2. OVERVIEW
 Anatomy and physiology
 CNS centers
 Arcs and loops
 Spinal tracts
 Basic concepts of neurourological
function
 Reflexes
 Dysfunction
 Pharmacological management

3. Anatomy and physiology
 Upper urinary tract dysfunction is rare
due to neurological disease
 Lower urinary tract is richly supplied
with both autonomic and somatic
nervous system

4. Bladder anatomy
 Three anatomical layers
 Inner mucosal layer
 Muscular middle layer
○ Outer and inner longitudinal layer
○ Middle circular layer
 Outer adventitial layer
 Functinally bladder is divided in to parts
 Body
 Trigone

6. Receptors of the bladder
 Parasympathetic (musacrinic)
 Sympathetic
 Dual action
 Beta adrenargic
 Alpha adrenergic

8. CNS centers
 PONS
 Pontomesencephalic reticular formation
 Afferents from bladder receptors of
distension
 Sphincter detrusor synergesia
 Reticulospinal tracts spincter and detrusor
centers of the spinal cord

9.  Cortex, basal ganglia and cerebellum
 Paracentral lobule involved in voluntary
initiation of micturition and inhibition of reflex
voiding
 Lesions results in frequency and urgency
 Direct control of voluntary micturition
influencing the onufs nucleus through CST
 Pontine micturition center

11.  Spinal cord centers
 Sympathetic anteriomediolateral gray
column thoracolumbar cord T9-L1
 Parasympathetic nuclei intermediolateral
region of sacral cord S2-S4
 Onuf’s nucleus anterior horn of sacral cord

12. Arcs and Loops
 Supra spinal arc
 Parasympathetic afferent input from tension
receptor in the bladder wall to pontine
micturition centers
 Reticulospinal tracts to centers to sacral
cord
 3 to 4 yrs of age voiding is a reflex process
 Lesions above the brain stem manifested
clinically by frequency and urgency with
preserved detrusor sphincter synergesia

14.  Sympathetic nervous system arc
 Efferent sympathetic innervation T9-L1
through ventral routes, sympathetic ganglia
in the para vertebral chain preaortic and
parvertebral chains
 Touch, pain, and temperature from bladder
through spinothalamic tract

17.  Parasympathetic nervous system arc
 Efferents originate in the sacral cord travels
throgh ventral spinal roots and pelvic nerves
and joins with sympathetic nerves to create
a large autonomic plexus
 Proprioceptive information of bladder
sensation and pain through posterior
columns and spinothalamic centers to PMC
and supraspinal centers

19.  Pudendal system arcs
 Efferent somatic innervation of ext sphincter
from the onufs nucleus through pudendal
nerves
 Afferent carry exteroceptive and
proprioceptive sensation from pelvic floor
 Afferent fibers from the ext sphincter and
pelvic floor synapse with pudendal motor
neurons in ventral horns of the spinal cord
and helps in voluntary and reflex activity

21. LOOPS
 Loop 1
 Pathways between frontal cortex, basal
ganglia, thalamic nuclei, cerebellum and
pontomesencephalic reticular formation
 Predominantly inhibitory
 Interruption leads to loss of volitional control of
micturition reflex – uninhibited detrusor
 CVA, brain tumor, head injury, multiple
sclerosis, Parkinson’s disease.

23.  LOOP 2
 Sensory afferent neurons from detrusor –
posterior and lateral columns, ‘’long routing’’ in
spinal cord - pontomesencephalic portion in
brain stem
 Efferent neurons from micturition center travel
down in reticulospinal tract ‘’long routing’’ to
detrusor without any synapse in spinal cord
 Required to establish an adequate magnitude
and duration of detrusor reflex to accomplish
complete bladder emptying

24. contd
 Interruption – hyper-reflexic detrusor –
unable to produce a voluntary voiding
contraction
 Spinal cord trauma, multiple sclerosis, spinal
cord tumor, arachnoiditis

26.  LOOP 3
 Detrusor and pudendal motor nuclei and
their interneurons in sacral cord
 Coordination between detrusor contraction
and striated urethral sphincter relaxation
during voiding

28.  LOOP 4
 Motor cortex in frontal lobe – traverse via
pyramidal tract in lateral columns of spinal
cord, synapse on pudendal sphicter nucleus.
 Voluntary control over striated muscle of the
urethral sphincter during bladder storage
and voiding

30. Spinal tracts
 Corticospinal tract
 Reticulospinal tract
 Spinothalamic tract
 Posterior columns

31. Basic concepts of
neurourological function
 Two phases
 Low pressure insensanate filling and storage
of urine
 Efficient evacuation under voluntary control
 Filling and storage of urine
 Passive filling phase initial phase occurs till
proxim al urethral pressure > exceeds the
bladder
 Continence reflex phase bladder pressure >
urethral pressure

32.  Frontal micturition center by bladder
distension enhances sympathetic activity
and external sphincter
 Micturition
 Normal urinary voiding is voluntary
disinhibition of pontine and sacral reflex
activity in response to bladder distension

33. REFLEXES
 Superficial anal reflex
 Anal reflex or anal wink consists contraction
of anal sphincter in response to stroking or
pricking the skin of perianal region
 Inferior haemarhoidal nerve (S2-S5)
 Caudaequina or conus medullaris lesions
 Bulbocavernosus reflex
 Stimulating the skin of glans or penis
response is felt by placing a gloved finger in
rectum

34. Neurogenic bladder dysfunction
5 types (2 UMN; 3LMN)
 Uninhibited
 Reflex
 Autonomous
 Motor paralytic
 Sensory paralytic

35. Nomenclature
 Urgency is the complaint of a sudden and
compelling desire to pass urine that is
difficult to defer.
 Urge incontinence is the complaint of
involuntary leakage accompanied by
urgency. Leakage may range from drops to
soaking
 Retention bladder is unable to empty itself
to a point that there is over 100 cc's (3.5
ounces) of urine left over in the bladder
after urinating*

36. Uninhibited bladder
 Lesion affecting the second frontal gyrus
and the pathways leading from it down
to the pontine centre
 Frontal lobe tumours, parasagittal
meningiomas, anterior communicating
artery aneurysms, normal perssure
hydrocephalus, Parkinson’s disease and
multisystem atrophy

37. Uninhibited bladder
Features are:
 Urgency at low bladder volumes
(detrusor hyperreflexia)
 Sudden uncontrollable evacuation
 No residual urine - little risk of infection
 If severe intellectual deterioration occurs
urine may be passed at random, without
appropriate concern.

38. Spinal bladder
 Damage to spinal cord by trauma, tumor, multiple
sclerosis
 Fullness is not appreciated
 Intravesical pressure may only be indicated by
sweating, pallor, flexor spasms, dramatic rise in
blood pressure
 Reflex emptying without warning
 Incomplete evacuation may improve with practice
and may be performed at will if massaged and
suprapubic pressure applied
 Detrusor – sphincter dyssynergia .
 Evidence of bilateral pyramidal lesion – enhanced
reflexes and extensor plantar response
 Bladder is small and contracted, can hold
maximum of 250ml

39. Autonomous bladder(subsacral
lesions)
 Damage to sensory and motor
components in cauda equina or pelvis
 Cauda equina lesions, Pelvic
surgery, pelvic malignant lesions, spina
bifida and high lumbar disc lesions
 MRI or myelogram is obligatory to
exclude high disc lesions

40. Autonomous bladder(subsacral
lesions) contd
Features
 Continual dribbling incontinence
 Considerable residual urine with high
infection risk
 No sensation of bladder fullness- large
atonic bladder
 May be associated with perineal
numbness and loss of sexual function

41. Sensory bladder
 Similar to autonomous bladder
 Anatomical explanation is uncertain
 Primary problem is sensory denervation
 Ultimately overdistension, myogenic
damage and contractile failure
 Rare disorders : Tabes dorsalis, SACD
and Multiple sclerosis, Diabetes mellitus

42. Sensory bladder contd..
Features :
 Massive retention of urine in litres – high
risk of infection
 Dribbling incontinence of sufficiently
large volumes
 Voiding possible with considerable
straining but evacuation is incomplete

43. Motor paralytic
 Areflexic detrusor
Marked by painful distention
Inability to initiate urination
Difficulty initiating
urination, straining, decreased size and
force of stream, interrupted stream, and
recurrent urinary tract infection.

44. Pharmacological methods
 Urinary retention
 Cholinergic agents to increase detrusor
motor function
○ Bathnechol improves detrusor funtion
particularly in denervation and
selectively affects bladder and gut
 Alpha adrenergic blockers such as
prazosin

45.  Urinary incontinence
 Inhibition of detrusor activity and increase
functional capacity of bladder
 Anticholinergics such as propanthaline
 Anticholinergic with smooth muscle
relaxing properties such as oxybutinin
 TCA such as imipramine with
anticholinergic activity

46. Thank u