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NEUROGENIC BLADDER Dr. sh. Alaie Neurologist. NEUROGENIC BLADDER Definition Is a malfunctioning bladder due to any type of neurologic disorder.

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Presentation on theme: "NEUROGENIC BLADDER Dr. sh. Alaie Neurologist. NEUROGENIC BLADDER Definition Is a malfunctioning bladder due to any type of neurologic disorder."— Presentation transcript:

1 NEUROGENIC BLADDER Dr. sh. Alaie Neurologist

2 NEUROGENIC BLADDER Definition Is a malfunctioning bladder due to any type of neurologic disorder.

3 NEUROGENIC BLADDER Voiding: 1)Filling = storage :bladder acts as low pressure receptacle 1)Filling = storage :bladder acts as low pressure receptacle Sphincter high resistance Sphincter high resistance 2)Voiding = Emptying :Bladder contracts Sphincter opens Sphincter opens Both Should be done in Normal Pressure

4 Normal Voiding:1)Normal Detrusor 4-8 /day 2)Normal Sphincter 3)Synergy 3)Synergy 4)Voluntrily 4)Voluntrily Normal Pressure

5 Anatomy BRAIN Master control of the entire Urinary system Medial aspect of Precentral gyrus Inhibitory signal to detrussor until a suitable time &place Injury :1)Unawareness to entire voiding process 2) Spastic bladder 2) Spastic bladder

6 ANATOMY PONS PMC:coordinating Bladder &Urethral Sphincter =Synergy Facilitate Urination 1)detrussur contraction 2)sphincter relaxation 2)sphincter relaxation Ingury :1)Spastic bladder 2)DSD 2)DSD

7 ANATOMY SPINAL CORD Supra sacral:intermediary between PMC &Sacral cord Lat.CorticoSpinal &ReticuluSpinal Lat.CorticoSpinal &ReticuluSpinal Injury: 1)Spastic Bladder 2)DSD 2)DSD

8 ANATOMY Sacral cord Primitive Voiding Center for Reflex Arc S2,S3,S4 Injury :Detrusor Areflexia

9 ANATOMY Peripheral nerves 1)Sympathetic :bladder & internal sphincter 2)parasympathetic: bladder 3)Somatic:Onuf neucleus: Ex.sphincter Injury:Areflexic bladder:sensory /motor

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13 Physiology 1)Filling accumulation of urine while the pressure is low accumulation of urine while the pressure is low If Pv >Pu : Urine Leackage If Pv >Pu : Urine Leackage Reflux Reflux Sympathetic :1)inhibit parasympathetic 2)relaxation &expansion of detrussor 2)relaxation &expansion of detrussor 3)close the bladder neck 3)close the bladder neck Pudendal : contraction of the Ex.Sphincter Pu>Pv Pu>Pv

14 NEUROGENIC BLADDER Physiology 2)Emptying: Bladder filling to capacity: stretch receptors:pelvic nerve Bladder filling to capacity: stretch receptors:pelvic nerve & Hypogastric nerve & Hypogastric nerve Sacral cord:voiding Sacral cord:voiding After 3-4 Yr old:sympathetic : relaxes in. sphincter Ps: detrusor contraction Ps: detrusor contraction Pudendal: relaxation of ex.sphincter Pudendal: relaxation of ex.sphincter Pv>Pu: voiding

15 TYPES of NEUROGENIC BLADDER 1)Detrusor :Overactive:Impaired filling Underactive:Impaired Emptying 2)Sphincter:Overavtive:Impaired Emptying Underactive:Leackage Underactive:Leackage 3)Loss of coordination:Impaired Emptying

16 Types of Bladder Dysfunction 1- Failure of Storage (Detrusor Hyperreflexia) 2- Failure of Emptying a) Detrusor Hypoactivity a) Detrusor Hypoactivity b) Detrusor – Sphincter dyssynergia=DSD b) Detrusor – Sphincter dyssynergia=DSD 3- Mixed type All can be dangerous to upper tract

17 SYMPTOMS Storage Failure a) frequency / nocturia Urination>8 times a day Urination>8 times a day or or > 2 times over night > 2 times over night b) urgency: extreme desire to void c) Incontinency : urge in continence d) hesitancy,intermittency,straining to void,terminal dribbling.

18 SYMPTOMS Emptying Failure a) feeling of incomplete emptying b) frequency, urgency c) incontinency (overflow) d) hesitancy,intermittency,straining to void,terminal dribbling.

19 Symptoms are the same in all types! 70% mismanagement based on history alone!

20 COMPLICATIONS 1)rise in Pv:REFLUX:Hydroureter/Hydronephrosis 2)Retention:Frequent UTI (+reflux:Pyelonephritis) 3)Urinary stones 4)Impaired social & personal life

21 NEUROGENIC BLADDER NEUROLOGIC DISEASES

22 Voiding dysfunction is important in multiple sclerosis Because of: 1- Frequency (up to 90% of patients) 2- Serious complications: 55% → 5% 3- Impairment of social &personal life & sexual activity 4- Could be successfully managed 5- Social & cultural aspects

23 MS SYMTOMS - Voiding dysfunction may be the sole initial complaint ( 2.3% ). - Or part of the presenting symptoms ( 10% )

24 NEUROLOGIC DISEASES CVA Cerebral Shock:Det.Areflexia:Retention Afew weeks/months later:Det.Hyperreflexia

25 NEUROLOGIC DISEASES MSA Urinary symptoms are common Come early (60% before or associated with other symptoms other symptoms Even 4yr before diagnosis

26 AUTONOMIC DYSREFLEXIA Is a lethal emergency Acute massive disorderd autonomic(S) response to specific stimuli in SC injury above T6- T8 More common in cervical After shock period but up to yrs after injury Stimuli below level of the lesion

27 AUTONOMIC DYSREFLEXIA Headache/HTN(even ICH or sezure) Flashing of face,body above the lesion Sweating Usually bradycardia,maybe tachycardia/arrhytmia Stimulus from: bladder/rectum: distention,manipulation GI/bone FX /sexual activity /bed sore

28 AUTONOMIC DYSREFLEXIA Endoscopic procedure: spinal/ general anesthesia SL niphedipin/ oral niphedipin/ trazocin Significant rise in BP without other symptoms

29 Diagnosis 1- History: ask strictly about voiding symptoms and feeling of incomplete emptying 2- exam: pelvic exam Sacral reflex exam Sacral reflex exam Signs of spinal cord involvment Signs of spinal cord involvment 3- Lab : U/A, U/C, BUN, Cr

30 Diagnosis 4- Imaging : sonography a) Anatomy a) Anatomy b) Residue ( up to 100 CC ) b) Residue ( up to 100 CC )

31 Diagnosis 5- In – out catheter method: a) Well hydrated for 48 hr b) Drink 2 glasses of water, before exam c) First desire to void = capacity(300 – 500cc) d) Measure residue after voiding

32 Diagnosis Urodynamic study A general term for the study of the storage and voiding function

33 Diagnosis Urodynamic study a) Bladder eapacity (300 – 500cc) b) Detrussor pressure, Max 10 Cm H2o c) DSD d) Detressor instability e) L.P.P (leak point pressure)

34 Diagnosis Urodynamic study Indication - urologic problems: Contraversy - Neurologic problems: All with neurogenic bladder should undergo urodynamic study to characterize the nature of the problem and to determine prognosis and management. All with neurogenic bladder should undergo urodynamic study to characterize the nature of the problem and to determine prognosis and management.

35 MANAGEMENT GOALS 1- upper tract preservation 2- absence or control of infection 3- adequate storage at low I.V.P 4- adequate emptying at low I.V.P 5- adequate control 6- no catheter 7- social acceptability

36 MANAGEMENT STORAGE FAILURE 1) Non surgical: a) Non pharmacologic a) Non pharmacologic b) Pharmacologic b) Pharmacologic 2) surgical

37 MANAGEMENT STORAGE FAILURE NON PHARMACOLOGIC 1- voiding diary: 3-5 days a) Total 24hr urinary output a) Total 24hr urinary output b) Number of voids b) Number of voids c) Voiding interval c) Voiding interval d) Diurnal distribution d) Diurnal distribution e) Timing and triggers for incontinence e) Timing and triggers for incontinence

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39 MANAGEMENT STORAGE FAILURE Bladder training program : 1- lengthen the amount of time between voiding. 2- increase the amount of urine the bladder can hold. 3- improves the control over the urge. 4- patient gives voiding program to his bladder.

40 1- Kegel exercise. 2- delaying urination,5 min → 10 min Walk instead of running at urge Walk instead of running at urge Relaxation techniques Relaxation techniques 3- sheduled bathroom trips: Every 1hr initially. 4- irritating factors: Alcohol, caffeine, acidic foods (tomatoes, grapefruit) 5- change of temperature. 6- bio feedback and acupuncture. MANAGEMENT STORAGE FAILURE BLADDER TRAINING PROGRAM

41 1- anti cholinergics: a) Tolterodine 1-2 mg/bid a) Tolterodine 1-2 mg/bid b) Oxybutinine 5 mg/TDS b) Oxybutinine 5 mg/TDS 2- TCA: imipramin 25 mg/day 3- desmopressin, spray, 1-2 puff 4- Ca antagonists/potassium channel openers/prostaglandin inhibitors … ?? MANAGEMENT STORAGE FAILURE pharmacologic

42 Warning!!!Anticholinergic: 1- check for residue before 2- check for pharmacologic retention after MANAGEMENT STORAGE FAILURE pharmacologic

43 MANAGEMENT STORAGE FAILURE SURGICAL 1- intravesical injection of botolinum toxin oxybutinin capsaicin? 2- electrical stimualtion 3- denervation techniques 4- augmentation cystoplasty

44 MANAGEMENT EMPTYING FAILURE 1- Non surgical a) Non pharmacologic a) Non pharmacologic b) Pharmacologic b) Pharmacologic 2- surgical

45 MANAGEMENT EMPTYING FAILURE NON PHARMACOLOGIC 1- Valsalva – crede manuver: Increase I.V.P 2- trigger void 3- clean intermittent catheterization( CIC )

46 MANAGEMENT EMPTYING FAILURE NON PHARMACOLOGIC CIC 1- safe 2- extremely effective 3- most practical means of attaining catheter - free state 4- preserves the independence 5- protects the kidneys 6- prevents incontinence 7- decrease infections 8- non expensive

47 MANAGEMENT EMPTYING FAILURE NON PHARMACOLOGIC CIC 9- can be used in all types of dysfunction 10- decrease residue after a while - If the patient can eat or write can do CIC Cornerstone of treatment

48 MANAGEMENT EMPTYING FAILURE PHARMACOLOGIC 1- bethanechol? 2- baclofen 3- prosteglandin??

49 MANAGEMENT EMPTYING FAILURE SURGICAL 1- electrical stimulation 2- bladder myoplsty 3- reduction cytoplasty


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