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• The normal function of the urinary bladder is to store and expel urine in a coordinated, controlled fashion.
• This coordinated activity is regulated by the central and peripheral nervous systems. • Neurogenic bladder is a term applied to a malfunctioning urinary bladder due to neurologic dysfunction or insult emanating from internal or external trauma, disease, or injury.
URINARY BLADDER AND SPHINCTER
1. The detrusor muscle
2. Internal urethral sphincter
3. External urethral sphincter
Autonomic nervous system 2.• Normal voiding essentially is a spinal reflex that is modulated by the central nervous system (brain and spinal cord)which coordinates the functions of the bladder and urethra. somatic nervous system . COMPONENTS OF MICTURITION REFLEX a) Brain b) Pons c) Spinal cord d) Peripheral nerves 1.
Detrusor frontal centre Limbic centre Pons centre Striated sphincter frontal centre Hypothalamic centre Hypo gastric nerve Bladder Pudendal nerve Pelvic nerve Sacral centre .
.The mechanical process of urination is coordinated by the pons in the area known as the pontine micturition centre (PMC). BRAIN .Tonically inhibitory signals to the detrusor muscle to prevent the bladder from emptying. .Micturition control centre is located in the frontal lobe and diffusively in the premotrice area (paracentral lobule).1. . . 2. BRAIN STEM .Master control of the entire urinary system.The pons is responsible for coordinating the activities of the urinary sphincters and the bladder so that they work in synergy.
• PMC – Excitatory in nature.Specialized area known as the sacral reflex centre. • PMC affected by emotions. • Sacral spinal cord . SPINAL CORD • Spinal cord acts as an important intermediary between the pons and the sacral cord. • Stimulation of PMC urethral sphincters to open & detrusor to contract expel the urine. An intact spinal cord is critical for normal micturition. . • The sacral reflex centre is the primitive voiding centre. It is responsible for bladder contractions.
. uretheral sphincter. S2-S4 Pelvic nerve detrusor muscles contraction.• PERIPHERAL NERVES 1. 2. sphincter maintain continence. . SOMATIC NEURONS:Onuf nucleus (ant horn cell S2-S4) Pudendal N. . AUTONOMIC NEURONS a) PARASYMPATHETIC – Excitatory. sleletal muscles of ext.acetylcholine. .Filling phase contraction of ext.Acetylcholine – excitatory stimulation.
(mainly L2) Fundus of bladder Relaxation of bladder Beta 2 receptor Trigone. bladder outlet increases bladder outlet resistance Alpha1 receptor .Inhibitory T10-L2 Inferior mesenteric ganglion Hypogastric N.B) SYMPATHETIC NERVOUS SYSTEM.
. Sympathetic nerves directly cause relaxation and expansion of the detrusor muscle. Sympathetic nerves close the bladder neck by constricting the internal urethral sphincter.FILLING PHASE Sympathetic nerves facilitate urine storage in the following ways: Sympathetic nerves inhibit the parasympathetic nerves from triggering bladder contractions.
Emptying phase Inhibition of somatic neurons relaxation of external sphincter. The sympathetic nerves send a message to the internal sphincter to relax and open. The parasympathetic nerves trigger contraction of the detrusor. .
causing a complete loss of voiding control.PATHOPHYSIOLOGY 1. • Primitive voiding reflex—remain intact. . The bladder empties too quickly and too often. • Signs of urge incontinence or spastic bladder (Detrusor hyperreflexia or overactivity). and storing urine in the bladder is difficult. BRAIN LESION • Lesions of the brain above the pons destroy the master control centre. with relatively low quantities.
4. 2. 5.• Example:1. 3. Stroke Hydrocephalus Brain tumor Cerebral palsy Encephalitis .
• Somatic reflex activity is either depressed or absent. • The autonomic activity is depressed . .urinary retention.SPINAL CORD LESION • Spinal cord injury . • Spinal shock phase. flaccid paralysis below the level of injury.initial response . • Urodynamic findings are consistent with areflexic detrusor.spinal shock.
• Spinal shock phase wears off. • The voiding disorder is similar to that of the brain lesion except that the external sphincter may have paradoxical contractions as well. If both the bladder and external sphincter become spastic at the same time: • Detrusor-sphincter dyssynergia because the bladder and the external sphincter are not in synergy . bladder function returns but the detrusor activity increases in reflex excitability to an overactive state—detrusor hyperreflexia.
• Spinal cord lesion (above T6) . & a unique complication of autonomic dysreflexia. . striated sphincter dyssynergia and smooth sphincter dyssynergia . • Spinal cord lesions (below T6) -no autonomic dysreflexia.Urodynamic findings of detrusor hyperreflexia.
INJURY – Detrusor areflexia. • If a sensory neurogenic bladder – not able to sense when the bladder is full. .SACRAL CORD INJURY & PERIPHERAL N. • In the case of a motor neurogenic bladder. a condition known as detrusor areflexia. • Selected injuries of the sacral cord and the corresponding nerve roots arising from the sacral cord may prevent the bladder from emptying. the individual will sense the bladder is full and the detrusor may not contract.
distended. • Overflow incontinence (painless. constantly leaking bladder). • Urinary retention.• Incomplete bladder emptying. flaccid. .
• Example:- • • • • • • • • • Sacral cord tumor Herniated disc Myelodysplasias Injuries that crush the pelvis. Diabetes mellitus AIDS Poliomyelitis Guillain-Barré syndrome Severe herpes in the genitoanal area .
USG & MRI.Urine routine & culture. a) b) c) d) e) f) History & physical examination Lab studies. 5. • 3. 2. Diagnostic procedures Postvoid residual urine Uroflow rate Filling cystometrogram Voiding cystometrogram (pressure-flow study) Cystogram Electromyography .APPROACH 1. Blood urea nitrogen and creatinine. Other test.voiding diary & pad test. 4.
3. constipation) or by simply changing a few medications. . 4. Urge incontinence may be treated with behavioral modification or with bladder-relaxing agents. Mixed incontinence may require medications as well as surgery. Stress incontinence may be treated with surgical and nonsurgical means. urinary tract infection. Overflow incontinence may be treated with some type of catheter regimen.MANAGMENT 1. Functional incontinence may be resolved by treating the underlying cause (eg. 5. 2.
Absorbent products • Pads or garments designed to absorb urine to protect the skin and clothing. 2. • They are a temporary means of keeping the patient dry. 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. .1. • Disposable and reusable forms.
Intermittent catheterization . 1. Indwelling urethral catheters 2.Catheters • Bladder catheterization may be a temporary measure or a permanent solution for urinary incontinence. Suprapubic catheters 3.
• Sympathomimetic drugs and tricyclic agents increase bladder outlet resistance to improve symptoms of stress urinary incontinence.Drugs • The 3 main categories of drugs used to treat urge incontinence include Anticholinergic drugs. . The internal sphincter contains high concentrations of alpha-adrenergic receptors. • Stress incontinence results from a weak urinary sphincter. Antispasmodics and Tricyclic antidepressant agents.
antispasmodic drugs have been reported to increase bladder capacity and effectively decrease or eliminate urge incontinence. • Oxybutynin • Tolterodine • Flavoxate • Drotaverine .• 1. Antispasmodic drugs:. • Propantheline • Dicyclomine • Hyoscyamine sulfate 2. By exerting a direct spasmolytic action on the smooth muscle of the bladder.They are effective in treating urge incontinence because they inhibit involuntary bladder contractions.Anticholinergic drugs:.These relax the smooth muscles of the urinary bladder.
Tricyclic antidepressant drugs:.They function to increase norepinephrine and serotonin levels. they exhibit anticholinergic and direct muscle relaxant effects on the urinary bladder.• 3. • Imipramine hydrochloride • Amitriptyline hydrochloride . In addition.
procedures that increase urethral outlet resistance i)bladder neck suspension ii)periurethral bulking therapy iii)sling procedures iv)artificial urinary sphincter.procedures that improve bladder compliance or bladder capacity i)sacral neuromodulation ii)botulinum toxin injections iii)detrusor myomectomy iv) bladder augmentation . • Urge incontinence .Surgical Care • Stress incontinence .
If left untreated. and urethral erosion.these skin disorders may lead to pressure sores and ulcers. .contact dermatitis and skin breakdown. • Chronic indwelling catheters .recurrent bladder infection. • The use of intermittent catheterization may result in bladder infections or urethral injury. ascending pyelonephritis. bladder stones. • Decompensated bladder that does not empty well. the postvoid residual urine can lead to overgrowth of bacteria and subsequent urinary tract infection.COMPLICATIONS OF T/T • Prolonged contact of urine.
. hematoma. bladder stone formation. • Untreated urinary tract infections may lead to urosepsis and death. bowel injury.• Chronic suprapubic tubes may result in bladder spasms. and bladder infection. • Potential problems unique to suprapubic catheters include skin infection. and problems with catheter reinsertion.
COMPLICATION 1. Infection Hydronephrosis Calculus Renal amyloidosis Sexual dysfunction . 2. 3. 5. 4.