Neurogenic bladder

1. NEUROGENIC BLADDER

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 ( nervi erigentes ) arise from 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. 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

11. 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

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

13. Symptomatology

14. Detrusor Hypereflexia

15. Detrusor Sphincter Dyssynergia

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

17. 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

18. 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

19. 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

20. Types according to the level of bladder dysfunction

21. 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.

22. b) Pontine lesion – “ Reflex / Automatic bladder” DH, Arreflexia in pts with INO c) Spinal ( subpontine / suprasacral ) “ Spastic Bladder” Disorders of storage and emptying DSD (true only if above T6 level), DH

23. d) Sacral and subsacral lesions I) Afferent fibres involved only – “ Atonic / Areflexic bladder” Overflow incontinence Straining for micturition No DSD, no DH II) Both afferent and efferent involved – “Autonomous bladder” Small capacity , acting of its own. No DSD/DH

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

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

26. Spinal causes ( subpontine / suprasacral )

27. Sacral and Subsacral causes

28. 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 )

29. 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

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

31. 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

32. Neurogenic Detrusor overactivity

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

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