NEUROGENIC BLADDER

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NEUROGENIC BLADDER

• Dr. sh. Alaie
• Neurologist

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NEUROGENIC BLADDER

• Definition
• Is a malfunctioning bladder due to any type of
  neurologic disorder.

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NEUROGENIC BLADDER

• Voiding
• 1)Filling storage bladder acts as low
  pressure receptacle
• Sphincter high
  resistance
• 2)Voiding Emptying Bladder contracts
• Sphincter opens
• Both Should be done in Normal Pressure

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• Normal Voiding1)Normal Detrusor
• 4-8 /day 2)Normal Sphincter
• 3)Synergy
• 4)Voluntrily
• Normal Pressure

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Anatomy

• BRAIN
• Master control of the entire Urinary system
• Medial aspect of Precentral gyrus
• Inhibitory signal to detrussor until a suitable
  time place
• Injury 1)Unawareness to entire voiding
  process
• 2) Spastic bladder

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ANATOMYPONS

• PMCcoordinating Bladder Urethral
  Sphincter Synergy
• Facilitate Urination 1)detrussur contraction
• 2)sphincter
  relaxation
• Ingury 1)Spastic bladder
• 2)DSD

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ANATOMYSPINAL CORD

• Supra sacralintermediary between PMC
  Sacral cord
• Lat.CorticoSpinal ReticuluSpinal
• Injury 1)Spastic Bladder
• 2)DSD

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ANATOMYSacral cord

• Primitive Voiding Center for Reflex Arc
• S2,S3,S4
• Injury Detrusor Areflexia

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ANATOMYPeripheral nerves

• 1)Sympathetic bladder internal sphincter
• 2)parasympathetic bladder
• 3)SomaticOnuf neucleus Ex.sphincter
• InjuryAreflexic bladdersensory /motor

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Physiology

• 1)Filling
• accumulation of urine while the pressure is
  low
• If Pv gtPu Urine Leackage
• Reflux
• Sympathetic 1)inhibit parasympathetic
• 2)relaxation expansion of
  detrussor
• 3)close the bladder neck
• Pudendal contraction of the Ex.Sphincter
• PugtPv

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NEUROGENIC BLADDER Physiology

• 2)Emptying
• Bladder filling to capacity stretch
  receptorspelvic nerve
• Hypogastric nerve
• Sacral cordvoiding
• After 3-4 Yr oldsympathetic relaxes in.
  sphincter
• Ps detrusor contraction
• Pudendal relaxation of
  ex.sphincter
• PvgtPu voiding

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TYPES of NEUROGENIC BLADDER

• 1)Detrusor OveractiveImpaired filling
  UnderactiveImpaired Emptying
• 2)SphincterOveravtiveImpaired Emptying
• UnderactiveLeackage
• 3)Loss of coordinationImpaired Emptying

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Types of Bladder Dysfunction

• 1- Failure of Storage (Detrusor Hyperreflexia)
• 2- Failure of Emptying
• a) Detrusor Hypoactivity
• b) Detrusor Sphincter dyssynergiaDSD
• 3- Mixed type
• All can be dangerous to upper tract

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SYMPTOMS Storage Failure

• a) frequency / nocturia
• Urinationgt8 times a day
• or
• gt 2 times over
  night
• b) urgency extreme desire to void
• c) Incontinency urge in continence
• d) hesitancy,intermittency,straining to
  void,terminal dribbling.
  

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SYMPTOMS Emptying Failure

• a) feeling of incomplete emptying
• b) frequency , urgency
• c) incontinency (overflow)
• d) hesitancy,intermittency,straining to
  void,terminal dribbling.

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Symptoms are the same in all types!

• 70 mismanagement based on history alone!

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COMPLICATIONS

• 1)rise in
  PvREFLUXHydroureter/Hydronephrosis
• 2)RetentionFrequent UTI
  (refluxPyelonephritis)
• 3)Urinary stones
• 4)Impaired social personal life

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NEUROGENIC BLADDER

• NEUROLOGIC DISEASES

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Voiding dysfunction is important in multiple
sclerosis

• Because of
• 1- Frequency (up to 90 of patients)
• 2- Serious complications 55 ? 5
• 3- Impairment of social personal life
  sexual activity
• 4- Could be successfully managed
• 5- Social cultural aspects

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MSSYMTOMS

• - Voiding dysfunction may be the sole initial
  complaint ( 2.3 ).
• - Or part of the presenting symptoms (
  10 )

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NEUROLOGIC DISEASESCVA

• Cerebral ShockDet.AreflexiaRetention
• Afew weeks/months laterDet.Hyperreflexia

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NEUROLOGIC DISEASESMSA

• Urinary symptoms are common
• Come early (60 before or associated with
• other symptoms
• Even 4yr before diagnosis

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AUTONOMIC DYSREFLEXIA

• Is a lethal emergency
• Acute massive disorderd autonomic(S) response to
  specific stimuli in SC injury above T6- T8
• More common in cervical
• After shock period but up to yrs after injury
• Stimuli below level of the lesion

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AUTONOMIC DYSREFLEXIA

• Headache/HTN(even ICH or sezure)
• Flashing of face,body above the lesion
• Sweating
• Usually bradycardia,maybe tachycardia/arrhytmia
• Stimulus from bladder/rectum
  distention,manipulation
• GI/bone FX /sexual activity /bed sore

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AUTONOMIC DYSREFLEXIA

• Endoscopic procedure spinal/ general
  anesthesia
• SL niphedipin/ oral niphedipin/ trazocin
• Significant rise in BP without other symptoms

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Diagnosis

• 1- History ask strictly about voiding
  symptoms and feeling of
  incomplete emptying
• 2- exam pelvic exam
• Sacral reflex exam
• Signs of spinal cord involvment
• 3- Lab U/A, U/C, BUN, Cr

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Diagnosis

• 4- Imaging sonography
• a) Anatomy
• b) Residue ( up to 100CC)

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Diagnosis

• 5- In out catheter method
• a) Well hydrated for 48 hr
• b) Drink 2 glasses of water, before exam
• c) First desire to void capacity(300 500cc)
• d) Measure residue after voiding

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Diagnosis Urodynamic study

• A general term for the study of the storage and
  voiding function

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DiagnosisUrodynamic study

• a) Bladder eapacity (300 500cc)
• b) Detrussor pressure, Max 10 Cm H2o
• c) DSD
• d) Detressor instability
• e) L.P.P (leak point pressure)

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DiagnosisUrodynamic study Indication

• - urologic problems Contraversy
• - Neurologic problems
• All with neurogenic bladder
  should undergo urodynamic study to
  characterize the nature of the problem and
  to determine prognosis and
  management .

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MANAGEMENTGOALS

• 1- upper tract preservation
• 2- absence or control of infection
• 3- adequate storage at low I.V.P
• 4- adequate emptying at low I.V.P
• 5- adequate control
• 6- no catheter
• 7- social acceptability

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MANAGEMENTSTORAGE FAILURE

• 1) Non surgical
• a) Non pharmacologic
• b) Pharmacologic
• 2) surgical

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MANAGEMENTSTORAGE FAILURENON PHARMACOLOGIC

• 1- voiding diary 3-5 days
• a) Total 24hr urinary output
• b) Number of voids
• c) Voiding interval
• d) Diurnal distribution
• e) Timing and triggers for incontinence

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MANAGEMENTSTORAGE FAILURE

• Bladder training program
• 1- lengthen the amount of time between
  voiding.
• 2- increase the amount of urine the bladder
  can hold .
• 3- improves the control over the urge.
• 4- patient gives voiding program to his
  bladder.

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MANAGEMENTSTORAGE FAILUREBLADDER TRAINING
PROGRAM

• 1- Kegel exercise.
• 2- delaying urination,5 min ? 10 min
• Walk instead of running at urge
• Relaxation techniques
• 3- sheduled bathroom trips
• Every 1hr initially.
• 4- irritating factors Alcohol, caffeine, acidic
  foods (tomatoes, grapefruit)
• 5- change of temperature.
• 6- bio feedback and acupuncture.

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MANAGEMENTSTORAGE FAILUREpharmacologic

• 1- anti cholinergics
• a) Tolterodine 1-2 mg/bid
• b) Oxybutinine 5 mg/TDS
• 2- TCA imipramin 25 mg/day
• 3- desmopressin , spray, 1-2 puff
• 4- Ca antagonists/potassium channel
  openers/prostaglandin inhibitors??

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MANAGEMENTSTORAGE FAILURE pharmacologic

• Warning!!!
• Anticholinergic
• 1- check for residue before
• 2- check for pharmacologic retention after

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MANAGEMENTSTORAGE FAILURESURGICAL

• 1- intravesical injection of botolinum toxin
  oxybutinin
  
  capsaicin?
• 2- electrical stimualtion
• 3- denervation techniques
• 4- augmentation cystoplasty

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MANAGEMENTEMPTYING FAILURE

• 1- Non surgical
• a) Non pharmacologic
• b) Pharmacologic
• 2- surgical

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MANAGEMENTEMPTYING FAILURENON PHARMACOLOGIC

• 1- Valsalva crede manuver
  Increase I.V.P
• 2- trigger void
• 3- clean intermittent catheterization( CIC )

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MANAGEMENTEMPTYING FAILURE NON PHARMACOLOGIC

• CIC
• 1- safe
• 2- extremely effective
• 3- most practical means of attaining catheter -
  free state
• 4- preserves the independence
• 5- protects the kidneys
• 6- prevents incontinence
• 7- decrease infections
• 8- non expensive

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MANAGEMENTEMPTYING FAILURE NON PHARMACOLOGIC

• CIC
• 9- can be used in all types of dysfunction
• 10- decrease residue after a while
• - If the patient can eat or write can do CIC
• Cornerstone of treatment

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MANAGEMENTEMPTYING FAILURE PHARMACOLOGIC

• 1- bethanechol?
• 2- baclofen
• 3- prosteglandin??

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MANAGEMENT EMPTYING FAILURESURGICAL

• 1- electrical stimulation
• 2- bladder myoplsty
• 3- reduction cytoplasty