Neuropathic bladder disorders

1. Neuropathic bladder disorders

2. U.B is probably the only visceral smooth muscle organ that is under complete voluntary control from the cerebral cortex. • near the internal meatus they arrange in 3 layers, inner longitudinal, middle circular & outer longitudinal. • The circular muscle end in the bladder neck forming the internal sphincter

3. The external sphincter is a true sphincter in the prostatic urethra in male & in the mid urethra in female they are supplied by pudendal nerve • The bladder supply by both sensory & motor, • the sensory pass to the S2,3&4 segments of spinal cord, • the efferent nerves from S2,3,&4 to the bladder through pelvic nerve that initiate muscle contraction. • In the bladder sensation of fullness (300-400ml) pass to the spinal cord through sensory impulse which lead to contraction of detrusor through efferent nerves.

4. to control act of micturition there is inhibitory reflex from cerebral cortex through the spinal cord to inhibit the contraction of smooth muscle of bladder so act of micturition not started until favorable place & time are to start. • micturition usually assisted by abdominal muscle contraction.

5. The micturition reflex • Intact reflex pathways via the spinal cord & the pons are required for normal micturition. • Afferents from the bladder are essential for activation of the sacral center, which then cause detrusor contraction, bladder neck opening, & sphincteric relaxation. • The pontine center through its connection with sacral center, may send either excitatory or inhibitory impulses to regulate the micturition reflex.

6. Electrical or chemical stimulation of medial pontine micturition center generate contraction of detrusor & relaxation of the external sphincter. • Disruption of pontine control, as in upper spinal cord injury, leads to contraction of detrusor without sphincteric relaxation • (detrusor – sphincter dyssynergia).

7. Urodynamic studies • Techniques used to obtain graphic recording of the activity of urinary bladder. • Uroflowmetry • is the study of flow of urine from the urethra. • The normal peak flow rate for male 20-25 ml/s & for female 25-30 ml/s. • lower flow rate suggest bladder outlet obstruction or weak detrusor.

8. Cystometry • the urodynamic evaluation of the reservoir of urinary bladder • normal bladder capacity is 400-500 ml. • the 1st desire to void is felt when volume reach 150-200 ml. • but the detrusor filling pressure should remain unchanged until there is definite sense of fullness 350-400 ml. the true capacity of bladder.

9. Detrusor contraction before this point are considered abnormal & the result of hyperreflexic or uninhibited bladder. • Normal voiding pressure in the bladder shouldn’t raise above 40 ml of water, with normal voiding there shouldn’t be any residual urine & voiding accomplished without straining. • The interference with normal conduction of nerves of the bladder called neurogenic bladder.

10. Classification of neurogenic bladder according to the level of injury

11. 1-Spastic neuropathic bladder due to lesion above the sacral micturition center • Most lesion in the cerebral cortex or spinal cord above the micturition center (S2,3 &4 spinal segment) will cause bladder spasticity. • Common lesions above the brain stem affect voiding include dementia, CVA, multiple sclerosis, tumors, & inflammatory disorders such as encephalitis & meningitis

12. These lesions can produce urge, frequency, and urge incontinency. • Sacral level produce bladder arflexia • Supra sacral (like spinal cord disorder) will produce un inhabited bladder contraction with detruso-sphincter dyssynergia • Supra pontine lesion (CVA) produce un inhabited bladder contraction with detruso-sphincter synergia

13. Clinical finding • the severity of symptoms depend on the site & extent of the lesion as well as the length of time from injury • symptoms include involuntary urination, which is often frequent spontaneous, scant, & triggered by spasms in lower extremities, • A true sensation of fullness is lacking, • The sensory level of injury need to be established, followed by assessment of anal, blbocavernosal, knee, ankle, & toe reflexes.

14. 2-Flaccid (atonic) neuropathic bladder due to lesion at or below the sacral • Affect either motor or sensory fibers or both. • Injury to the detrusor motor nucleus • The most common cause of flaccid neuropathic bladder is injury to the spinal cord at the micturition center, S2-4.

15. Other causes of anterior horn cell damage include infection due to poliovirus or herpes zoster & iatrogenic factors such as radiation or surgery • External sphincter & perineal muscle tone are diminished. • Evacuation of bladder may be accomplished by straining but with variable success • .

16. Injury to the afferent feedback pathways • Flaccid neuropathic bladder also result from variety of neuropathies, include • -DM, • -tabes dorsalis, • -pernicious anemia, • which lead to loss of sensory input to the detrusor nucleus

17. The end result loss of perception of bladder filling permits overstretching of the detrusor. • Atony of the detrusor result in weak, inefficient contractility. Capacity is increase & residual urine is significant.

18. Clinical finding • lower motor lesion • pt experience flaccid paralysis & loss of sensation affecting the muscles & dermatomes below the level of injury. • The principle urinary symptom is retention with overflow incontinence. • male pt lose their erections. • Extremity reflexes are hypotonic or absent. • -Perineal sensation at level of S2 & 3 • -anal tone S2. • -out side of the foot S2 & sole S2&3.

19. D.Dx of neuropathic bladder 1-Cystitis 2-Chronic urethritis 3-Psychological disturbance 4-Cystocele 5- Bladder outlet obstruction 6-Interstitial cystitis pt is woman above 40 yr with frequency, nocturia, & suprapubic pain releated to bladder fullness . Capacity is limited (often <100 ml), urinalysis is normal. Distention of bladder with cystoscope produce bleeding from petechial hemorrhages

20. Diagnosis In addition to history &clinical finding GUE may show infection. Renal function test may be normal or impaired. X-ray finding U/S, plain film, MRI. Cystoscope & urodynamic studies.

21. Treatment The aim of treatment is to preserve the renal function by low intravesical pressure. 1-Spinal shock During this stage with atonic bladder, -clean intermittent catheterization -encourage fluid intake -follow up by Urodynamic studies

22. 2-specifc types of neuropathic bladder • A-Spastic neuropathic bladder • Trigger techniques : used If reasonable bladder capacity & the pt able to go 2-3 hr between voiding with continent during this period • (tapping the abdomen suprapubically, or scratching the skin of lower abdomen genitalia & thighs.) • But if markedly diminished functional vesical capacity( <100 ml) involuntary voiding every 15 min. one of the following regimen can be used.

23. 1- indwelling catheter with or without anticholinergic medication. 2-condom catheter 3- sphincterotomy. 4-sacral rhizotomy. 5-Nuerostimulation 6-urinary diversion

24. B-Flaccid bladder • straining using the abdominal & diaphragmatic muscle. • Crede maneuver, manual suprapubic pressure to raise intra-abdominal pressure. • clean intermittent catheterization (CIC).