11. BRADLEY’S LOOPS : 1ST LOOP
Also called the cerebral loop
Connects the cortical areas with the pontine micturition centers “BARRINGTON
NUCLEUS”
Cortex influences the pons and decides when to void and when to not.
16. LOOP 3
Detrusor contraction sends
Afferent to Pudendal Nerve nucleus i.e.Onuff’s nucleus(somatic)
Inhibits external urethral sphincter
Hence the sphincter relaxes and allows voiding
17. LOOP 4
“Urethral reflex”
Flow of urine into the urethra stimulates the local plexuses and further helps in
relaxation of the external sphincter
Helps in voiding
18. 5th LOOP
Cortex influences the Onuff’s nucleus
Which sends signals via somatic pudendal nerve
Relaxes the external sphincter and helps voiding
“Meaning everyone can voluntarily void even without a full bladder” because your
cortex decided so.
24. EAU GUIDELINES ON NEURO-UROLOGY
PRE VOID :
frequency
Urgency
Urge incontinence
NORMAL VOIDING
NO POST VOID
RESIDUE
PREVOID:
UMN features
VOID:
Hesitancy
Cannot hold in between
Detrussor-sphincter
dysynergia
Double void
POST VOID:
Residual urine present
PRE VOID:
Normal
VOID:
Hesitancy
Poor or absent flow
Overflow
incontinence
POST VOID:
Increased residual
urine
1
2
3
29. AUTOMATIC / REFLEX BLADDER
Infrapontine lesions
Sacral Reflex arc intact
The Pons decision over switching between bladder filling and voiding- lost
Frequent small voids
Small bladder
Seen in Multiple sclerosis / spinal cord tumours / spinal cord trauma.
30. AUTONOMOUS BLADDER
Sacral or infrasacral lesion
No nervous control over bladder
Acts independently
LMN bladder
Large volume residual urine present
Seen in conus medularis / cauda equine syndrome / peripheral neuropathy
31. SENSORY PARALYTIC BLADDER
Isolated afferent denervation lesions
No sensation of bladder filling
Bladder overdistended
Overflow incontinence
Voluntary voiding needed
Motor innervation intact
Saddle anaesthesia present (s2,s3,s4 afferent lost)
Seen In : multiple sclerosis / diabetes mellitus / tabes dorsalis
32. MOTOR PARALYTIC BLADDER
LMN bladder
Isolated motor denervation lesions
Bladder sensation present
Painful urine retention
Bulbocavernous and anal reflex absent
Has to void by Credes’ maneuver - pressure over distended bladder /lower abdomen
Seen in lumbosacral meningomyelocoele / lumbar canal stenosis / extensive pelvic surgery / poliomyelitis /
polyradiculopathy
35. Normally during coughing/ sneezing intra abdominal pressure increases
However urinary continence is maintained as the Nucleus retroambiguous sends signals to
ventrolateral medulla
Stimulates the Onuff’s nucleus
Contracts the external sphincter and pelvic floor muscles
Multiple pregnancy and childbirth with instrumentation damages the pelvic integrity – stress
incontinence
36. TREATMENT
The primary aims in treating neurourological disorders are:
1. protection of the upper urinary tract;
2. improvement of urinary continence;
3. restoration of (parts of) the LUT function;
4. improvement of the patient’s QoL.
Further considerations are the patient’s disability, cost-effectiveness, technical
complexity, and possible complications
37. Conservative treatment
Assisted bladder emptying Triggered reflex voiding is not recommended as there
is a risk of pathologically elevated bladder pressures. Only in the case of absence,
or surgically reduced outlet obstruction it may be an option.
Caution: bladder compression techniques to expel urine (Credé) and voiding by
abdominal straining (Valsalva manoeuvre) create high pressures and are
potentially hazardous, and their use should be discouraged
38. Rehabilitation
In selected patients, pelvic floor muscle exercises, pelvic floor electro-stimulation,
and biofeedback might be beneficial
39. External appliances
Social continence for the incontinent patient can be achieved using an appropriate
appropriate method of urine collection.
Medical therapy
A single, optimal, medical therapy for patients with neurourological symptoms is
not yet available. Muscarinic receptor antagonists are the first-line choice for
treating neurourological disorders.
40. REFERENCES
EAU guidelines on neurourology
DeJong’s The Neurologic Examination
Localization in Clinical neurology