Neurogenic bladder

DR. WAEL ABUISNENEH

 Neurogenic bladder
The urinary bladder is probably the only visceral
smooth muscle that is under complete
voluntary control from cerebral cortex
It has both somatic & autonomic innervations

The functional features include:

1. A normal capacity of 400 – 500 ml
2. Sensation of fullness
3. Volume change without change in intraluminal
pressure
4. Initiation & maintenance of contraction until
bladder is empty
5. Voluntary initiation or inhibition of voiding
 The sphincteric unit
In both male & females : two sphincters
• Internal involuntary SM sph. at bladder neck
• External voluntary striated M. sph. from the prostate to
membranous urethra in males & at mid urethra in
females
N.B. : the ureterovesical junction prevent backflow of urine from
the bladder to the upper urinary tract.

Innervations
Parasympathetic : the anterior primary divisions S 2 – 4
Sympathetic : T10 – L 2
Somatic motor innervation :S 2 – 3 though the pudendal N.
 The micturition reflex

Intact pathway via the spinal cord & pons

required for normal micturition.
The pontine center send either excitatory
or inhibitory impulses to regulate the
micturition reflex
Disruption of pontine control as in upper
spinal cord injury lead to contraction of
the bladder without sphenecteric
Relaxation ( detrusor-sphincter
dyssynergia)
 Classification of neurogenic bladder
• Upper motor neuron : spastic , uninhibited : injury
above spinal cord micturition center
• Lower motor neuron: flaccid , atonic, areflexic : injury
in the pelvic nerves or spinal micturition center
• Spinal shock

N.B. Spinal shock

Immediately after injury, regardless of the level, there
is a stage of flaccid paralysis with numbness below the
level of the injury that lead to bladder overfilling to the
point of overflow incontinence & rectal impaction.
It last few weaks up to 6 months
 Feature:
UMNL Upper motor neuron lesion: reduced bladder capacity
, involuntary detrusor contraction , high intravesical & detrusor
pressure , spasticity of pelvic striated M. , autonomic dysreflexia in
cervical cord lesions
LMNL lower motor neuron lesion : large bladder capacity,
lack of voluntary detrusor contraction, low intravesical pressure,
deceased tone in external sphincter.

• N.B.: full neurologic exam. is required for those patients to assess the
level of sensory and motor loss

Investigations
• Urinalysis
• Renal function test
• Imaging study (U/S-IVU)
• Instrumental exam. Cystoscopy
• Urodynamic studies
Urodynamic studies
Technique used to obtain graphic recording of activity in UB, urethral
sphincters , & pelvic musculature
 Differential diagnosis

• Cystitis
• Chronic urethritis
• Vesical irritation 2ry to psychic disturbance
• Interstitial cystitis
• Cystocele
Treatment :
The treatment is guided by the need to restore low
pressure activity & to empty the bladder
effectively in order to preserve renal function,
continence, & control infection
-Spinal shock
-Bladder drainage by clean self intermittent
catheterisation(CSIC) , indwelling catheter or
suprapubic cystostomy
- Increase fluid intake to 2 – 3 l/day
- Prophylaxis for calculus formation by reducing
calcium & oxalate intake
- Spastic neuropathic bladder

• Voiding by trigger technique.

• Anticholinergic medications (parasympatholytic
drugs) like Detrositol , ditropan (oxybutynin)
• CSIC ( clean self intermittent catheterization ) or
Indwelling catheter
• Condom catheter & leg bag
• Sphinterotomy to decrease outlet resistance
• Sacral rhizotomy at S 3-4
• Neurostimulation
• Urinary diversion
- Flaccid neuropathic bladder

• Crede maneuver ( manual suprapubic

pressure) accompanied by straining
• Bladder training & care , voiding every 2hr
• CSIC every 3-6 hr
• TUR in hypertrophied bladder neck or BPH
• Parasympathmimetic drugs like bethanecol
chloride( Urecholine) 5 – 50 mg every 6-8hr
complications
• Infection : cystitis, periurethritis, prostatitis, epididymoorchitis,
pyelonephritis
• Hydronephrosis
• Calculus formation
• Renal amyloidosis
• Sexual dysfunction
• Autonomic dysrelexia: sympathetically mediated reflex behavior, in
patients with cord lesion above T1
symptoms include dramatic elevation in systolic &/or diastolic
pressure, increase pulse pressure, bradycardia, headache,
piloerection.
symptoms brought by overdistention of the bladder
Treatment:
Immediate catheterisation
Oral nifedipine (20mg) 30 min before cystoscopy as prophylaxis
Alpha adrenergic blockers
prognosis

The greater threat to those patients is progressive renal

damage caused by pyelonephritis , calculosis,
hydronephrosis