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Historical Importance:
- In world war I, 39% of pt with Spinal cord injury died

because of UTI resulting from neurogenic bladder. - In world war II, mortality decreased to 10% but still the most common was renal failure resulting from spinal injury.

 Currently, although UTIs occur frequently in those

with SCI, death from this cause is extremely unusual. And less than 3 percent of deaths following SCI are now attributable to chronic renal failure.
 This dramatic decline in morbidity and mortality from

urological causes has been a result of the advent of antibiotics, effective bladder management, and frequent monitoring of the upper and lower urinary tracts.

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Basic Anatomy  The main organs involved in urination are the urinary bladder and the urethra.  Bladder has mainly two parts: Body: The main area where urine is collected The smooth muscle of the bladder body is known as the Detrusor which is responsible for voiding of bladder. from here the urethra starts. Neck: Lower and most depended part. Capacity: Anatomical : 1500ml Physiological: 650ml bladder sensations felt: 200ml Ugre to urinate: 400 ml Uncontrollable urge: 650ml .

Hence it is not a true sphincter. . although they do not encircle the urethra completely. exception to this is Trigone. Ureters opens on both the posterolateral angles of trigone  Smooth muscle bundles along with elastic fibers pass on either side of the urethra. and these fibers are sometimes called the internal urethral sphincter. smooth triangular part at the lower end of bladder where mucosa is firmly attached. The interior of bladder shows irregular folds(rugae) due to loose attachment of mucosa.

the sphincter of the membranous urethra (external urethral sphincter). Farther along the urethra is a sphincter of skeletal muscle. . which is under voluntary control and supplied by the pudendal nerve.

Neuroanatomy of Micturition   Muscles of Bladder Smooth (Involuntary)   Striated (Voluntary) Ext. Detrusor. Internal urethral Sphincter. . urethral sphincter.

Very important role in males in preventing the reflux of semen into the bladder during ejaculation.Nervous Innervation  Sympathetic (promotes filling) Both afferent and efferent supply T11.T12. .L1& L2 α-action: trigone contraction. β-action: Detrusor relaxation. No effect on micturation.

3. Parasympathetic (Promotes emptying) Both efferent and afferent. S2. .4. Contracts detrusor and relaxes sphincter. Acts via muscarinic receptors (Acetylcholine).

4).3. Supplies the external sphincter which is under voluntary control. Hence. Gained usually by age of 5-7 yrs. Efferents arises from nucleus of Onuf. Somatic Pudendal nerve (S2. . it prevents bed wetting.

Physiology of Micturition  Micturition reflex center – sacral cord 2-4  Higher centers mainly Inhibitory Paracentral lobule Others: Limbic system Thalamus mainly Facilitatory Pons post. hypothalamus .

stretch receptors .

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Physiology of Micturation 350-400ml of urine Increase in intra-vesical pressure ~25cm H2O. Afferents carried by pelvic parasymp. . In cortex they are recorded as desire to micturate. Nerve to sacral area of spinal cord and relayed to pons.stimulation of stretch receptors.

Sphincter. Inhibition of somatic N. . Contraction of detrusor & relaxation of int. If circumstances are: Favorable Stimulation of parasymp. & ext. Not favorable Social inhibition But this is only temporary.

Bladder Pressure-Volume Relationship .

Few important definitions  Urinary hesitancy .  Urinary urgency – sudden compelling urge to urinate .difficulty in beginning the flow of urine. .when uncontrollable it causes urge incontinence  Incontinence – if bladder control is lost and urine leakage occurs it is called incontinence.

sneezing. . Stress urinary incontinence: incontinence that occurs as a result of external mechanical disturbances like Coughing.  Urge urinary incontinence: incontinence that occurs as a result of the uncontrollable urge to urinate  Mixed urinary incontinence. a combination of the two types of incontinence. lifting weight etc.

urine loss not associated with any pathology or problem in urinary system. Overflow incontinence – frequent dribble of urine as a result of inefficient bladder emptying  Functional incontinence. . Occurs in physical or cognitive impairment like Alzheimer’s or head injury.

Spinal / automatic Flaccid bladder 1. Lapide’s classification Spastic bladder 1. Motor atonic 3. Autonomous 2.Neurogenic Bladder  Bladder abnormalities resulting from diseases affecting the innervation of bladder both peripheral or central. Cortical / autonomic 2. Sensory atonic .

Multi-system atrophy . Parasagital meningiomas 3. Normal pressure hydrocephalus 5.Cortical/Uninhibited/autonomic/ infantile bladder  Site of lesion: btw paracentral lobule to pons  Causes: 1. ACA aneurysm 4. Parkinson’s disease 6. Frontal lobe tumors 2.

e. complete evacuation occurs on its own.loss of social inhibition i.Urgency at low bladder volume .e. pt.No residual volume i. . C/F: . passes urine just like an infant without his knowledge. .

Spinal/Reflex/Automatic Bladder
 Site: from Pons to S1
 Causes:

- Acute transverse myelitis - Trauma - Neoplasm - Multiple Sclerosis

 C/F:

Depends on the extent of lesion
Incomplete If inhibitory fibers gone Urgency Eg: MS If excitatory fibers gone Hesitancy eg: tumors Complete Retention with overflow incontinence. f/b automatic bladder

 Automatic Bladder

- After recovery from stage of spinal shock, the activity of the bladder is controlled by the local reflex arc. - When a specific volume is reached(250ml), the bladder empties reflexly. - But contrary to CORTICAL BLADDER emptying is incomplete. - Evacuation can be improved by bladder massage or suprapubic pressure. N.B: Stage of spinal shock is seen only if the insult to spinal cord is acute

Pelvic trauma/surgery/malignancy . it affects both motor & sensory components  Causes: .Autonomous/Atonic Bladder  Site: Sacral region(S2.4) Hence.Spina bifida/ meningomyocele .Sacral arachnoiditis .3.Cauda equina syndrome .

-loss of potency & saddle anesthesia. . -patient can evacuate the bladder by applying external pressure. atonic bladder with painless retention of urine. -large. C/F: -loss of bladder sensation. -continuous overflow incontinence with stress incontinence. -high risk of UTI.

Motor paralytic bladder  Site: Efferent limb  Causes: .Pelvic tumor .trauma .Poliomyelitis .Polyradiculopathy .

Painful distention of bladder. C/F: . Cystometry: No contractions of detrusor. of .Narrow/interrupted stream of urine. . compensatory distention bladder & overflow incontinence.In later stages.Inability to initiate or continue micturition. . .

.Multiple Sclerosis.DM. . .Syringomyelia. . .SACD.Sensory Paralytic bladder  Site: Afferent limb  Causes: .Tabes dorsalis.

. . . C/F: .very large & hypotonic bladder with massive retention of urine. can initiate micturition as the motor limb is normal .Painless distention of the bladder.continuous overflow incontinence. .large residual volume.Contrary to Autonomous bladder pt.

Can they stop urine passing in mid-stream at will? (for cortical fn which innervates ext. Is there any numbness in perineum? 1. Is there continuous leak(sensory/autonomous) or sudden passage of urine(automatic)? 4. . have sensation of the bladder? (rules out sensory and autonomous bladder) 2. sphincter) 3.Questions to be asked in cases of neurogenic bladder Do the pt.

Is there any associated disorder of potency? .5. Is there any associated rectal disorder? 6.

. and intravenous pyelograms(IVP). a urologic evaluation is done every year. although there is no consensus among doctors on the frequency this type of examination.creat. such as ultra-sound. -renal scans -tests that evaluate anatomy. S. CT scans.  Upper tract evaluations -B.U.N.Urologic Evaluation  Generally.

. Lower tract evaluations . This is the only test able to assess bladder contractility and the extent of a bladder outlet obstruction. Uroflow rate is a useful screening test used mainly to evaluate bladder outlet obstruction.Filling cystometrogram (CMG) assesses the bladder capacity.Uroflow rate is a useful screening test used mainly to evaluate bladder outlet obstruction. and the presence of phasic contractions (detrusor instability). the bladder may be contractile or the bladder outlet may be obstructed.Voiding cystometrogram (pressure-flow study) Pressure-flow study simultaneously records the voiding detrusor pressure and the rate of urinary flow.postvoid residual urine (PVR) PVR is high.Urine analysis . . . . compliance.

and vesicoureteral reflux. . urethral obstruction..A voiding cystogram can assess bladder neck and urethral function (internal and external sphincter) during filling and voiding phases.It should be noted that urodynamics is an important evaluation for determining bladder function as no clue about raised intravesical pressure can be obtained from history and clinical examination .Electromyography (EMG) helps to ascertain the presence of coordinated or uncoordinated voiding. A voiding cystogram can identify a urethral diverticulum. .Cystoscopy to evaluate bladder anatomy. . Failure of urethral relaxation during bladder contraction results in uncoordinated voiding (detrusor sphincter dyssynergia).

hot spicy food. beverages. lemon etc. high K+ containing fruits.  Avoid Caffine. and nerves. citrus fruits like grapes. blood flow.General points in Mx of neurogenic bladder A. Behavioural changes  Stop smoking: reduce chronic coughing reduces downward pressure on the pelvic floor  Weight reduction: Excessive body weight affects bladder pressure. . beer. chocolates.

Stop drinking after dinner 3. Timed voiding 5.Life Style changes 6 steps for continence: 1. Voiding diary . Drink less than 5 glasses/day (40 oz) 2. Regular pelvic floor exercises 6. Elevate legs 4.

hold.Kegel’s exercise 1. 4. relax). Perform Kegel exercises 3-4x during the day. . and repetitions every couple of days. 3. Do sets of repetitions of squeezing (start with 5 repetitions: squeeze. Contract your pelvic floor muscles as hard as you can and hold them (squeeze 3-5 sec and relax for 5 sec). 2. intensity. Increase lengths.

Crede’s and Valsalva  Credé is a method of applying suprapubic pressure to express urine from the bladder.the bladder does not empty completely. .  Credé and Valsalva used in individuals who have lower motor neuron injuries with low outlet resistance or who have had a sphincterotomy.  Valsalva manovure causes an increase in the abdominal pressure. Credé is usually used when the bladder is flaccid or a bladder contraction needs to be augmented.However.Thus the individual uses the abdominal muscles and the diaphragm to empty the bladder.

 Vesicoureteral reflux.Avoid Crede’s and Valsalva in:  Detrusor sphincter dyssynergia. .  Hydronephrosis.  Bladder outlet obstruction.

positive reinforcement.  Bladder training generally consists of self-education.Bladder Exexcise  Bladder training involves relearning how to urinate. adjustment of fluid intake and avoidance of dietary stimulants. scheduled voiding with conscious delay of voiding. In addition. This method of rehabilitation most often is used for active women with urge incontinence and sensory urge symptoms.  The interval goal between each void usually is set between 2 and 3 hours. . distraction and relaxation techniques allow delayed voiding to help distend the urinary bladder.

1 . .15mg tid . Anti-cholinergics: Mech: Blocks the muscarinic receptors and thus increases the capacity by relaxing the bladder.5mg 6hrly .Propanthelien 10 .Hyoscine 8 .Dicyclomine .Pharmacological options  For Spastic Bladder 1.20mg tid 0.

Fatigue.Constipation.Blurred vision . . . . .Dizziness. .Dry mouth.Tachycardia.Slow thinking . .• Side Effects .

Eg.5mg OD Trospium 20mg OD  TCA’S: Block the serotonin and norepinephrine uptake and thus causing decreased cortical facilitatory impulses therby causing reduced frequency of contractions. It also has direct detrusor relaxing action. Imipramine 25mg BD Amytriptilline 10mg HS . Eg.5mg OD Solefenacin 5mg OD Oxybutinin 2. Dorefenacin 7. Antispasmodics: It also causes relaxation of detrusor but are more selective.

false passages. and bladder neck obstruction.Clean Intermittent self Catheterization(CISC)  The normal capacity of the bladder is less than 500 ml. Avoid if:  Inability to catheterize themselves. .  A caregiver who is unwilling to perform catheterization.  If more then 500ml of fluid is drained at a particular time then the fluid intake must be decreased and the frequency of catheter should be increased.  Bladder capacity less than 200 ml.  Abnormal urethral anatomy such as stricture. Catheterizing the bladder every 4–6 hours prevents overdistention of the bladder.

Freedom from indwelling catheter. Advantages of CISC over Indwelling Cathter: . .Less chances of infection.pt’s autonomy is maintained . .

Indwelling catheter .

bladder capacity and compliance tend to decrease overtime. . Types Urethral Suprapubic  Because complete bladder filling often does not occur and individuals who use indwelling catheterization tend to have uninhibited bladder contractions.

especially when maintaining fluid balance is critical) Terminally ill pt. No care giver In chronic SCI who are unable to perform intermittent catheterization or reflex voiding. have uncontrollable urinary incontinence. .Indications  Acute central nervous system trauma( allows precise     monitoring of urinary output. Where other less invasive procedures have failed.

 Bacterial colonisation usually occurs by the end of 2 weeks. Frequency of changing: Every 3-4 weeks under all aseptic precautions preferably done by trained health professional.Usualy asymtomatic. .

1989) If the catheter tip and balloon irritate the trigone of the bladder. A belt. . If concretions cause blockage and impede drainage. or 30 mls of Renacidin can be instilled daily for 20–30 minutes Daily irrigation of the catheter with betadine or sterile water is not recommended because irrigation denudes the uroepithe-lium (Elliot et al. Urine analysis every 2-3 months for asymptomatic bacteriuria. a silicone catheter can be used. tape. or other device is used to secure the catheter to the abdomen or thigh.Catheter Care  Genitals and part of catheter outside the body must be kept      clean by soap water and disinfectants. an anticholiner-gic medication may be prescribed to prevent invol-untary detrusor contractions and urinary leakage.. .

Complications: Encrusting around the catheter. Infection Hematuria Spasm of bladder Long term Cx: Stones Contracture of bladder Urethral stricture .

Prostatitis. bladder neck obstruction. such as stricture. . or epididymo-orchitis. false     passages. or urethral fistula Recurrent urethral catheter obstruction. urethritis. A desire to preserve sexual genital function.Indications for Suprapubic Cathter  Urethral abnormalities. Perineal skin breakdown due to urine leakage secondary to urethral incompetence.

2. Sexual activity preserved. . trauma etc. 3. No urethral Cx like stricture. Voiding can be tested(to look for recovery). Advantages of suprapubic cathter: 1. Less irritation because it bypasses the trigone. 4.

but is widely used for failure of medical therapy  Not indicated in patients with difficulties to empty their bladders . Clostridium botulinum  Injections into the bladder under direct vision  Blocks chemically nerve ends  As early as 2 days after injections it improves urgency and frequency  Duration between 3-6 months  Not FDA-approved for neurogenic bladder.Botox  Neurotoxin.

Local side effects:  Excessive bladder muscle relaxation can cause urinary retention  Pain  Infections  Bleeding General side effects:  Muscular weakness  Less effective during prolonged time  Some people build up a resistance .

and urinary retention  Proven efficacy in patients for whom more  Over 14 years FDA-approved conventional therapy has been unsatisfactory  Neurologic diseases -like MS.Sacral Neuromodulation  “Pacemaker for the bladder”  Treatment for urgency.are undergoing sacral neuromodulation with good success . frequency. Parkinson's disease and SCI injuries. urge incontinence.

How does it work?  Leads float next to bladder nerves  Leads are connected to a battery placed at the buttocks  Leads sent mild electrical impulses out to the sacral nerves  Can be discontinued at any time .

dantrolene . Baclofen. fat or silicone) Overdistention of bladder Central Neurological De-innervation: SA Block Artificial sphincter 5α reductase inhibitor(finasteride) BZD.Other Interventions  Pessaries  Periurethral bulking agents (periurethral injection of      collagen.