Neurogenic bladder
-
Upload
vishal-ramteke -
Category
Health & Medicine
-
view
925 -
download
6
Transcript of Neurogenic bladder
NEUROGENIC BLADDER
Outline of the presentation
• Applied physiology • Symptomatology• Types according to levels of bladder
dysfunction• Investigations• Treatment available
Bladder functions
• Storage - at low pressure until such time as it is convenient and socially acceptable to void
• Voiding - initiated by inhibition of the striated sphincter and pelvic floor, followed some seconds later by a contraction of the detrusor muscle.
1.Cortical micturition centre
2.Pontine micturition centre
3.Spinal micturition centre
4. Peripheral nerves
Sympathetic
(T11 –L2)
Parasympathetic
( S2,3,4)
(S2,3,4)
Control of micturition
Cortical micturation centre(CMC)
Location: Paracentral lobule in the medial aspect of the frontoparietal cotex
Function: Inhibitory to PMC
Dysfunction – loss of social control of bladder
The brain’s control of the PMC is part of the social training that children experience at age 2 - 4 years
Pontine Micturition Centre (PMC)Also called Barrington’s nucleus • Lateral regionFunction - continence, storage urine stimulation results in a powerful contraction of the urethral sphincter• Medial regionFunction - micturition center stimulation results in decrease in urethral pressure and silence of pelvic floor EMG signal, followed by a rise in detrusor pressure.
Sacral reflex or Sacral/Primitive micturition centre (SMC/PMC)
1. Sacral parasympathetic nucleus (SPN): S234- pelvic splanchnic nerves (nervi erigentes) arise from
2. Somatic – Onufoid nucleiCollection of external urethral sphinter motoneurones
3. Levator Ani Motoneurones
Peripheral innervation
Stimulation Response
Parasympathetic(S 2-4)
Excitatory to detrusor, relaxes sphincter - void
Sympathetic(T11- L2)
Inhibitory to detrusor, ↑trigone & Urethral tone
Somatic ( S2 - 4) Excitatory to the external sphincter
Micturition reflex
Internal sphincter – no important role in micturition, prevents leakage during filling andprevents reflux of semen into bladder during ejaculation
Sympathetic nerves – no part in micturition
The Micturition Reflex
Sensation of bladder fullness via pelvic and pudendal nerves to S 2,3,4
Periaqueductal gray matter
Medial Pontine micturition center
Frontal lobe decides social appropriateness
Onuf’s nucleus to pudendal nervesDetrussor center (S 2,3,4) to pelvic nerves
RECIPROCAL ACTIVITY BETWEEN SPHINCTER & DETRUSOR
Micturition
On-off switch
Relay center
Primitive voiding
CerebralPMC
SMC
Symptomatology
Detrusor Hypereflexia
Detrusor Sphincter Dyssynergia
Resultant
Poorly sustained hyperreflexic bladder contraction (DH) and (DSD)
Raised post voiding residual (PVR)
Exacerbation of urgency
Neuropathy• Long history of
neuropathic symptoms, • Stocking glove
anesthesia• Absent knee and ankle
jerks will be absent • Small fiber sensory
impairment demonstrable to the level of the ankles
• Other features of autonomic involvement
• Sexual dysfunction
Cauda equina• Bladder, sexual & bowel
dysfunction• S 2, 3, 4 sensory loss• Lax anal sphincter • Bulbocavernosus (sacral
reflexes) reflex lost• +/- Foot deformities, lower limb abnormalities• Cutaneous markers over the
back & sacrum
Spinal Cord• Signs of upper motor
neuron lesion in the lower limbs (unless the lesion is central intramedullary and small)
• Erectile dysfunction in men
• +/- Paraparesis
Brainstem• Marked neurological
deficits dorsal and discreet lesion defect of bladder function
• MLF lesion Internuclear ophthalmoplegia
Extrapyramidal diseases• Extrapyramidal features • MSA, Parkinsons disease• Autonomic dysfunction• Cerebellar signs
Suprapontine• Frontal lobe disorders• Dementia, personality change• Aware about incontinence
unless extensive lesions• Severe urgency, frequency &
urge incontinence without dementia, socially aware and embarrassed by
incontinence• Urinary retention
Types according to the level of bladder
dysfunction
a) Suprapontine/cortical lesion –
“Uninhibited /Cortical bladder”
Severe urgency, frequency & urge incontinence
with dementia – incontinent and inappropriate voiding
without dementia- socially aware & embarrassed by their incontinence.
b) Pontine lesion – “ Reflex / Automatic bladder”
DH, Arreflexia in pts with INO
c) Spinal (subpontine/suprasacral)“ Spastic Bladder”
Disorders of storage and emptyingDSD (true only if above T6 level), DH
d) Sacral and subsacral lesionsI) Afferent fibres involved only – “Atonic /Areflexic bladder”Overflow incontinenceStraining for micturition No DSD, no DH
II) Both afferent and efferent involved –“Autonomous bladder” Small capacity , acting of its own. No DSD/DH
UMN-SPASTIC
LMN- FLACCID AREFLEXIC
CerebralPMC
SMC
Causes of various levels of dysfunction
a) Suprapontine and Pontine Causes• Stroke• Tumors• Dementia (AD,FTD)
Spinal causes (subpontine/suprasacral)
Sacral and Subsacral causes
Management- Investigations Noninvasive bladder investigations- Post void residual volume –• In out catheterization,• Ultrasound ( N is <100ml)
Uroflowmetry- • Voided volume ( >100ml)• Maximal flow, maximal and average flow rate (M > 20ml/sec and F > 15ml/sec)
Cystometry-
• Measure detrusor pressure (Intravesical presure – Rectal pressure)
• Bladder infused till 400 to 600ml – Pressure should not rise to >15cm water (Stable bladder)
• Neurogenic detrusor overactivity – Involutary detrusor contraction during filling phase
• Voiding phase – Detrusor pressure M < 50cm water F < 30cm water
Sphincter EMG – Reinnervation with prolonged duration of MUAPs
Neuroimaging – Cauda equina & conus lesions,spinal, supra pontine and pontine lesions
Treatment - Detrusor overactivity• Anticholinergics - Oxybutynin, tolterodine - M3 blockers- darifenacin
• Tricyclic antidepressants - Imipramine
• Desmopressin intranasally – once in 24 hrs
• Botulinum toxin A
• Intravesical capsaicin – instilled with a balloon catheter
Neurogenic Detrusor overactivity
Treatment
Only Urinary Retention
(If residual volume > 100ml) • Clean intermittent self
catheterisation (CISC)• Permanent indwelling
catheter
Detrusor overactivity &Retention
• Anticholinergic drugs• CISC
Treatment
• External device – condom catheter• Sacral nerve stimulators – for DI• Nerve root stimulators – S 2,3,4 for voiding assisting defecation• Surgery – Augmentation cystoplasty, artificial
sphincter, urinary diversion with stoma collection bag