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Neurogenic bladder Dr Pankaj rathi DM Neurology Trainee Shri Aurobindo Medical College Indore

Neurogenic Bladder

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Neurogenic bladder Dr Pankaj rathi DM Neurology Trainee Shri Aurobindo Medical College Indore

  1. 1. NEUROGENIC BLADDER Dr Pankaj Rathi DM Trainee
  2. 2. Outline of the Presentation • Introduction • Anatomy and physiology • History taking • Pathophysiology of Neurogenic Bladder ----Failure to Empty ----Failure to Store • Reflex Neurogenic Bladder • Autonomous Neurogenic Bladder • Conclusion
  3. 3. Why Understanding of Bladder • 15% of all population have some bladder dysfunction if thoroughly investigated and worked upon. • People above 60 years have …50% bladder symptoms • Bladder dysfunction ..makes a patients ..smelling even untouchable • Most of the dysfunction are treatable • Even good history and clinical examination can lead to Diagnosis • Very few patients require sophisticated investigation • Hence..I PLEAD your valuable ATTENTION
  4. 4. Bladder functions Storage - at low pressure until such time as it is convenient and socially acceptable to void ( 98% ) Voiding - initiated by inhibition of the striated sphincter and pelvic floor, followed some seconds later by a contraction of the detrusor muscle.( 2 % )
  5. 5. Definition Neurogenic bladder is most easily defined as a failure of the bladder to function normally as a result of neurologic insult to any component of this control mechanism.
  6. 6. Anatomy • Bladder is divided into the detrusor and the base, which includes the trigone and bladder neck • The bladder outlet Internal (smooth muscle) sphincter in the bladder neck and proximal urethra  The external (striated muscle) sphincter of the membranous urethra.
  7. 7. Sympathetic supply • Spinal Cord segments (T10-L2)– Preganglionic. • Postganglionic -- Hypogastric and pelvic nerves to the bladder. • Causes relaxation of detrusor muscles • Promotes urinary retention • Release noradrenaline and provide excitatory inputs to the bladder neck and the urethra.
  8. 8. Parasympathetic Nerve supply • Sacral spinal segments (S2–S4) • Stimulation causes contraction of detrusor muscles and inhibitory effect on urethra • Initiates micturition .
  9. 9. Urethral Sphincters
  10. 10. Central Control of Micturition • Cortical Centre  Medial Frontal lobe  Cingulate gyrus Final control by directing micturition centres to initiate or delay voiding, depending on the social situation. • Pontine centre in the brainstem, which is responsible for co-ordinating relaxation of the external sphincter with bladder contractions
  11. 11. Pontine Micturition Centre (PMC --Barrington’s nucleus or M-region) • Essential for the coordination of micturition. • In the bladder emptying stage, the PMC sends excitatory influence > sacral spinal cord >detrusor contraction • Simultaneously sending inhibitory influence > thoracolumbar cord > internal urinary sphincter relaxation. • Bladder storage phase, PMC inhibition > sacral spinal cord > detrusor relaxation • Simultaneously sending excitatory influence > thoracolumbar cord > internal urethral sphincter contraction.
  12. 12. Receptors
  13. 13. • Sensation of bladder filling (100–200 cc) • First urge to void (300–400 cc) • Strong urge to void (400–500 cc) • Normal bladder capacity(300–600cc)
  14. 14. History taking in Neurogenic bladder • Do they have sense of bladder filling ? • Can they feel the urine passing ? • Can they stop urine passing in midstream at will ? • Does the bladder leak continually or suddenly pass large volumes ? • Is there any associated rectal disorder ? • Is there any disorder of potency in male ? • Is there any numbness in perineum ?
  15. 15. • Do you leak urine when you cough, laugh, lift something or sneeze? How often? • Do you ever leak urine when you have a strong urge on the way to the bathroom? How often? • How frequently do you empty your bladder during the day? • How many times do you get up to urinate after going to sleep? Is it the urge to urinate that wakes you?
  16. 16. • Do you wear pads that protect you from leaking urine? How often do you have to change them? • Do you ever find urine on your pads or clothes and were unaware of when the leakage occurred? • Does it hurt when you urinate? • Do you ever feel that you are unable to completely empty your bladder
  17. 17. Physical Examination • Pelvic anatomy • Neurological examination • Mechanical issues such as prostate enlargement or bladder prolapse • Spinal cord
  18. 18. Classification of Neurogenic Bladder Dysfunction (1) Lesions above the pontine micturition center (e.g., stroke or brain tumor) producing an uninhibited bladder. (2) Lesions between the pontine micturition center and sacral spinal cord (e.g., traumatic spinal cord injury or multiple sclerosis involving cervicothoracic spinal cord) producing an upper motor neuron bladder. (3) Sacral cord lesions that damage the detrusor nucleus but spare the pudendal nucleus producing a mixed type A bladder. (4) Sacral cord lesions that spare the detrusor nucleus but damage the pudendal nucleus producing a mixed type B bladder. (5) Lower motor neuron bladder from sacral cord or sacral nerve root injuries.
  21. 21. A 70-year-old woman is admitted to the neurology ICU after a left-sided ischemic stroke. On Examination , right-sided motor deficits, the patient is unable to void. A catheter is placed for bladder drainage. The patient recovers some motor function, and her bladder eventually regains the ability to empty; however, the patient now complains of severe urgency and frequency as well as new-onset urge incontinence. Urodynamic testing demonstrates normal bladder sensation and filling parameters; however, multiple unstable contractions are noted during the filling phase.
  22. 22. The patient is able to generate normal bladder pressures and empties the bladder to completion. Although she contracts the external sphincter in an attempt to prevent leakage associated with the unstable contractions, she is able to relax the sphincter voluntarily to allow a normal voiding contraction. •How would you classify the type of neurogenic bladder in this patient? •How should this patient be managed?
  23. 23. Uninhibited Neurogenic Bladder Dysfunction Cortical and subcortical structure damage. • Urgency at low bladder volume (Detrusor Hypereflexia ) • Sudden uncontrollable evacuation • No residual urine and little risk of infection • No high bladder pressures developed that can lead to upper urinary tract damage • Safe Bladder • PMC is intact .
  24. 24. Causes of Uninhibited Bladder • Lesion affecting IInd frontal gyrus and pathway leading from it down to pontine micturition centre • Frontal lobe Tumors • Parasagital meningioma • Anterior communicating artery aneurysms , • NPH , • Parkinsons disease • MSA
  25. 25. TREATMENT OF FAILURE TO STORE • Unstable bladder contractions • Urgency • Urge incontinent episode • Drugs to block parasympathetic activation of bladder contraction • Oxybutynin, tolterodine, trospium, darifenacin, and solifenacin
  26. 26. Upper motor neuron neurogenic bladder (REFLEX NEUROGENIC BLADDER)
  27. 27. A 35-year-old man with a history of a complete T2 spinal cord injury is referred for urinary incontinence . He does not use a catheter and voids into a diaper. Investigation : • Serum creatinine level --2.5 mg/dL • Renal ultrasonography : Bilateral hydronephrosis with some bilateral renal cortical thinning. • Urodynamic testing : Poorly compliant bladder with baseline storage pressures rising above 40 cm H2O after only 100 mL of fluid is instilled. • Unstable contractions against a closed bladder outlet.
  28. 28. • The procedure is stopped early because the patient complains of facial flushing, headache, and sweating. At this time, the patient’s blood pressure is 240/120 mm Hg and heart rate is 40 bpm • How does this patient’s spinal cord injury contribute to his clinical picture, and how should this patient be managed ?
  29. 29. Upper motor neuron neurogenic bladder Spinal Bladder • Bladder fullness is not appreciated and intravesical pressure rises may only be indicated by profuse sweating , pallor, flexor spasms and rise in BP • Reflex emptying of bladder may occur without warning • Bladder is small and contracted and capable of holding maximal volume of 250 ml • The spinal cord damage renders the bladder and sphincters spastic.
  30. 30. • Bladder hypertonicity >high storage pressures > upper urinary tract at risk for reflux and eventual loss of renal function. • Instability and reflex incontinence • Patient is often unaware of any of these problems.
  32. 32. Goals of Therapy
  33. 33. • Protecting upper urinary tracts from sustained high filling and voiding pressures (>40cm ) • Achieving regular bladder emptying, avoiding stasis and bladder overdistension and minimising postvoiding residual volumes to less than 100mls (ideally <50mls) • Preventing and treating complications. • Maintaining continence and avoiding frequency and urgency
  34. 34. • Clean intermittent self-catheterisation (CISC) every 4-6 hours • Anticholinergic medication Oxybutynin hydrochloride (5mg tds) Tolterodine (1-2mg bd) Solifenacin (5-10mg) • Cystoscopic placement of an intraurethral stent • BTX injection into the external sphincter to provide a “medical sphincterotomy
  35. 35. Botulinum toxin (BTX) • Multiple detrusor injections (200 U or 300 U) were performed cystoscopically, resulting in a significant improvement in incontinent episodes when compared with placebo and a durable response lasting up to the end of the 24-week study • Other possible side effects include detrusor areflexia, urinary retention, increased residual urinary volume, and erectile dysfunction Botox Detrusor Hyperreflexia Study Team. J Urol 2005;174:196–200.
  36. 36. Int. braz j urol. vol.33 no.2 Rio de Janeiro Mar./Apr. 2007
  37. 37. March 2, 2000 N Engl J Med 2000; 342:665
  38. 38. Resiniferatoxin (RTX) RTX administration subjectively improved incontinence grade in 62% of patients with anticholinergic refractory detrusor overactivity as compared with 21% of patients in the placebo group • Eur Urol 2005;48: 650–5.
  39. 39. Surgical Therapy-Uninhibited Neurogenic Bladder
  40. 40. Surgical Therapy-Uninhibited Neurogenic Bladder Sacral nerve neuromodulation Significantly decreased urge incontinent episodes from 8.8 to 2.3 episodes per day as well as reduced pad usage from a mean of 4.7 to 0.82 pads daily in patients with urge incontinence refractory to conservative therapy. Improvements in urinary urge incontinence, urgency/frequency, or retention were sustained over time, with 59% of patients reporting more than a 50% reduction in pad usage 3 years after initial implantation Urol 2000; 163:1849–54.
  42. 42. Case 1 A 45-year-old woman with insulin-dependent diabetes since childhood is referred for urinary incontinence . On examination : Diabetic neuropathy. No history of urinary retention but states that she has had dribbling urinary incontinence that is not associated with an urge to void. Urine examination : Normal . Postvoid residual volume 1500 mL of urine The patient states that she had no urge to void at that time. Video urodynamics demonstrate that the patient has a large capacity,poorly sensitive bladder and impaired bladder contractility.
  43. 43. Case 2 • A 23-year-old man presents to the emergency department with complaints of groin pain and urinary retention. • He has a history of multiple sexually transmitted diseases, including herpes simplex, gonorrhea, and chlamydia. • He has been unable to void for 18 hours despite a strong urge to void. • Physical examination reveals an active herpetic infection with multiple vesicular lesions at the base of the penile shaft. A catheter is placed with return of 1 L of clear urine. • Cystoscopy reveals no obstructive lesions and a normal-appearing bladder and urethra. • Urodynamic testing demonstrates normal sensation and capacity, but the patient is unable to generate any voiding contractions.
  44. 44. How would you classify the type of neurogenic bladder in each of these patients?
  45. 45. SENSORY NEUROGENIC BLADDER • Case 1 demonstrates lack of bladder sensation that has led to overfilling of the bladder. • Poor bladder sensation • Bladder get distended without triggering a reflex bladder contraction. • Patient is unaware that the bladder is distended. • Over time, detrusor failure and urinary retention .
  46. 46. • Dribbling incontinance of sufficientely large volume that patient claim that they have normal micturation • Residual urine measured in liters with high infection risk • Voiding possible with considerable starining but evacuation is incomplete .
  47. 47. MOTOR NEUROGENIC BLADDER • Case 2 demonstartes normal sensation of bladder filling but is unable to generate detrusor pressure sufficient to empty the bladder. • Hallmark of the motor Neurogenic bladder, a result of insult or injury to the efferent nerve supply to the detrusor muscle. • Patient’s sensation remains intact, this is solely a motor deficit. • Possible etiologies of injury to the efferent nerves to the bladder include herpetic infection, trauma, and iatrogenic injury due to pelvic surgery
  48. 48. MOTOR NEUROGENIC BLADDER • Hallmark of the motor Neurogenic bladder, a result of insult or injury to the efferent nerve supply to the detrusor muscle. • Patient’s sensation remains intact, this is solely a motor deficit. • Possible etiologies of injury to the efferent nerves to the bladder include herpetic infection, trauma, and iatrogenic injury due to pelvic surgery
  49. 49. TREATMENT OF FAILURE TO EMPTY • The mainstay of therapy catheter drainage • Sacral nerve root neuromodulation ( Interstim therapy ) • Early studies demonstrated improvement in urinary flow from virtually no flow to a mean maximal flow rate of 13.9 mL/sec.12 • In addition, postvoid residual volumes improved from 7 8 % of total voided volume to 5 % to 10 % of total voided volume. J Urol 1 9 9 8;15 9 :14 7 6–8
  51. 51. • A 45-year-old man is referred for urinary retention after recently undergoing an abdominoperineal resection for rectal cancer. • No significant past history of urinary symptoms • A catheter was placed intraoperatively without difficulty, but the patient was unable to void after the catheter was removed. • After 12 hours, the catheter was replaced, with return of 600 mL of urine. • During that time, the patient was comfortable and had no sensation of needing to void. • Urodynamic testing demonstrates a normal capacity, compliant bladder. The patient is unable to sense filling at any volume and is also unable to generate any voiding contraction.
  52. 52. • Damage to motor and sensory componenets in cauda equina or pelvis • Not able to feel sensation of bladder filling and unable to generate bladder contractions
  53. 53. Autonomous bladder ( Subsacral lesions ) • Cauda Equina lesions , pelvic surgery , pelvic malignant disease , spina bifida and high lumbar disc lesions • Continual driblling incontinance • Considerable residual urine and high infection risk • Large atonic bladder • Can be associated perineal numbness and loss of sexual functions
  54. 54. Treatment No high bladder storage pressure • Clean intermittent catheterization • Indwelling catheters • Sacral nerve root neuromodulation.
  55. 55. Urodynamic Studies • Filling cystometrogram • Micturition cystometrogram • Four channel recording of abdominal pressure ( Rectal catheter ) , total bladder pressure ( via bladder catheter ) , substracted true intravesical( detrusor ) pressure and flow rate .
  56. 56. Urodynamic Studies
  57. 57. Normal parameters • Empty bladder pressure –1 cm H20 • Vesical sensation felt at 100-150 ml ( 6 cm H20) • Bladder distended 400 to 600 ml , rhythmical contraction accompanied by sense of urgency build up
  58. 58. Summary of European Association of Urology (EAU) Guidelines on Neuro-Urology EUROPEAN UROLOGY 69 (2016) 324–333 • For neurogenic detrusor overactivity, antimuscarinic therapy is the recommended first-line medical treatment.1a A • Alternative routes of administration (ie, transdermal or intravesical) of antimuscarinic agents may be used. 2 A • Outcomes for neurogenic detrusor overactivity may be maximized by considering a combination of antimuscarinic agents. 3 B
  59. 59. • To decrease bladder outlet resistance, a-blockers could be prescribed. 1b A • For underactive detrusor, no parasympathicomimetics should be prescribed. 1a A • In neurogenic stress urinary incontinence, drug treatment should not be prescribed. 4 A • Botulinum toxin injection in the detrusor is the most effective minimally invasive treatment to reduce neurogenic detrusor overactivity. 1a A • Sphincterotomy is a treatment option for detrusor sphincter dyssynergia. 3 A
  60. 60. Take Home message • Neurological evaluation is important to diagnose type of neurogenic bladder. • Urodynamic studies are important to diagnose detrusor hyperreflexia (DH), detrusor sphincter dyssynergia (DSD), detrusor areflexia and organic outlet obstruction • For DH, anticholinergics are primary T/t. • For DSD, anticholinergics with α - blocker may be tried along with CIC • For detrusor areflexia best therapy is CIC • Long term use of indwelling urinary catheter to be avoided
  61. 61. References • Harrisons’ Principles of Internal Medicine • Victor Adam Neurology • John Pattern : Neurological differential diagnosis • Bickerstaff : Neurological examination in Clinical Practice • Bradley : Neurology in clinical practice • Neurogenic BladderAdvances in Urology Volume 2012, Article ID 816274, 16 pages