Referat:

Neurogenic Bladder
d r. F r a n k l i n L . S i n a n u
Topic Discussed in this presentation

• Physiology of micturition reflex

• Evaluation of bladder disorders
• Anatomic lesion associated with neurogenic bladder
• Treatment of neurogenic bladder
Anatomy
Physiology

Lower urinary tract has 2 basic physiologic functions:

1. Low pressure storage of adequate volume of urin
with appropriate sensation and periodic
2. Voluntary expulsion of urine from the bladder in a
coordinated and complete fashion
Micturition Reflex
Evaluation of neurogenic bladder

• History
• Physical examination
• Laboratory evaluation
• Radiologic
• Urodynamic testing of lower urinary tract
 History
Filling/storage symptoms Voiding symptoms (bladder
(bladder): & sphincter):
• Urgency • Hesitancy
• Frequency (>8x /24 hr) • Straining to void
• Dysuria
• Incontinence
• Double voiding
• nocturia
 Examination
 Physical examination
• Motor and sensory
function
• Physiologic and Pathologic
reflexes
• Bulbocavernous reflex
• Anal Reflex
• Cremastoric Reflex
 Renal function test
 Upper urinary tract imaging:
– USG
– CT scan
 Lower urinary tract imaging:
– cystoscopy
– cystography
– voiding cystogram
Urodynamic Testing

• Cystometry
• Uroflowmetry
• Electromyography
• Video urodynamics
Neurologic Lesions 1

1. Suprapontine
2. Spinal lesions 2

3. Lesions at or distal to the

sacral spinal cord

3
 Suprapontine Lesions

 CVA:  Supraspinal
– especially frontal lobe neurodegenerative disorders:
– started with detrusor areflexia (retention) • loss of inhibition to the PMC
than leads to detrusor overactivity (dementia)
– 44-88% incontinence → 70-80% regain
continence • detrusor overactivity and
sphincter bradykinesia
 Brain Tumors: (parkinson)
– local compression and destruction of cortical
tissues
– area frequently involved is superior aspect of
frontal lobe
– detrusor overactivity and incontinence
 Spinal Lesions
 Spinal cord injury
• Above T6:
– Detrusor overactivity
– Absent sensation below level
– Smooth sphincter synergy
– Striated sphincter dyssynergy
– Smooth sphincter dyssynergy
– Autonomic Dysreflexia
• Below T6 – Sacral cord:
– Detrusor overactivity
– Absent sensation below level
– Smooth sphincter synergy
– Striated sphincter dyssynergy
• Distal to sacral cord:
– Detrusor areflexia
– Fixed external sphincter tone
 Spinal Lesions
 Spinal shock
• Loss of all functions below injury
• Urinary retention that leads to
overflow incontinence
• Generally lasts 6 to 12 weeks
 Neurospinal dysraphism
• 90 % incidence of lower urinary tract
dysfunction
• Typically myelodysplastic has an
areflexic bladder with an open
bladder neck
• But many also came with
overactivity or poorly compliant
bladder
 Lesions at or distal to the sacral spinal cord
 Sacral SCI
• Detrusor areflexia with normal
compliance is the initial
urodynamics
• Bladder outlet competent but non
relaxing smooth sphincter with a
fixed external urethra
• Usually patients attempt void using
valsava or crede maneuver
 Disk disease
• Due to nerve root compression
• Difficulty voiding and exhibit
straining or urinary retention, but
usually continent
• Laminectomy may not improve
bladder function
• Preintervention urodynamic
evaluation is important.
 Lesions at or distal to the sacral spinal cord

 Radical Pelvic Surgery

• Similar findings with sacral SCI
• Most common are abdominal perineal resection and radical
hysterectomy
• Direct bladder or urethral injury, devascularization of the pelvic organ
• Tethering, encasement, or destruction of the innervation of LUT
• Reported 10 – 60 % after these procedures → 15 – 20 % is permanent
 Treatment

Four general goals of neurogenic bladder management:

1) Protecting renal functions and the upper urinary tract
2) Minimizing LUT complications
3) Treating the bothersome symptoms
4) Choosing a management program compatible with
individual patient goals and abilities
Treatment
Based on the goals, the treatment focus on:
1) Maintenance of low storage pressure
2) Prevention of incontinence
3) Promotion of efficient bladder emptying
4) Avoidance of infection
 Treatment
 Failure to store urine (incontinence)
–Management of detrusor overactivity or impaired
compliance
–Management of outlet deficiency

 Failure to empty urine (retention)

–Management of detrusor acontractility
(underactivity)
–Management of detrusor sphincter dyssynergia
 Overactivity or impaired compliance
(urge incontinence, frequency)

 Life style interventions:  Sacral neuromodilation:

– Reduce fluid intake • Percutaneously placed
– Avoid dietary irritants electrodes in S3-4 foramen to
– Timed voiding stimulate the afferent nerve
– Pelvic floor exercise
 Augmentation cystoplasty:
 Medications: • Graft of vascularized
– Anticholinergic: decrease PANS segment of small
– Β3 adrenergic: increase SANS bowel,colon, or stomach.
– Tricyclic antidepressants
– Botulinum Toxin A injection into bladder
 Outlet deficiency
(stress incontinence, open bladder neck)

 Bulking agents injection:  Bladder neck closure:

– Collagen injection into • Combined with supravesical
periurethral, transurethral, or urinary diversions
perineal

 Sling procedures:
– Fascial sling transvaginal or
 Supravesical Urinary
perineal diversions:
– Mesh sling • Last resort of management
 Artificial sphincters:
– Highest continence level
 Underactivity or acontractility

 Intermittent Catheterization:  Crede and valsava

– First line treatment maneuver
– Every 4 – 6 hours
– Clean or sterile
 Sacral neuromodulation
 Indwelling catheters:
– Foley or suprapubic cystostomy
– Inferior than CIC  Urinary diversions:
– Risk of metaplasia • Last resort of management
 Detrusor – Sphincter Dyssynergia
External Sphincter Internal Sphincter
Dyssynergia Dyssynergia
 External sphincterectomy:  Adrenergic blocker
– Combined with condom catheter  Cystoscopic incision
– Not considered for women

 Urethral stenting:
– Prosthetic stent placement

 Botulinum Toxin A injection:

– Into external sphincter
Thank you
Cystometry
Video Urodynamic
Uroflowmetry