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Neurogenic Bladder (Emedicine)

Physiology and Pathophysiology


Physiology

Filling phase
During the filling phase, the bladder accumulates increasing volumes of urine while the pressure inside the bladder
remains low. The pressure within the bladder must be lower than the urethral pressure during the filling phase. If the
bladder pressure is greater than the urethral pressure (resistance), urine will leak out.
The filling of the urinary bladder depends on the intrinsic viscoelastic properties of the bladder and the inhibition of the
parasympathetic nerves. Thus, bladder filling primarily is a passive event.
Emptying phase
The storage phase of the urinary bladder can be switched to the voiding phase either involuntarily (reflexively) or
voluntarily. Involuntary reflex voiding occurs in an infant when the volume of urine exceeds the voiding threshold.
When the bladder is filled to capacity, the stretch receptors within the bladder wall signal the sacral cord. The sacral
cord, in turn, sends a message back to the bladder indicating that it is time to empty the bladder.
Delaying voiding or voluntary voiding
When an individual cannot find a bathroom nearby, the brain bombards the PMC with a multitude of inhibitory signals
to prevent detrusor contractions. At the same time, an individual may actively contract the levator muscles to keep the
external sphincter closed or initiate distracting techniques to suppress urination.
Thus, the voiding process requires coordination of both the ANS and somatic nervous system, which are in turn
controlled by the PMC located in the brainstem.
Pathophysiology
If a problem occurs within the nervous system, the entire voiding cycle is affected. Any part of the nervous system
may be affected, including the brain, pons, spinal cord, sacral cord, and peripheral nerves. A dysfunctional voiding
condition results in different symptoms, ranging from acute urinary retention to an overactive bladder or to a
combination of both.
Urinary incontinence results from a dysfunction of the bladder, the sphincter, or both. Bladder overactivity (spastic
bladder) is associated with the symptoms of urge incontinence, while sphincter underactivity (decreased resistance)
results in symptomatic stress incontinence. A combination of detrusor overactivity and sphincter underactivity may
result in mixed symptoms.

Etioplogy
Brain lesion
Spinal cord lesion
Sacral cord injury.
Peripheral nerve injury

Summary of definitions
Neurogenic bladder is a malfunctioning bladder due to any type of neurologic disorder.
Detrusor hyperreflexia refers to overactive bladder symptoms due to a suprapontine upper motor neuron neurologic
disorder. External sphincter functions normally. The detrusor muscle and the external sphincter function in synergy (in
coordination).
DSD-DH refers to overactive bladder symptoms due to neurologic upper motor neuron disorder of the suprasacral
spinal cord. Paradoxically, the patient is in urinary retention. Both the detrusor and the sphincter are contracting at the
same time; they are in dyssynergy (lack of coordination).
Detrusor hyperreflexia with impaired contractility (DHIC) refers to overactive bladder symptoms, but the detrusor
cannot generate enough pressure to allow complete emptying. The external sphincter is in synergy with detrusor
contraction. The detrusor is too weak to mount an adequate contraction for proper voiding to occur. The condition is
similar to urinary retention, but irritating voiding symptoms are prevalent.
Detrusor instability refers to overactive bladder symptoms without neurologic impairment. External sphincter functions
normally, in synergy.
Overactive bladder refers to symptoms of urinary urgency, with or without urge incontinence, usually associated with
frequency and nocturia. The cause may be neurologic or nonneurologic.
Detrusor areflexia is complete inability of the detrusor to empty due to a lower motor neuron lesion (eg, sacral cord or
peripheral nerves).
Urinary retention is the inability of the urinary bladder to empty. The cause may be neurologic or nonneurologic.
Types of Neurogenic Bladders
Supraspinal Lesions
Cerebrovascular accident
Brain tumor
Parkinson disease
Shy-Drager syndrome.
Spinal Cord Lesions

Workup
Laboratory Studies
Urinalysis and urine culture: Urinary tract infection can cause irritative voiding symptoms and urge incontinence.
Urine cytology
Carcinoma-in-situ of the urinary bladder causes symptoms of urinary frequency and urgency. Irritative voiding
symptoms out of proportion to the overall clinical picture and/or hematuria warrant urine cytology and cystoscopy.
Chem 7 profile
Blood urea nitrogen (BUN) and creatinine (Cr) are checked if compromised renal function is suspected.
Other Tests
Voiding diary
A voiding diary is a daily record of the patient's bladder activity. It is an objective documentation of the patient's
voiding pattern, incontinent episodes, and inciting events associated with urinary incontinence.
Pad test
This is an objective test that documents the urine loss. Intravesical methylene blue test or oral Pyridium or Urised
may be used. Methylene blue and Urised turns the urine color blue; Pyridium turns the urine color orange.
Patients should resume their usual physical activities while wearing a Peri-pad. If the pads turn to orange or blue, the
patient is experiencing urine loss. If the pads remain white, moisture most likely is a normal vaginal fluid.

Diagnostic Procedures
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. Both of these conditions
will cause urinary retention with overflow incontinence.
Uroflow rate
Uroflow rate is a useful screening test used mainly to evaluate bladder outlet obstruction. Uroflow rate is volume of
urine voided per unit of time.
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.
Filling cystometrogram
A filling cystometrogram (CMG) assesses the bladder capacity, compliance, and the presence of phasic contractions
(detrusor instability). Most commonly, liquid filling medium is used.
An average adult bladder holds approximately 50-500 mL of urine. During the test, provocative maneuvers help to
unveil bladder instability.
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.
Pressure-flow studies can be combined with voiding cystogram and videourodynamic study for complicated cases of
incontinence.
Cystogram
A static cystogram (anteroposterior and lateral) helps to confirm the presence of stress incontinence, the degree of
urethral motion, and the presence of a cystocele. Intrinsic sphincter deficiency will be evident by an open bladder
neck. Presence of a vesicovaginal fistula or bladder diverticulum also may be noted.
A voiding cystogram can assess bladder neck and urethral function (internal and external sphincter) during filling and
voiding phases. A voiding cystogram can identify a urethral diverticulum, urethral obstruction, and vesicoureteral
reflux.
Electromyography
Electromyography (EMG) helps to ascertain the presence of coordinated or uncoordinated voiding. Failure of urethral
relaxation during bladder contraction results in uncoordinated voiding (detrusor sphincter dyssynergia).
EMG allows accurate diagnosis of detrusor sphincter dyssynergia common in spinal cord injuries.
Cystoscopy
The precise role of cystoscopy in the evaluation of neurogenic bladder allows discovery of bladder lesions (eg,
bladder cancer, bladder stone) that would remain undiagnosed by urodynamics alone.
General agreement is that cystoscopy is indicated for people complaining of persistent irritative voiding symptoms or
hematuria. The physician can diagnose obvious causes of bladder overactivity, such as cystitis, stone, and tumor,
easily. This information is important in determining the etiology of the incontinence and may influence treatment
decisions.
Videourodynamics
Videourodynamics is the criterion standard for evaluation of a patient with incontinence. Videourodynamics combines
the radiographic findings of voiding cystourethrogram (VCUG) and multichannel urodynamics.
Videourodynamics enables documentation of lower urinary tract anatomy, such as vesicoureteral reflux and bladder
diverticulum, as well as the functional pressure-flow relationship between the bladder and the urethra.

Treatment
Medical Care
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.
Functional incontinence may be resolved by treating the underlying cause (eg, urinary tract infection, constipation) or
by simply changing a few medications.
Do not consider anti-incontinence products to be a cure-all for urinary incontinence; however, judicious use of pads
and devices to contain urine loss and maintain skin integrity are extremely useful in selected cases. Absorbent pads
and internal and external collecting devices have an important role in the management of chronic incontinence. The
criteria for use of these products are fairly straightforward, and they are beneficial for women who meet the following
conditions: (1) women who fail all other treatments and remain incontinent, (2) women who are too ill or disabled to
participate in behavioral programs, (3) women who cannot be helped by medications, (4) women with incontinence
disorders that cannot be corrected by surgery, and (5) women who are awaiting surgery.
Absorbent products
Absorbent products are pads or garments designed to absorb urine to protect the skin and clothing. Available in both
disposable and reusable forms, they are a temporary means of keeping the patient dry until a more permanent
solution becomes available. By reducing wetness and odor, they help maintain the patient's comfort and allow her to
function in normal activities. They may be used temporarily until a definitive treatment takes effect or if the treatment
yields less-than-perfect results. Absorbent products are helpful during the initial assessment and workup of urinary
incontinence. As an adjunct to behavioral and pharmacologic therapies, they play an important role in the care of
persons with intractable incontinence.
Urethral occlusive devices
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. Urethral
occlusive devices are more attractive than absorbent pads because they tend to keep the patient drier; however, they
may be more difficult and expensive to use than pads. Urethral occlusive devices must be removed after several
hours or after each voiding.
Catheters
Urinary diversion, using various catheters, has been one of the mainstays of anti-incontinence therapy. The use of
catheters for bladder drainage has withstood the test of time. Bladder catheterization may be a temporary measure or
a permanent solution for urinary incontinence. Different types of bladder catheterization include indwelling urethral
catheters, suprapubic tubes, and self-intermittent catheterization.
Indwelling urethral catheters
Commonly known as Foley catheters, indwelling urethral catheters historically have been the mainstay of treatment
for bladder dysfunction. If urethral catheters are used for a long-term condition, they must be changed monthly.
These catheters may be changed at an office, a clinic, or at home by a visiting nurse. The standard catheter size for
treating urinary retention is 16F or 18F, with a 5-mL balloon filled with 10 mL of sterile water. Larger catheters (eg,
22F, 24F) with bigger balloons are used for treating grossly bloody urine found in other urologic conditions or
diseases. Proper management of indwelling urethral catheters varies per individual.
Suprapubic catheters
A suprapubic tube is an attractive alternative to long-term urethral catheter use. The most common use of a
suprapubic catheter is in individuals with spinal cord injuries and a malfunctioning bladder. Both people who are
paraplegic and people who are quadriplegic have benefited from this form of urinary diversion. When suprapubic
tubes are needed, usually smaller (eg, 14F, 16F) catheters are placed. Like the urethral catheter, change the
suprapubic tube once a month on a regular basis.
Intermittent catheterization
Intermittent catheterization or self-catheterization is a mode of draining the bladder at timed intervals, as opposed to
continuous bladder drainage. A prerequisite for self-catheterization is the patients' ability to use their hands and arms;
however, in a situation in which a patient is physically or mentally impaired, a caregiver or health professional can
perform intermittent catheterization for the patient. 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 who is not physically handicapped or mentally impaired.
Many studies of young individuals with spinal cord injuries have shown that intermittent catheterization is preferable
to indwelling catheters (ie, urethral catheter, suprapubic tube) for both men and women. Intermittent catheterization
has become a healthy alternative to indwelling catheters for individuals with chronic urinary retention due to an
obstructed bladder, a weak bladder, or a nonfunctioning bladder. Young children with myelomeningocele have
benefited from the use of intermittent catheterization. In addition, self-catheterization is recommended by some
surgeons for women during the acute healing process after anti-incontinence surgery.
Intermittent catheterization may be performed using a soft, red, rubber catheter or a short, rigid, plastic catheter. The
use of plastic catheters is preferable to red rubber catheters because they are easier to clean and last longer.
The bladder must be drained on a regular basis, either based on a timed interval (eg, on awakening, every 3-6 hours
during the day, and before bed) or based on bladder volume. Remember that the average adult bladder holds
approximately 400-500 mL of urine. Ideally, the amount drained each time should not exceed 400-500 mL. This
drainage limit may require decreasing the fluid intake or increasing the frequency of catheterizations. If
catheterization is performed every 6 hours and the amount drained is 700 mL, increase the frequency of
catheterization to, perhaps, every 4 hours to maintain the volume drained at 400-500 mL.
Intermittent catheterization is designed to simulate normal voiding. Usually, the average adult empties the bladder 4-5
times a day. Thus, catheterization should occur 4-5 times a day; however, individual catheterization schedules may
vary, depending on the amount of fluid taken in during the day.
Candidates for intermittent catheterization must have motivation and intact physical and cognitive abilities. Anyone
who has good use of her hands and arms can perform self-catheterization. Young children and the older population
are able to do this everyday without problems. For individuals who are impaired, a home caregiver or a visiting nurse
can be instructed to perform intermittent catheterization. Self-catheterization may be performed at home, at work
anywhere.
Intermittent catheterization may be performed using either a sterile catheter or a nonsterile clean catheter.
Intermittent catheterization, using a clean technique, is recommended for young individuals with a bladder that cannot
empty and without any other available options. Patients should wash their hands with soap and water. Sterile gloves
are not necessary. Clean intermittent catheterization results in lower rates of infection than the rates noted with
indwelling catheters.
Studies show that in patients with spinal cord injuries, the incidence of bacteria in the bladder is 1-3% per
catheterization and 1-4 episodes of bacteriuria occur per 100 days of intermittent catheterization performed 4 times a
day. Furthermore, the infections that do occur usually are managed without complications. In general, routine use of
long-term suppressive therapy with antibiotics in patients with chronic clean intermittent catheterization is not
recommended. The use of chronic suppressive antibiotic therapy in people regularly using clean intermittent
catheterization is undesirable because it may result in the emergence of resistant bacterial strains. In high-risk
populations, such as patients with an internal prosthesis (eg, artificial heart valve, artificial hip) or patients who are
immunosuppressed because of age or disease, determine whether to use antibiotic therapy for asymptomatic
bacteriuria on individual merits.
For the older population and individuals with a weak immune system, the sterile technique of intermittent
catheterization has been recommended. Persons who are older are at higher risk than younger persons for
developing bacteriuria and other complications caused by intermittent catheterization because they do not have a
strong defense system against infection. Although the incidence of infection and other complications for older patients
who are using sterile versus clean intermittent catheterization is not well established, sterile intermittent
catheterization appears to be the safest method for this high-risk population.
Potential advantages of performing intermittent catheterization include patient autonomy, freedom from indwelling
catheter and bags, and unimpeded sexual relations. Potential complications of intermittent catheterization include
bladder infection, urethral trauma, urethral inflammation, and stricture. Concurrent use of anticholinergic therapy will
maintain acceptable intravesical pressures and prevent bladder contracture. Studies have demonstrated that long-
term use of intermittent catheterization appears to be preferable to indwelling catheterization (ie, urethral catheter,
suprapubic tube) with respect to urinary tract infections and the development of stones within the bladder or kidneys.

Surgical Care
Surgical care for stress incontinence involves procedures that increase urethral outlet resistance. Operations that
increase urethral resistance include bladder neck suspension, periurethral bulking therapy, sling procedures, and
artificial urinary sphincter.
Surgical care for urge incontinence involves procedures that improve bladder compliance or bladder capacity; these
include sacral neuromodulation, botulinum toxin injections, [1,2 ]detrusor myomectomy, and bladder augmentation