2. The normal function of the urinary bladder is
to store and expel urine in a coordinated,
controlled fashion.
This coordinated activity is regulated by the
central and peripheral nervous systems.
Neurogenic bladder is a term applied to a
malfunctioning urinary bladder due to
neurologic dysfunction or insult emanating
from internal or external trauma, disease, or
injury.
3. Normal voiding essentially is a spinal reflex
that is modulated by the central nervous
system (brain and spinal cord), which
coordinates the functions of the bladder and
urethra.
The bladder and urethra are innervated by
autonomic nervous system (ANS) and somatic
nervous system respectively.
4. The micturition control center is located in the
frontal lobe of the brain.
The primary activity of this area is to send
tonically inhibitory signals to the detrusor
muscle
The signal transmitted by the brain is routed
through 2 intermediate stops (the brainstem
and the sacral spinal cord) prior to reaching the
bladder.
5. The pontine micturition center (PMC) is a
major relay center between the brain and the
bladder.
The conscious sensations associated with
bladder activity are transmitted to the pons
from the cerebral cortex.
Stimulation of the PMC causes the urethral
sphincters to open while facilitating the
detrusor to contract and expel the urine
6. The PMC is affected by emotions.
The ability of the brain to control the PMC is
part of the social training that children
experience during growth and development
7. Is long communication pathway between the
brainstem and the sacral spinal cord
The sacral spinal cord is a specialized area of
the spinal cord known as the sacral reflex
center. It is responsible for bladder
contractions.
The sacral reflex center is the primitive voiding
center,controls urination reflex in infancy.
8.
9. Under normal conditions, the bladder and the
internal urethral sphincter primarily are under
sympathetic nervous system control.
The sympathetic nervous system causes
urinary accommodation.
The parasympathetic nervous system
facilitates of voluntary urination.
The somatic nervous system regulates the
actions of the muscles under voluntary
control. Activation of the pudendal nerve
causes urinary accommodation
12. Urgency: Loss of normal ability to postpone micturation
beyond time when desire is first precieved.
Incontinence: involuntary passage of urine.
Stress incontinence:leakage of urine due to coughing or
straining ofen due to pelvic floor muscle weakness.
Hesitancy: difficulty in initiating micturation.
Dribbling: incomplete urination iin a clean stop fashion.
Overflow incontinence:progressive bladder involment
with continuous or intermittent dribbling of urine.
13. 1.BRAIN LESION:
Lesions of the brain above the pons destroy the
master control center, causing a complete loss
of voiding control.
The voiding reflexes of the bladder—the
primitive voiding reflex—remain intact.
14. Affected individuals show signs of urge
incontinence, or spastic bladder.
Presents with FREQUENCY,URGENCY &
URGE INCONTINENCE.
This condition is termed as “detrusor
hyperreflexia or overactivity or uninhibited
bladder or automatic bladder.”
15. 2. Spinal cord lesion
Diseases or injuries of the spinal cord between
the pons and the sacral spinal cord also result
in spastic bladder or overactive bladder.
The voiding disorder is similar to that of the
brain lesion except that the external sphincter
may have paradoxical contractions as well.
16. Result in uninhibited bladder contraction
with uncoordinated sphincter activity.
Presents with FREQUENCY,URGENCY &
URGE INCONTINENCE and an overwhelming
desire to urinate but only a small amount of
urine may dribble out
Condition termed as “detrusor-sphincter
dyssynergia”
17. 3.Sacral cord injury:
1.Sensory neurogenic bladder is present, the
affected individual may not be able to sense
when the bladder is full.
2.Motor neurogenic bladder, the individual will
sense the bladder is full and the detrusor may
not contract.
18. Present with difficulty eliminating urine and
experience overflow incontinence; the
bladder gradually overdistends until the urine
spills out.
Condition termed as “detrusor areflexia”
21. SUPRASPINAL LESION PRESENTATION
Cerebrovascular accident Detrusor areflexia followed by
detrusor hyperreflexia
Brain tumor Detrusor hyperreflexia
Parkinson disease Detrusor hyperreflexia and urethral
sphincter bradykinesia
Shy-Drager syndrome Detrusor hyperreflexia with open
internal sphincter at rest
22. SPINAL LESION PRESENTATION
Spinal Shock Detrusor areflexia followed by
detrusor hyperreflexia
Spinal cord lesions (above or below
sixth thoracic vertebrae)
Detrusor-sphincter dyssynergia
Spinal cord lesions (at the sixth
thoracic vertebrae)
Detrusor-sphincter dyssynergia with
Autonomic dysreflexia
23. Peripheral Nerve Lesions PRESENTATION
Diabetic cystopathy Sensory neurogenic bladder followed
by Motor neurogenic bladder
Tabes dorsalis (neurosyphilis) Detrusor areflexia with normal
sphincteric function.
Herpes zoster Detrusor hyperreflexia followed by
Detrusor areflexia
24. Postvoid residual urine
The postvoid residual urine (PVR) measurement is a
part of basic evaluation for urinary incontinence. If
the PVR is high, the bladder may be contractile or
the bladder outlet may be obstructed.
Uroflow rate
Uroflow rate is a useful screening test used mainly
to evaluate bladder outlet obstruction.
Low uroflow rate may reflect urethral obstruction, a
weak detrusor, or a combination of both. This test
alone cannot distinguish an obstruction from a
contractile detrusor.
25. Voiding cystometrogram (pressure-flow study)
Pressure-flow study simultaneously records the voiding
detrusor pressure and the rate of urinary flow. This is the
only test able to assess bladder contractility and the
extent of a bladder outlet obstruction.
Cystogram
A static cystogram helps to confirm the presence of
stress incontinence, the degree of urethral motion, and
the presence of a cystocele.
A voiding cystogram can assess bladder neck and
urethral function (internal and external sphincter)
during filling and voiding phases
26. Electromyography
Electromyography (EMG) helps to ascertain the presence
of coordinated or uncoordinated voiding.
Cystoscopy
The role of cystoscopy in the evaluation of neurogenic
bladder is to allow discovery of bladder lesions (eg, bladder
cancer, bladder stone) that would remain undiagnosed by
urodynamics alone.
27. Treatment of urinary incontinence varies by type, as
follows:
Stress incontinence may be treated with surgical
and nonsurgical means
Urge incontinence may be treated with behavioral
modification or with bladder-relaxing agents
Mixed incontinence may require medications as
well as surgery
Overflow incontinence may be treated with some
type of catheter regimen
28. Certain fluids can irritate the bladder:
Carbonated drinks
Citrus juices
Caffeinated drinks, e.g. soda, tea, coffee
Alcoholic beverages
29. The benefits of adequate fluid intake include prevention of dehydration,
constipation, urinary tract infection.
Trying to prevent incontinence by restricting fluids excessively may lead
to bladder irritation and actually worsen urge incontinence, and kidney
stone formation.
Bowel regulation
Avoid constipation and straining
Routine defecation schedule
Stop smoking
To reduce chronic coughing reduces downward pressure on the pelvic floor
Weight reduction
Excessive body weight affects bladder pressure, blood flow, and nerves
30. Absorbent products are pads or garments designed to
absorb urine to protect the skin and clothing.
ADVANTAGES DISADVANTAGES
Absorb 20-300ml of urine dependency
Used in intractable incontinence as
an adjunct to behavioral and
pharmacologic therapies
Improper use of absorbent products
may contribute to skin breakdown
and urinary tract infections.
31. Urethral occlusive devices are artificial devices
that may be inserted into the urethra or placed
over the urethral meatus to prevent urinary
leakage.
These devices are palliative measures to prevent
involuntary urine loss.
ADVANTAGES DISADVANTAGES
Keep the patient drier they may be more difficult to put
and expensive
Best suited for an active woman
with incontinence who does not
desire surgery
Devices may be more difficult to
change.
The urethral plug may fall into the
bladder or fall off the urethra.
32. Indwelling urethral catheters
The usual practice is to change indwelling catheters once
every month
All indwelling catheters in the urinary bladder for more
than 2 weeks become colonized with bacteria.
Indwelling urethral catheters are a significant cause of
urinary tract infections
Another problem of long-term catheterization is bladder
contracture
Anticholinergic therapy and intermittent clamping of the
catheter in combination is beneficial.
33. ADVANTAGES DISADVANTAGES
usually smaller
more patient-friendly.
Bowel perforation is known to occur
with first-time placement of
suprapubic tubes
more sanitary for the individual, No
risk of urethral damage
are contraindicated in persons with
chronic unstable bladders or intrinsic
sphincter deficiency
Bladder spasms occur less often Does not prevent bladder spasms from
occurring in unstable bladders
When the tube is removed, the hole in
the abdomen quickly seals itself within
1-2 days.
34. Of all 3 possible options (ie, urethral
catheter, suprapubic tube, intermittent
catheterization), intermittent
catheterization is the best solution for
bladder decompression of a motivated
individual.
The bladder must be drained on a regular
basis, either based on a timed interval or
based on bladder volume.
Amount drained each time should not
exceed 400-500 mL.
35. Weakness of levator muscles results in pelvic
prolapse and stress incontinence .
Used in both stress incontinence and urge
incontinence.
1. Find your pelvic floor muscles.
2. Squeeze your pelvic floor muscles as hard as
you can and hold them (squeeze 3-5 sec and
relax for 5 sec).
3. Do sets of repetitions of squeezing (start with
5 repetitions: squeeze, hold, relax).
4. Increase lengths, intensity, and repetitions
every couple of days.
5. Perform Kegel exercises 3-4x during the day
36. Used in stress incontinence in premenopausal
women.
A single weight is inserted into the vagina and held in
place by tightening the perivaginal muscles (levator
ani muscles) for as many as 15 minutes. As the levator
ani muscles become stronger, the exercise may be
increased to 30 minutes.
This exercise is performed twice daily.
The best results are achieved when Kegel exercises are
performed with intravaginal weights.
37. Biofeedback is an intensive therapy
Biofeedback allows the patient to correctly
identify the pelvic muscles that need
rehabilitation.
Biofeedback is best used in conjunction with
pelvic floor muscle exercises and bladder
training.
The best biofeed back protocol is one that
reinforces levator ani muscle contraction with
inhibition of abdominal and bladder
contraction.
38. Electrical stimulation is a more sophisticated form of
biofeedback used for pelvic floor muscle rehabilitation.
This treatment involves stimulation of levator ani muscles
using painless electric shocks.
Like biofeedback, pelvic floor muscle electrical
stimulation has been shown to be effective in treating
female stress incontinence, as well as urge and mixed
incontinence.
39. Bladder training generally consists of self-education,
scheduled voiding with conscious delay of voiding,
and positive reinforcement
Patients urinate according to a scheduled timetable
rather than the symptoms of urge.
Initially, the interval goal is determined by the
patient's current voiding habits and is not enforced at
night.
The first voiding interval may be increased by 15- to
30-minute increments with slow increments.
40. Sympathomimetic drugs, estrogen, and tricyclic
agents increase bladder outlet resistance to improve
symptoms of stress urinary incontinence.
Pharmacologic therapy for stress incontinence and an
overactive bladder may be most effective when
combined with a pelvic exercise regimen.
The 3 main categories of drugs used to treat urge
incontinence include anticholinergic drugs,
antispasmodics, and tricyclic antidepressant agents.
41. Conjugated estrogen increases the tone of urethral muscle and
strengthen pelvic muscles, which is important in urethral
support (prevents urethral hypermobility)
Improves uretheral mucosal seal effect, which is important in
urethral function (prevents intrinsic sphincter deficiency).
Improvement seen in 29-66% of women.
DOSAGE:
0.625 mg PO qd for 21 consecutive days discontinue at 3- to 6-
mo intervals.
2-4gms of cream may be administered intravaginally qd in a
usual cyclic regimen.
42. First line medicinal therapy in women with urge
incontinence.
They are effective in treating urge incontinence because
they inhibit involuntary bladder contractions.
Adverse effects include blurred vision, dry mouth,
palpitations, drowsiness, and facial flushing.
Ex: Propantheline bromide - 15 mg PO tid/qid
Dicyclomine hydrochloride- 10-20 mg PO tid
Hyoscyamine sulfate- 0.125 mg PO q4h
43. Direct spasmolytic action on the smooth muscle of the bladder.
Competitive muscarinic receptor antagonist.
The adverse-effect profile of antispasmodic drugs is similar to that
of anticholinergic agents.
Ex: Solifenacin succinate - 5 mg PO qd
Darifenacin- 7.5 mg PO qd(Do not exceed 7.5 mg PO qd in
patients with moderate hepatic impairment)
Oxybutynin
Tolterodine- 2 mg PO bid
44. They function to increase norepinephrine and serotonin
levels.
In addition, they exhibit anticholinergic and direct muscle
relaxant effects on the urinary bladder.
It has alpha-adrenergic effect on the bladder neck and
antispasmodic effect on detrusor muscle.
It has Local anesthetic effect on bladder mucosa
Ex: Imipramine-10-50 mg PO qd/tid
Amitriptyline- 10 mg/d PO; titrate prepration by 10 mg/wk
until maximum dose of 150 mg is reached
45. Oral Osmotic Delivery System (OROS).
Ditropan XL: innovative drug delivery system.
Tablet has a bilayer core that contains a drug layer
and a push layer that contains osmotic components.
Ditropan XL achieves steady-state levels over a 24-h
period.
It avoids first-pass metabolism of the liver and upper
GI tract to avoid cytochrome P450 enzymes.
It has excellent efficacy with minimal adverse effects.
46. BOTEXINJECTION
Endoscopic procedure/outpatient
Botulinum toxin type A
Onset within 2 days to 2 weeks after treatment
Effect lasts ~ 6 months
Side effects rare and minor (<10%)
Efficacy:
Reduction from baseline incontinence: 40%-80%
65%-87% of patients became completely continent
(between caths) after Botox
Main issue is cost.
47.
48.
49. CATEGORY B CATEGORY C CATEGORY D CATEGORY X
Dicyclomine Propantheine Bromide
Hyoscyamine sulfate
Imipramine Conjugated
estrogen
Oxybutynin Solifenacin succinate
Derifenacin
Tolterodine
Amitriptyline
Trospium
50. Surgical care for stress incontinence involves
procedures that increase urethral outlet
resistance, which include the following:
Bladder neck suspension
Periurethral bulking therapy
Sling procedures
Artificial urinary sphincter
