADDER Dr. Uttam Laudari JR III Department of Sugery Kathmandu Medical college

2. Outline of the presentation Applied physiology Symptomatology Types according to levels of bladder dysfunction Investigations Treatment available

3. Bladder functions Storage - at low pressure until such time as 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.

4. 1.Cortical micturition centre 2.Pontine micturition centre 3.Spinal micturition centre 4. Peripheral nerves Sympathetic (T11 – L2) Parasympathetic ( S2,3,4) (S2,3,4) Control of micturition

5. Cortical micturation centre(CMC) Location : Paracentral lobule in the medial aspect of the frontoparietal cotex Function: Inhibitory to PMC Dysfunction – loss of social control of bladder The brain’s control of the PMC is part of the social training that children experience at age 2 - 4 years

6. Pontine Micturition Centre (PMC) Also called Barrington’s nucleus Lateral region Function - continence , storage urine stimulation results in a powerful contraction of the urethral sphincter Medial region Function - micturition center stimulation results in decrease in urethral pressure and silence of pelvic floor EMG signal, followed by a rise in detrusor pressure.

7. Sacral reflex or Sacral/Primitive micturition centre (SMC/PMC) 1. Sacral parasympathetic nucleus (SPN) : S234- pelvic splanchnic n erves Somatic – Onufoid nuclei Collection of external urethral sphinter motoneurones 3. Levator Ani Motoneurones

8. Peripheral innervation

9. Stimulation Response Parasympathetic (S 2-4) Excitatory to detrusor , relaxes sphincter - void Sympathetic (T11- L2 ) Inhibitory to detrusor , ↑ trigone & Urethral tone Somatic ( S2 - 4) Excitatory to the external sphincter

10. Activation of the pudendal nerve causes contraction of the external sphincter and the pelvic floor muscles, which occurs with activities such as Kegel exercises. Difficult or prolonged vaginal delivery may cause temporary neurapraxia of the pudendal nerve and cause stress urinary incontinence. 

11. Micturition reflex Internal sphincter – no important role in micturition , prevents leakage during filling and prevents reflux of semen into bladder during ejaculation Sympathetic nerves – no part in micturition

12. The M icturition R eflex 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 & DETRUSOR Micturition

13. On-off switch Relay center Primitive voiding Cerebral PMC SMC

14. Symptomatology

15. Detrusor Hypereflexia

16. Detrusor Sphincter Dyssynergia

17. Resultant Poorly sustained hyperreflexic bladder contraction (DH) and (DSD) Raised post voiding residual (PVR ) Exacerbation of urgency

18. If spinal cord injury has occurred, the patient will demonstrate symptoms of urinary frequency, urgency, and urge incontinence but will be unable to empty his or her bladder completely. This occurs because the urinary bladder and the sphincter are both overactive, a condition termed detrusor sphincter dyssynergia with detrusor hyperreflexia (DSD-DH).

19. If the sacral cord becomes severely injured ( eg , spinal tumor , herniated disc), the bladder may not function. Affected patients may develop urinary retention, termed detrusor areflexia . The detrusor will be unable to contract, so the patient will not be able to urinate and urinary retention will occur

20. Neuropathy Long history of neuropathic symptoms, Stocking glove anesthesia Absent knee and ankle jerks will be absent Small fiber sensory impairment demonstrable to the level of the ankles Other features of autonomic involvement Sexual dysfunction Cauda equina Bladder, sexual & bowel dysfunction S 2, 3, 4 sensory loss Lax anal sphincter Bulbocavernosus (sacral reflexes) reflex lost +/- Foot deformities, lower limb abnormalities Cutaneous markers over the back & sacrum

21. Spinal Cord Signs of upper motor neuron lesion in the lower limbs (unless the lesion is central intramedullary and small) Erectile dysfunction in men +/- Paraparesis Brainstem Marked neurological deficits dorsal and discreet lesion defect of bladder function MLF lesion Internuclear ophthalmoplegia

22. Extrapyramidal diseases Extrapyramidal features MSA, Parkinsons disease Autonomic dysfunction Cerebellar signs Suprapontine Frontal lobe disorders Dementia, personality change Aware about incontinence unless extensive lesions Severe urgency, frequency & urge incontinence without dementia, socially aware and embarrassed by incontinence Urinary retention

23. Types according to the level of bladder dysfunction

24. a) Suprapontine /cortical lesion – “Uninhibited /Cortical bladder” Severe urgency, frequency & urge incontinence with dementia – incontinent and inappropriate voiding without dementia - socially aware & embarrassed by their incontinence.

25. b) Pontine lesion – “ Reflex / Automatic bladder” DH, Arreflexia c) Spinal ( subpontine / suprasacral ) “ Spastic Bladder” ( hyperactive bladder) Urge incontinence Disorders of storage and emptying DSD (true only if above T6 level), DH

26. c) Spinal ( subpontine / suprasacral ) The bladder empties too quickly and too frequently. The voiding disorder is similar to that of the brain lesion except that the external sphincter may have paradoxical contractions as well. If both the bladder and external sphincter become spastic at the same time, the affected individual will sense an overwhelming desire to urinate but only a small amount of urine may dribble out DSD

27. d) Sacral and subsacral lesions I) Afferent fibres involved only – “ Atonic / Areflexic bladder” Overflow incontinence Straining for micturition No DSD, no DH

28. d) Sacral and subsacral lesions prevent the bladder from emptying If a sensory neurogenic bladder is present, the affected individual may not be able to sense when the bladder is full. In the case of a motor neurogenic bladder, the individual will sense the bladder is full and the detrusor may not contract, a condition known as detrusor areflexia . These individuals have difficulty eliminating urine and experience overflow incontinence; the bladder gradually overdistends until the urine spills out. Typical causes are a sacral cord tumor , herniated disc, and injuries that crush the pelvis. This condition also may occur after a lumbar laminectomy, radical hysterectomy, or abdominoperineal resection.

29. II) Both afferent and efferent involved – “Autonomous bladder” Small capacity , acting of its own. No DSD/DH

30. Peripheral nerve injury Diabetes mellitus and  AIDS  are 2 of the conditions causing peripheral neuropathy resulting in urinary retention. These diseases destroy the nerves to the bladder and may lead to silent, painless distention of the bladder. Patients with chronic diabetes lose the sensation of bladder filling first, before the bladder decompensates. Similar to injury to the sacral cord, affected individuals will have difficulty urinating. They also may have a hypocontractile bladder. Other diseases manifesting this condition are poliomyelitis, Guillain-Barré syndrome, severe herpes in the genitoanal area, pernicious anemia , and neurosyphilis ( tabes dorsalis ).

31. UMN-SPASTIC LMN- FLACCID AREFLEXIC Cerebral PMC SMC

32. Causes of various levels of dysfunction a) Suprapontine and Pontine Causes Stroke Tumors Dementia (AD,FTD)

33. Spinal causes ( subpontine / suprasacral )

34. Sacral and Subsacral causes

35. Management- Investigations Noninvasive bladder investigations- Post void residual volume – In out catheterization , Ultrasound ( N is <100ml) Uroflowmetry - Voided volume ( >100ml) Maximal flow, maximal and average flow rate ( M > 20ml/sec and F > 15ml/sec )

36. Cystometry - Measure detrusor pressure ( Intravesical presure – Rectal pressure ) Bladder infused till 400 to 600ml – Pressure should not rise to >15cm water (Stable bladder ) Neurogenic detrusor overactivity – Involutary detrusor contraction during filling phase Voiding phase – Detrusor pressure M < 50cm water F < 30cm water

37. Sphincter EMG – Reinnervation with prolonged duration of MUAPs Neuroimaging – Cauda equina & conus lesions , spinal , supra pontine and pontine lesions

38. treatment Stress incontinence weak urinary sphincter  internal sphincter contains high concentrations of alpha-adrenergic receptors. Activation of the alpha-receptors results in contraction of the internal urethral sphincter and increases the urethral resistance to urinary flow . stress incontinence and an overactive bladder may be most effective when combined with a pelvic exercise regimen 3 main categories of drugs used to treat urge incontinence include anticholinergic drugs, antispasmodics, and tricyclic antidepressant agents.

39. Propantheline bromide    decrease incidence of urge incontinence by 13-17% when 30 mg was used qid . When stronger doses were used (60 mg qid ), the cure rate was reported to be over 90 % Adult dosing is 15 mg PO tid / qid

40. Dicyclomine hydrochloride  is an anticholinergic agent with smooth muscle relaxant properties. It blocks the action of acetylcholine at parasympathetic sites in secretory glands and smooth muscle. In a medical study, subjective improvement was reported by 62% of the subjects while taking dicyclomine hydrochloride 10 mg tid . The reported cure rate was 90%. Adult dosing is 10-20 mg PO tid .

41. Hyoscyamine sulfate  is an anticholinergic agent with antispasmodic properties used for the treatment of urge incontinence. It blocks the action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands, and the CNS, which in turn has antispasmodic effects.

42. Anitcholinegic contraindication Narrow angle glaucoma Urinary retention, bowel obstruction, ulcerative colitis, myasthenia gravis, and severe heart diseases

43. If single therapy fails Combination therapy with oxybutinin or imipramine Oxybutynin causes direct smooth muscle relaxation of the urinary bladder and has local anesthetic properties  Imipramine has a direct inhibitory and local anesthetic effect on the bladder smooth muscle, like oxybutynin imipramine also increases the bladder outlet resistance at the level of the bladder neck Ultimately relax the unstable bladder and holds urine

44. Estrogen derivatives Conjugated estrogen increases the tone of urethral muscle by up-regulating the alpha-adrenergic receptors in the surrounding area and enhances alpha-adrenergic contractile response to strengthen pelvic muscle which is important in urethral support (prevents urethral hypermobility ) Result is an improved mucosal seal effect, which is important in urethral function (prevents intrinsic sphincter deficiency ) postmenopausal women with mild-to-moderate incontinence. Both types of stress incontinence benefit from estrogen fortification.

45. Treatment - Detrusor overactivity Anticholinergics - Oxybutynin , tolterodine - M3 blockers- darifenacin Tricyclic antidepressants - Imipramine Desmopressin intranasally – once in 24 hrs Botulinum toxin A Intravesical capsaicin – instilled with a balloon catheter

46. Neurogenic Detrusor overactivity

47. Treatment Only Urinary Retention (If residual volume > 100ml) Clean intermittent self catheterisation (CISC) Permanent indwelling catheter Detrusor overactivity & Retention Anticholinergic drugs CISC ( Clean Intermittent Self Catheterization (CISC)

48. Treatment External device – condom catheter Sacral nerve stimulators Nerve root stimulators – S 2,3,4 for voiding assisting defecation Surgery – Augmentation cystoplasty , artificial sphincter, urinary diversion with stoma collection bag