Neurogenic bladder 2016

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 : reduced bladder capacity, involuntary detrusor contraction, high intravesical & detrusor pressure, spasticity of pelvic striated M., autonomic dysreflexia in cervical cord lesions LMNL : 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 BOO

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 - UDS - 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