BLADDER DYSFUNCTION

DR. YUVARAJ BADHE

MBBS, FCPS (Medicine), DNB (Medicine)
 Innervation Of The Bladder
Hypogastric nerve: (Sympathetic)
– From T11, T12 and L1, L2……Thoraco-
Lumber
– Relaxation of bladder muscle &
Contraction of internal urinary
sphincter . ……Stores urine
Pelvic Nerve: (parasympathetic)
– Motor + sensory
– From sacral plexus S2,3,4
– Motor part = parasympathetic fibers
– Contraction of bladder muscle &
Relaxation of internal urinary sphincter
….. Expels urine
Pudental Nerve: (Somatic)
– Voluntary control
– External urinary sphincter…contraction
– S2,3,4 – antero lateral horns of S2,3,4
 Receptors

1) β3 - Bladder wall
(Detrusor muscle
relaxation)

2) M3 – Bladder wall
(Detrusor muscle
contraction)

3) a1 – Internal sphincter

4) Nicotinic – external
sphincter
 Micturition reflex
When bladder is empty:
– Little urine in bladder leads to SLOW sensory
impulses in sensory pelvic nerve. (pelvic
afferent)

– The Pelvic nerve stimulates the Hypogastric

nerve at the Thoracic level.

Detrusor relaxation (β3) + internal sphincter

constriction(a1)

– The Pons also stimulates the Hypogastic nerve

and inhibits the Pudendal nerve  external
sphincter contraction.

– Thus urine is not expelled.

When Bladder is Full:
– Stretching of bladder  pelvic sensory
nerve sends FAST signals.
– This is directly carried to the PONTINE
MICTURATION CENTRE, bypassing the
thoraco lumbar regions.
– The Pons:
1. Inhibits hypogastric nerve
(sympathetic)
a) No relaxation of detrusor (β3)
b) Relaxation of internal sphincter
(a1)
2. Stimulates Pelvic efferent nerve 
contraction of detrusor (M3)
3. Inhibits Pudental nerve 
relaxation of external sphincter (N)
 Full bladder response

Empty bladder

L L

S S
Neurologic Disorders
Causing
Bladder Disturbances
1.Complete destruction of Cord below T12
Autonomous bladder….
Etiology: Other features:
• Conus lesion: • Anal sphincter and colon are
• Trauma, similarly affected
• Tumour, • Saddle anesthesia
• Necrotizing transverse myelitis, • Abolition of bulbocavernosus
• Hemorrage and anal reflex
• Multiple sclerosis

Features
Cystometrogram: low pressure
Bladder paralyzed for sensory and reflexive and no emptying
activity contractions

No awareness of state of fullness T/T : Catheterization and

anticholinergics
Voluntary initiation of micturition impossible

Detrusor tone lost  bladder distends 

Hypogastric nerve: (Sympathetic)
From T11, T12 and L1, L2……Thoraco-Lumber
Relaxation of bladder muscle & Contraction of
internal urinary sphincter . ……Stores urine

Pudental Nerve: (Somatic)

Voluntary control
External urinary sphincter…contraction
S2,3,4 – antero lateral horns of S2,3,4

Pelvic Nerve: (parasympathetic)

Motor + sensory
From sacral plexus S2,3,4
Motor part = parasympathetic fibers
Contraction of bladder muscle &
Relaxation of internal urinary
sphincter ….. Expels urine
 2. Disease of Sacral Motor Neurons
Atonic Bladder (Motor)
• Structure affected:
– sacral root or peripheral nerve
• Etiology:
– lumbosacral meningomyelocele,
– Tetherd cord syndrome
– Cauda equina: compression by epidural
tumor, prolapsed disc, abscess
-radiculitis from herpes or CMV

• Features:
– LMN paralysis of bladder
– Voluntary initiation of micturition lost
– Overflow incontinence
– Sacral and bladder sensations are intact
Hypogastric nerve: (Sympathetic)
From T11, T12 and L1, L2……Thoraco-Lumber
Relaxation of bladder muscle & Contraction of
internal urinary sphincter . ……Stores urine

Pudental Nerve: (Somatic)

Voluntary control
External urinary sphincter…contraction
S2,3,4 – antero lateral horns of S2,3,4

Pelvic Nerve: (parasympathetic)

Motor (sensory Normal)
From sacral plexus S2,3,4
Motor part = parasympathetic fibers
Contraction of bladder muscle &
Relaxation of internal urinary
sphincter ….. Expels urine
 3. Disease of Sacral Sensory Neurons
Atonic Bladder (Sensory)

• DM & tabes dorsalis

• Motor fibres intact

• Small fibres which carry sensations are

damaged– DM

• Features:
– LMN paralysis of bladder
– Voluntary initiation of micturition lost
– Overflow incontinence
– Sacral and bladder sensations are LOST

• t/t – intermittent self catheterization

Hypogastric nerve: (Sympathetic)
From T11, T12 and L1, L2……Thoraco-Lumber
Relaxation of bladder muscle & Contraction of
internal urinary sphincter . ……Stores urine

Pudental Nerve: (Somatic)

Voluntary control
External urinary sphincter
S2,3,4 – antero lateral horns of S2,3,4

Pelvic Nerve: (parasympathetic)

(Motor Normal) sensory
From sacral plexus S2,3,4
Motor part = parasympathetic fibers
Contraction of bladder muscle &
Relaxation of internal urinary
sphincter ….. Expels urine
 4.Upper spinal cord lesions above T12
Spastic Bladder

Etiology:
– M/C multiple sclerosis,
– trauma
– Transverse myelitis
– Cervical spondylosis
– AVM
– Syringomyelia
– Tropical spastic paraperesis

If cord lesion is sudden onset 

detrusor suffers spinal shock
 distension and overflow
• When spinal shock subsides 
Detrusor over activity (hyperreflexia)
 patient cannot control external
sphincter  incontinence

• Other features:
– Bulbocavernosus and anal reflex
present
– Bladder sensation depends on
extent of involvement of sensory
tracts
– Bladder capacity reduced and
initiation or voluntary micturition
impaired.
Hypogastric nerve: (Sympathetic)
From T11, T12 and L1, L2……Thoraco-Lumber
Relaxation of bladder muscle & Contraction of
internal urinary sphincter . ……Stores urine

Pudental Nerve: (Somatic)

Voluntary control
External urinary sphincter…contraction
S2,3,4 – antero lateral horns of S2,3,4

Pelvic Nerve: (parasympathetic)

Motor + sensory
From sacral plexus S2,3,4
Motor part = parasympathetic fibers
Contraction of bladder muscle &
Relaxation of internal urinary
sphincter ….. Expels urine
 5. Frontal Incontinence
• Confused mental state.

• Ignores desire to void and this

leads to subsequent incontinence

• No warning signs of fullness-

suddenly wet

• Supranuclear type of hyperactivity

and precipitant evacuation

• Lesion in: Posterior part of

superior frontal gyrus and
cingulate gyrus
 6 .Mixed type of neurogenic bladder
• In diseases such as MS, SACD,
tethered cord and syphylitic
meningomyelitis

• Lesions at multiple levels

ie spinal roots, sacral neurons,
their fibers and higher spinal
segments.

• Resultant picture is a
combination of sensory, motor
and spastic type of bladder
TYPE LESION SITE
1. Uninhibited bladder Cortico regulatory tracts

2. Spastic bladder Spinal cord above T12

3. Autonomous bladder Spinal cord below T12

4. Motor Atonic bladder Motor efferents S2 S3 S4

5. Sensory atonic bladder Sensory afferents S2 S3 S4

 Neurogenic bladder

Flaccid Mixed Spastic

- Volume large - Small volume
- Pressure low - Involuntary contraction
- Contraction absent - Bladder detrusor
- Peripheral nerve damage dyssynergia
or lesion at S2-S4 - in lesions above T12
THANK YOU