The document discusses the anatomy, physiology, and approach to patients with neurogenic bladder. It describes the key components of bladder anatomy including the detrusor muscle, internal and external urethral sphincters. It then explains the neural pathways involved in storage and voiding, including parasympathetic, sympathetic, and somatic control. Various types of neurogenic bladder are defined based on the location of neural lesions. The approach involves assessing presenting symptoms, relevant medical history, and physical exam to determine the type of neurogenic bladder.
2. ANATOMY
CONSISTS OF
• STORAGE ORGAN (MEMBRANOUS SAC COVERED BY
DETRUSSOR MUSCLE)
• OUTLET ( URETHRA AND SPHINCTERS)
DETRUSSOR MUSCLE -
• SMOOTH MUSCLE FIBRES ARRANGED IN SPIRAL,
LONGITUDINAL, AND CIRCULAR BUNDLES
3. URETHRAL SPHINCTERS
• EXTERNAL SPHINCTER (SPHINCTER URETHRAE): –
LOCATION –
• DISTAL INFERIOR END OF BLADDER IN FEMALES
• INFERIOR TO THE PROSTATE (AT THE LEVEL OF THE
MEMBRANOUS URETHRA) IN MALES
• SECONDARY SPHINCTER TO CONTROL FLOW OF URINE
THROUGH THE URETHRA
• SKELETAL MUSCLE
• VOLUNTARY CONTROL OF THE SOMATIC NERVOUS
SYSTEM.
• INNERVATED BY PUDENDAL NERVES
4. INTERNAL SPHINCTER MUSCLE OF URETHRA: –
LOCATION-
• JUNCTION OF PROXIMAL END OF URETHRA WITH
INFERIOR END OF BLADDER
• CONTINUATION OF DETRUSSOR MUSCLE
• SMOOTH MUSCLE
• UNDER AUTONOMIC CONTROL
• PRIMARY MUSCLE FOR PROHIBITING URINE
RELEASE
6. URETHRA CONSISTS OF
• INNER BAND OF LONGITUDINAL SMOOTH
MUSCLE
• MIDDLE BAND OF CIRCULAR SMOOTH
MUSCLE
• EXTERNAL BAND OF STRIATED MUSCLE
7. • PARASYMPATHETIC:
• CENTRE: S2-S4 IN INTERMEDIOLATERAL COLUMN
• SUPPLY THROUGH: PELVIC SPLANCHNIC NERVES
• END IN : GANGLIA IN BLADDER WALL
• NEUROTRANSMITTER : ACH VIA M2, M3
• FUNCTION: CHOLINERGIC TRANSMISSION IS THE
MAJOR EXCITATORY MECHANISM
• M2 AND M3 ON DETRUSSOR SMOOTH MUSCLE
INITIATES BLADDER DETRUSSOR CONTRACTION
AND INTERNAL SPHINCTER RELAXATION
8. • NON ADRENERGIC, NON-CHOLINERGIC
TRANSMITTERS-
• NON-CHOLINERGIC EXCITATORY
TRANSMISSION MEDIATED BY ATP ON P2X
PURINERGIC RECEPTORS IN DETRUSSOR
MUSCLE.
• INHIBITORY INPUT MEDIATED BY NITRIC
OXIDE (NO) ON URETHRAL MUSCLES
9.
10. • SYMPATHETIC:
• CENTRE: T11-L2 INTERMEDIOLATERAL COLUMN
• SUPPLY THROUGH:
• SYMPATHETIC CHAIN GANGLIA-PREVERTEBRAL
GANGLIA-HYPOGASTRIC AND PELVIC PLEXUS –
INFERIOR MESENTRIC GANGLION –POST
GANGLIONIC FIBRES
FUNCTION:
• VIA Β3-ADRENERGIC RECEPTORS -INHIBITION AND
RELAXATION OF THE DETRUSSOR MUSCLE.
• VIA ALPHA1 RECEPTORS CAUSES CONTRACTION
OF INTERNAL SPHINCTER
• FACILITATE BLADDER STORAGE AND CONTINENCE
15. AFFERENT PATHWAY-
DETRUSSOR SENSATIONS-
• PELVIC AND HYPOGASTRIC NERVES
BLADDER NECK AND THE URETHRA
• PUDENDAL AND HYPOGASTRIC NERVES
• MYELINATED (AΔ) AND UNMYELINATED (C) AXONS.
• INFORMATION ABOUT BLADDER FILLING.
• AΔ-FIBRES - PASSIVE DISTENSION AND ACTIVE
CONTRACTION
16. • C-FIBRES(‘SILENT’ C-FIBRES) -NOXIOUS STIMULI
SUCH AS CHEMICAL IRRITATION OR COOLING
• CELL BODIES LOCATED IN DORSAL ROOT
GANGLIA (DRG) AT THE LEVEL OF S2–S4 AND
T11–L2 SPINAL SEGMENTS.
• SYNAPSE WITH INTERNEURONS MEDIATING
SPINAL REFLEX AND SPINAL-TRACT NEURONS
PROJECTING TO HIGHER BRAIN CENTRES
INVOLVED IN BLADDER CONTROL
17. SENSORY ROLE OF NON NEURONAL CELLS -
• THE UROTHELIUM ENGAGES IN RECIPROCAL
CHEMICAL COMMUNICATION WITH NERVES
IN BLADDER WALL
• EXPRESSION OF NICOTINIC,MUSCARINIC
,ADRENERGIC AND TRANSIENT RECEPTOR
POTENTIAL VANILLOID RECEPTORS(TRPV1)
18. • THE SUBUROTHELIAL LAYER OF
MYOFIBROBLASTS ( INTERSTITIAL CELLS) LIE
IN CLOSE PROXIMITY TO NERVES LINKED BY
GAP JUNCTIONS
• TOGETHER WITH AFFERENT NERVES, THE
UROTHELIUM AND SMOOTH MUSCLE,
COLLECTIVELY HAVE THE PROPERTIES TO ACT
AS A STRETCH-RECEPTOR ORGAN
19.
20.
21.
22. CNS CONTROL
• PREGANGLIONIC NEURONS(PGNS) PRESENT IN
INTERMEDIATE GREY MATTER (LAMINAE V-
VII) OF SPINAL CORD
SACRAL(PARASYMPATHETIC) AND LUMBAR
SEGMENTS(SYMPATHETIC)
23. • THE SOMATIC MOTOR NEURONS LOCATED IN
THE VENTRAL HORN ( LAMINA IX ) IN ONUF’S
NUCLEUS,
• EXTENSIVE SYSTEM OF LONGITUDINAL
DENDRITES THAT TRAVEL WITHIN ONUF’S
NUCLEUS CONTROL THE EXTERNAL URETHRAL
SPHINCTER .
24.
25. HIGHER CENTRES
SPECIFIC FOR MICTURITION-
• BARRINGTON’S NUCLEUS (PONTINE
MICTURITION CENTRE /M REGION ) LOCATED
IN DORSOMEDIAL PONS
• PERIAQUEDUCTAL GREY ( PAG )
• CELL GROUPS IN CAUDAL AND PREOPTIC
HYPOTHALAMUS
• MEDIAL FRONTAL CORTEX
26. • NON SPECIFIC ( LEVEL SETTING MECHANISM)
WITH DIFFUSE SPINAL PROJECTIONS-
• SEROTONERGIC NEURONS OF MEDULLARY
RAPHE NUCLEI
• NORADRENERGIC NEURONS OF LOCUS
COERULUS
• NORADRENERGIC A5 CELL GROUP IN BRAIN
STEM
27.
28. • INTERNEURONS IN SPINAL CORD PROJECT TO
THE PAG
• NEURONS IN PMC RECEIVE INPUTS FROM
THE PAG AND ANTERIOR AND CAUDAL HYPO-
THALAMUS.
• PMC SENDS DESCENDING SIGNALS TO
PARASYMPATHETIC NUCLEUS OF SPINAL CORD
( EXCITATORY)
29. REGULATION OF FILLING AND VOIDING
• SIMPLE ON – OFF SWITCHING CIRCUITS
BLADDER FILLING AND GUARDING REFLEX-
• PARASYMPATHETIC INNERVATION OF DETRUSSOR IS
INHIBITED
• URETHRA- ACTIVATED, PREVENTING INVOLUNTARY
BLADDER EMPTYING- “GUARDING REFLEX”
30. • ORGANIZED BY INTERNEURONAL CIRCUITRY IN THE
SPINAL CORD
• INPUT FROM LATERAL PONS,ALSO KNOWN AS THE ‘L-
REGION’ OR ‘PONTINE STORAGE CENTRE’, ROLE IN
INVOLUNTARY SPHINCTER CONTROL
31. • SPINOBULBOSPINAL VOIDING-REFLEX PATHWAY
FUNCTIONS AS A SWITCH EITHER IN COMPLETELY ‘OFF’
MODE (STORAGE) OR MAXIMALLY ‘ON’ MODE (VOIDING)
• BLADDER FILLING --PARASYMPATHETIC TURNED OFF BUT
AT CRITICAL LEVEL OF BLADDER DISTENSION THE
AFFERENT ACTIVITY --SWITCHES THE PATHWAY TO
MAXIMAL ACTIVITY
32.
33. Voluntary control of bladder and urethra has
two important aspects
1-registration of bladder filling sensations and
2-manipulation of the firing of the voiding reflex
PAG has pivotal role in both.Acts as relay station
34. • Sends and receives projection from higher
brain centres
• controls the primary input to the PMC
• higher brain centres (particularly the
prefrontal cortex- tonic suppression of
voiding) suppresses excitatory signal to PMC --
prevent voiding or incontinence
35. • Anterior cingulate cortex – determines
attention to signals coming from bladder
afferents and reaction to it by deciding to
void or by recruiting mechanisms that allow
voiding to be postponed
• Frontal lobes -determine the
appropriateness of micturition
36. NEUROTRANSMITTERS
• Glutamic acid, acting on NMDA (N-methyl-D-
Aspartate) (excitatory)
• Inhibitory amino acids (GABA,glycine and
enkephalins) exert tonic inhibitory control in
the PMC
37.
38.
39. NEUROGENIC BLADDER
• BLADDER DYSFUNCTION CAUSED AS A RESULT OF
NEUROLOGICAL DISORDER IS REFERRED TO AS
NEUROGENIC BLADDER
TYPES ARE-
1-UNINHIBITED BLADDER
2-REFLEX BLADDER
3-AUTONOMOUS BLADDER
4-MOTOR PARALYTIC BLADDER
5-SENSORY PARALYTIC BLADDER
40. NEUROGENIC BLADDER
TYPES-
• UNINHIBITED BLADDER –
• LOSS OF CORTICAL INHIBITION OF REFLEX
VOIDING
• BLADDER TONE REMAINS NORMAL
• BLADDER DISTENSION CAUSES CONTRACTION IN
RESPONSE TO STRETCH REFLEX
• FREQUENCY ,URGENCY ,AND INCONTINENCE
THAT ARE NOT ASSOCIATED WITH DYSURIA
• BLADDER SENSATION USUALLY NORMAL
• NO RESIDUAL URINE
41. UNINHIBITED BLADDER FOUND IN –
• CEREBROVASCULAR ACCIDENT( FRONTAL
LOBE)
• BRAIN TUMORS
• HEAD INJURY
• MULTIPLE SCLEROSIS
• PARKINSON’S DISEASE
42. • REFLEX NEUROGENIC BLADDER
• ALSO CALLED SPASTIC OR HYPERREFLEXIC BLADDER
• LESIONS ABOVE SACRAL CORD AND BELOW PONTINE
MICTURITION CENTRE
• UMN CUT OFF LMN INTACT
• DETRUSOR SPHINCTER SYNERGIA LOST RESULTS IN
OBSTRUCTED VOIDING,INTERRUPTED URINARY
STREAM,INCOMPLETE BLADDER EMPTYING
• BLADDER CAPACITY SMALL AND MICTURITION REFLEX
AND INVOLUNTARY
• RESIDUAL URINE VOLUME VARIABLE
43. • CONTRACTIONS OCCUR SPONTANEOUSLY OR
PROVOKED BY COUGHING/CHANGING
POSTURE ( STRESS INCONTINENCE)
• DETRUSOR OVERACTIVITY- URINARY
FREQUENCY ,URINARY URGENCY,URGE
INCONTINENCE
44. FOUND IN -
• SEVERE MYELOPATHY
• EXTENSIVE BRAIN LESIONS
• ASSOCIATED WITH QUADRIPLEGIA/PARAPLEGIA
AND ADVANCED CASES OF MULTIPLE SCLEROSIS
• INTERRUPTION OF BOTH DESCENDING
AUTONOMIC TRACTS AND ASCENDING SENSORY
PATHWAYS ABOVE THE SACRAL SEGMENTS OF
THE CORD
45. AUTONOMOUS BLADDER/FLACCID BLADDER –
• NO EXTERNAL INNERVATION
• DESTRUCTION OF PARASYMPATHETIC SUPPLY
• ABSENCE OF SENSATION
• NO REFLEX OR VOLUNTARY CONTROL OF
BLADDER
• CONTRACTION AS A RESULT OF STIMULATION OF
INTRINSIC NEURAL PLEXUSES WITHIN BLADDER
WALL
• LARGE AMOUNT OF RESIDUAL URINE
46. • URINARY RETENTION
• OVERFLOW INCONTINENCE
• INCREASED RESIDUAL URINE
• SADDLE ANESTHESIA
• LOSS OF BULBOCAVERNOUS AND
SUPERFICIAL ANAL REFLEX
47. CAUSED BY
• NEOPLASTIC,TRAUMATIC ,INFLAMMATORY
LESIONS OF SPINAL CORD BELOW T12 LEVEL
• CONGENITAL ANOMALIES LIKE SPINA BIFIDA
• SACRAL MYELOMENINGOCELE AND TUMORS
OF CONUS MEDULLARIS ,CAUDA EQUINA
48. MOTOR PARALYTIC BLADDER –
• MOTOR NERVE SUPPLY IS INTERRUPTED
• BLADDER DISTENDS AND DECOMPENSATES
• SENSATION NORMAL
• RESIDUAL URINE AND BLADDER CAPACITY
VARIES
• PAINFUL URINARY RETENTION /INCOMPLETE
BLADDER EMPTYING
50. SENSORY PARALYTIC BLADDER –
• SENSATION IS ABSENT AND NO DESIRE TO VOID
• DISTENTION,DRIBBLING,AND DIFFICULTY BOTH IN
INITIATING MICTURITION AND IN EMPTYING
BLADDER
• LARGE AMOUNT OF RESIDUAL URINE
• URINARY RETENTION,OVERFLOW
INCONTINENCE,UTI
• PATIENT CAN VOID ( MOTOR INTACT) BUT NO
DESIRE TO VOID
51. CAUSED BY –
• INVOLVEMENT OF POSTERIOR
ROOTS/POSTERIOR ROOT GANGLIA OF THE
SACRAL NERVES /THE POSTERIOR COLUMNS
OF SPINAL CORD
• OCCURS IN TABES
DORSALIS,SYRINGOMYELIA,AND DIABETES
MELLITUS
52. SPINAL CORD INJURY (SCI)
• INITIALLY AREFLEXIC BLADDER AND COMPLETE
URINARY RETENTION THEN
• AUTOMATIC MICTURITION AND NEUROGENIC
DETRUSOR OVERACTIVITY (NDO) MEDIATED BY
SPINAL REFLEX PATHWAYS.
• INEFFICIENT VOIDING OWING TO
SIMULTANEOUS CONTRACTIONS OF THE
BLADDER AND THE URETHRAL SPHINCTER
(DETRUSOR–SPHINCTER DYSSYNERGIA)
53.
54.
55. APPROACH TO THE PATIENT
PRESENTING SYMPTOMS-
• URGENCY(SUDDEN, COMPELLING URGE TO URINATE)
• HESITANCY( DECREASED FORCE OF URINE STREAM,
WITH DIFFICULTY IN BEGINNING THE FLOW)
• FREQUENCY OF MICTURITION
• STRESS INCONTINENCE(UNINTENTIONAL LOSS OF
URINE ON PHYSICAL ACTIVITY)
• URGE INCONTINENCE(INVOLUNTARY LOSS WHEN
PERSON HAS DESIRE TO URINATE)
• URINARY RETENTION(INABILITY TO EMPTY THE
BLADDER COMPLETELY)
58. EXAMINATION
• DETAILED GENERAL AND NEUROLOGICAL
EXAMINATION
• WHETHER PATIENT IS CATHETERISED /
UNCATHETERISED
• ASSESSMENT OF HIGHER MENTAL FUNCTION
• ASSESSMENT OF MOTOR FUNCTION
• ASSESSMENT OF SENSORY SYSTEM
• CHARACTERISATION INTO UPPER MOTOR
NEURON INVOLVEMENT VS LOWER MOTOR
NEURON INVOLVEMENT
59. • WHEN PATIENT PRESENTS WITH
URGENCY/FREQUENCY/INCONTINENCE –
SIGNS OF UMN BLADDER – LOOK FOR BRISK
REFLEXES - SPASTICITY- EXAGERRATED DEEP
TENDON REFLEXES – PLANTARS EXTENSOR-
CAN BE DUE TO CORTICAL LESION ( WITH
HEMIPARESIS/BEHAVIOURAL SYMPTOMS) OR
LESIONS OF SPINAL CORD ABOVE S2-S4–
FURTHER BRAIN AND CORD IMAGING STUDIES
60. • WHEN PATIENT PRESENTS WITH
DISTENTION/RETENTION – SIGNS OF LMN
BLADDER – LOOK FOR REDUCED DEEP
TENDON REFLEXES- FLACCIDITY –OTHER
SENSORY INVOLVEMENT – CAN BE LESION OF
SPINAL CORD AT LEVEL OF S2-S4 – IMAGING
STUDIES AND FURTHER WORK UP
61. WORK UP
LABORATORY STUDIES-
• URINALYSIS AND URINE CULTURE – URINARY
TRACT INFECTION - IRRITATIVE VOIDING
SYMPTOMS AND URGE INCONTINENCE.
• URINE CYTOLOGY – IRRITATIVE VOIDING
SYMPTOMS OUT OF PROPORTION TO THE
OVERALL CLINICAL PICTURE AND/OR HEMATURIA
• RENAL FUNCTION STUDIES – BLOOD UREA
NITROGEN (BUN) AND CREATININE
62. • VOIDING DIARY-DAILY RECORD OF PATIENT'S
BLADDER ACTIVITY
• OBJECTIVE DOCUMENTATION OF PATIENT'S
VOIDING PATTERN, INCONTINENT
EPISODES,INCITING EVENTS ASSOCIATED
WITH URINARY INCONTINENCE.
64. POSTVOID RESIDUAL BLADDER VOLUME
• POSTVOID RESIDUAL URINE (PVR)
• IF THE PVR IS HIGH- POORLY CONTRACTILE
BLADDER / BLADDER OUTLET OBSTRUCTION.
65. UROFLOW RATE (volume of urine voided per
unit time)
• Useful in Bladder outlet obstruction,detrusor
weakness
• Alone cannot distinguish an obstruction from
detrusor weakness
66. Filling cystometrogram
• A filling cystometrogram (CMG) assesses the
bladder capacity, compliance, and the
presence of phasic contractions (detrusor
instability). Most commonly, liquid filling
medium is used.
• An average adult bladder holds approximately
50-500 mL of urine. Provocative manoeuvres
help to unveil bladder instability.
67.
68. Voiding cystometrogram
• Pressure-flow study simultaneously records
the voiding detrussor pressure and the rate of
urinary flow. This is the only test able to
assess bladder contractility and the extent of
a bladder outlet obstruction.
• Pressure-flow studies can be combined with
voiding cystogram and videourodynamic study
for complicated cases of incontinence.
69. Cystogram
• A static cystogram - confirm the presence of
cystocele, .The presence of a vesicovaginal fistula
or bladder diverticulum also may be noted.
• A voiding cystogram can assess bladder neck and
urethral function (internal and external
sphincter) during filling and voiding phases. A
voiding cystogram can identify a urethral
diverticulum, urethral obstruction, and
vesicoureteral reflux.
70.
71. Electromyography
• EMG – determines if voiding is coordinated or
uncoordinate
• EMG allows accurate diagnosis of the detrusor
sphincter dyssynergia that is common in
spinal cord injuries.
72. Cystoscopy
• bladder lesions (eg, bladder cancer, bladder
stone) that would remain undiagnosed by
urodynamics alone.
• Cystoscopy is indicated for patients
complaining of persistent irritative voiding
symptoms or hematuria. (cystitis, stone, and
tumor)
73.
74. Videourodynamics
• Videourodynamics is the criterion standard for
evaluation of a patient with incontinence.
Videourodynamics combines the radiographic
findings of voiding cystourethrogram (VCUG) and
multichannel urodynamics.
• Videourodynamics enables documentation of
lower urinary tract anatomy, such as
vesicoureteral reflux and bladder diverticulum, as
well as the functional pressure-flow relationship
between the bladder and the urethra.
75.
76. TREATMENT AND MANAGEMENT
• Overflow incontinence -emptying the bladder
with a catheter
• Stress incontinence –procedures increasing
urethral outlet resistance, include:
• Periurethral bulking therapy
• Sling procedures
• Artificial urinary sphincter
77. Urge incontinence- behavioral modification
Surgical care for urge incontinence include the
following:
• Sacral neuromodulation
• Botulinum toxin injections
79. • Anticholinergic drugs are the first-line
pharmacologic therapy in urge incontinence.
They are effective in treating urge
incontinence because they inhibit involuntary
bladder contractions.
80. • Solifenacin succinate
• Darifenacin
• Tolterodine L-tartrate for overactive bladder
• Beta-3 adrenergic receptor - Mirabegron was
approved in 2012 by the US Food and Drug
Administration (FDA) for the treatment of
overactive bladder.
81. Treatment contd.
• Vanilloids - The use of intravesical vanilloids in
human NDO is aimed at desensitizing bladder
afferents; prior instillation of a local
anaesthetic reduced the capsaicin-induced
irritation without blocking its effect(action on
TRPV1) not approved
• Botulinum neurotoxin A is effective in patients
of intractable NDO with spinal aetiology
82. BIBLIOGRAPHY
• The neural control of micturition by Clare J.
Fowler, Derek Griffiths, and William C. de
Groat, Nat Rev Neurosci. 2008 June ; 9(6):
453–466. doi:10.1038/nrn2401
• 7th edition DEJONG’S THE Neurological
Examination
• GUYTON AND HALLS textbook of physiology
11th edition
