Neurogenic bladder

Neurogenic Bladder
Autonomous Bladder
Automatic Bladder

1. NEUROGE NI C BLADDER DR.TARUN KUMAR BADAM PG DNB ORTHO INSTITUTE OF ORTHOPEDIC RESEARCH AND ACCIDENT SURGERY (IORAS)

2. GENERAL CONSIDERATIONS Urinary bladder is an important organ of our body , which stores and expels urine in co-ordinated and controlled fashion Co-ordinated activity is controlled by, Central nervous system Somatic peripheral nervous system Autonomic peripheral nervous system

3. NORMAL MICTURITION Normal micturition is primarily a spinal reflex, controlled by CNS ( Brain, Pons and Sacral spinal cord ), which co-ordinates functions of Urinary bladder and Urethral sphincter.

4. BRAIN Frontal lobe of Brain consists of Micturition Control Centre (MCC) Primary activity of this area is to send tonically inhibitory signals to Detrussor muscle via Pons to prevent Bladder emptying, until socially acceptable place is available It helps in voluntary control of Micturition Lesions in Frontal lobe of Brain due to Stroke,Cancer,etc results in loss of voluntary control of Normal Micturition Signals from Brain pass through Pons and Sacral spinal cord, before reaching the Urinary bladder

5. PONS Pons consists of Pontine Micturition Centre ( PMC ) PMC is a relay centre between Brain and Sacral Spinal Cord PMC is responsible for Co-ordinated activities of Detrussor and Urethral sphincter, so that they work in synergy i.e., Detrussor contraction and Sphincter relaxation PMC is affected by emotions, if individual is excited or scared sometimes can lead to urinary incontinence

6. Spinal Cord functions as a communication pathway between Pons and Sacral spinal cord

7. SACRAL SPINAL CORD It is terminal portion of Spinal Cord It contains Sacral Reflex Centre (SRC) It is a Primitive Micturition Centre In Infants upto 3-4 yrs of age, Micturition is controlled directly by SRC After 3-4 yrs of age due to Toilet training, Brain takes over the control of Micturition

8. AUTONOMIC PNS In Normal conditions, Urinary Bladder and Internal Urethral Sphincter are under the control of Sympathetic Nervous system When Sympathetic NS, is active- Relaxation of Detrussor and Contraction of Internal Urethral Sphincter, causing inhibition of Micturition When Parasympathetic NS is stimulated, Contraction of Detrussor and relaxation of IUS occurs, causing Micturition Sym NS - Hypogastric Plexus (T11- L2) Parasym NS - Pelvic Splanchnic nerves (S2-S5)

9. SOMATIC PNS is under direct control of Brain Voluntary control of Micturition occurs through Somatic PNS Somatic PNS - Pudendal Nerve( S2,S3,S4) supplies Pelvic musculature and External Urethral Sphincter

10. MICTURITION REFLEX

11. PATHOPHYSIOLOGY Neurogenic Bladder can occur if any of the before mentioned sites are affected

12. BRAIN LESIONS Lesions of the Brain above level of Pons destroys Micturition Control Centre Leads to Complete Loss of Voluntary control Primitive Neonatal Micturiton Reflex i.e., Sacral Reflex centre and Pontine Micturition Centre remains intact Loss of control over Primitive Neonatal Micturition Reflex makes it Autonomous Bladder empties too quickly and too often, Storage capacity is lost

13. Persistance of Pontine Micturition Centre controls Synergestic functions between Detrussor and Internal Urethral Sphincter So, URGE INCONTINENCE or SPASTIC BLADDER or DETRUSSOR HYPER-REFLEXIA Eg: Head Injury, Cerebral Palsy, Stroke, ICSOL

14. SPINAL CORD LESIONS Injuries or Diseases of the Spinal cord between Pons and Sacral spinal cord results in Micturiton control solely by Sacral Reflex Centre So, patients have URGE INCONTINENCE / SPASTIC BLADDER / DETRUSSOR HYPER-REFLEXIA But due to loss of Control by PMC , Synergestic function between Detrussor and IUS is lost , leading to dysynergia

15. ACUTE SPINAL CORD INJURY

16. POST SPINAL SHOCK

17. SACRAL CORD INJURY Sacral cord injuries may prevent bladder from emptying Sensory Neurogenic Bladder - may not be able to sense even when the Bladeer is full , due to injury to Afferent fibres in Pelvic nerves Motor Neurogenic Bladder - Bladder is full, patient has sense, Detrussor may not contract, due to injury to Efferent Parasympathetic fibres in Pelvic Sphlanchnic nerves ………….. DETRUSSOR AREFLEXIA

18. Sacral Cord Injuries leads to OVERFLOW INCONTINENCE Other causes are Herniated Disc, Lumbar Laminectomy, Pelvic crush injuries, Sacral cord tumours

19. PERIPHERAL NERVE LESIONS Pudendal Nerve injury leads to weakness of Pelvic floor muscles and External Urethral Sphincter Voluntary control of Micturiton is impaired STRESS INCONTINENCE

20. NEUROGENIC BLADDER malfunctioning of Bladder due to Neurologic dysfunction

21. TYPES Detrussor Hyper-reflexia Detrussor Sphincter Dys-synergia with Detrussor Hyper-reflexia ( DSD-DH ) Detrussor Hyper-reflexia with Impaired Contractility ( DHIC ) Detrussor Instability Detrussor Areflexia

22. Detrussor hyper-reflexia : due to Supra-pontine UMN lesion, EUS is Normal , and is in synergy with Detrussor DSD-DH : due to Infra-Pontine and Supra-Sacral UMN lesion, Detrussor and Sphincter contracting at same time i.e., Dyssynergy is present DHIC : due to overactive bladder, but detrussor can’t generate enough pressure to empty the bladder Detrussor Instabilty : Overactive bladder without Neurologic impairment Detrussor areflexia : LMN lesion with Inability of Detrussor to empty

23. DIAGNOSTIC PROCEDURES Post-voidal Residual urine Uroflow rate Voiding Cystometrogram Filling Cystometrogarm Electromyography Videourodynamics

24. MANAGEMENT ABSORBENT PRODUCTS URETHRAL OCCLUSIVE DEVICES CATHETERISATION PELVIC FLOOR EXERCISES VAGINAL WEIGHTS BIOFEEDBACK ELECTRICAL STIMULATION - Stress and urge incontinence BLADDER TRAINING - urge incontinence

25. MEDICATIONS ESTROGEN DERIVATIVES ANTICHOLINERGIC DRUGS TRICYCLIC ANTIDEPRESSANTS

26. Oestrogen derivatives: Conjugated Oestrogen(Premarin) upregulates Alpha-adrenergic receptors in neck of the bladder useful in mild to moderate stress incontinence mostly in Post-menopausal women In pre-menopausal women , its given along with Progestin

27. Anti-cholinergic drugs: effective in Urge incontinence due to Detrussor hyper-reflexia Mechanism - inhibits parasym activity and decreases depressor contractility Eg: SOAP-D Solefenacin, Oxybutynin, Atropine, Propantheline, Dicyclomine

28. Tri-cyclic Antidepressants: Imipramine has Alpha-adrenergic agonistic activity increases the outlet resistance in the neck of bladder in IUS

29. SURGICAL MANAGEMENT STRESS INCONTINENCE: Periurethral bulking therapy Sling Procedures Bladder Neck suspension URGE INCONTINENCE: Sacral Neuromodulation Botulinum Toxin Detrussor myomectomy

30. THANK YOU