Neurogenic bladder

Neurogenic Bladder and its
Management
Dr . Faheem Ul Hassan
Dr. Gowhar Mufti

Introduction
• The normal function of the urinary bladder
is to
– store and expel urine in a coordinated,
controlled fashion.
• This coordinated activity is regulated by
central and peripheral nervous systems.

Introduction
• Three mixed sensory and motor nerves
innervate the lower urinary tract.
• hypogastric
• pelvic and
• pudendal nerves

Introduction
• The hypogastric nerve carries
sympathetic autonomic innervation,
• The pelvic nerve carries the
parasympathetic autonomic innervation,
• Pudendal nerve carries the somatic
innervation to the lower urinary tract.

Introduction (voiding)
Intense bladder afferent Firing through
pelvic nerve to PMC
PSO to Detrusor and urethral smooth
muscles
Inhibits pudendal outflow to EUS
Detrusor contraction and EUS
relaxation
Micturition

Introduction
• Neurogenic bladder is a term applied to a
malfunctioning urinary bladder due to
neurologic dysfunction.

Uninhibited bladder
• lesions above the pontine micturition center
produce an uninhibited bladder
• Due to reduced cortical inhibition of PMC
there is
– Reduced awareness of bladder
fullness and a
– Low capacity bladder

DSD
• lesions between the pontine
micturition center and sacral
spinal cord producing an upper
motor neuron bladder
• Upper motor neuron neurogenic
bladder dysfunction is
characterized by detrusor-
sphincter dyssynergia (DSD),

DSD
• In DSD simultaneous detrusor
and urinary sphincter contractions
occur
• The spinal cord damage renders
the bladder and sphincters
spastic, especially if lesions are
above the T10 level

DSD
• The bladder capacity is usually
reduced due to the high detrusor
tonus (neurogenic detrusor
overactivity, or detrusor
hyperreflexia)
• If detrusor pressure exceeds EUS
pressure in the proximal urethra,
then incontinence may occur.

Mixed type A neurogenic Bladder
• In the mixed type A neurogenic
bladder detrusor nucleus
damage renders the detrusor
flaccid (detrusor areflexia),
• The pudendal nucleus is intact
& spastic producing a
hypertonic EUS.

Mixed type A neurogenic Bladder
• The bladder is large and has low
pressure
• spastic external sphincter produces
urinary retention.
• The detrusor pressure is low so upper
urinary tract damage from
vesicoureteral reflux does not occur,
and incontinence is uncommon.

Mixed type B neurogenic Bladder
• Flaccid EUS due to the
pudendal nucleus lesion
• Spastic bladder due to the
disinhibited detrusor nucleus.
• bladder capacity is low but
vesicular pressures are
usually not elevated
• This leads to problems with
incontinence, however.

LMN neurogenic Bladder
• the sacral MCs or related
peripheral nerves are damaged
• sympathetic outflow to the lower
urinary tract is intact
• detrusor tone is low (detrusor
areflexia) and internal urinary
sphincter innervation is intact.

Detrusor hyperactivity with impaired
bladder contractility DHIC
• first described in nursing home residents
• there is frequent but weak involuntary detrusor
contractions causing incontinence & incomplete
bladder emptying
• There is slow bladder contraction velocity, and
elevated urinary residual volume

Types
Detrusor Sphincter
Over activity Over activity
Inactivity Over activity
Over activity Inactivity
Inactivity Inactivity

• The evaluation begins with
• both day and nighttime voiding patterns.
• Voiding symptoms can be irritative or
obstructive.
History and Physical Examination

• Irritative
• Dysuria
• Urgency
• Frequency
• Obstructive
• Retention
• Hesitancy
• Staccato voiding
• Straining
• Feeling of incomplete voiding

• Whether the child has had a urinary tract
infection (UTI)
– UTI with fever (pyelonephritis)
– UTI without fever (cystitis)
• Constipation is noted
• lower extremity weakness or change in
sensation are recorded.

• Physical examination should include
evaluation of the
– abdomen,
– back,
– genitalia, and
– lower extremities.

• Abdominal examination should include
palpation for fecaloma and distended
bladder

• Examination of the back is essential and
should include
• Cutaneous findings of a hair patch or
• A dimple over the lumbosacral spine
• Asymmetric gluteal crease
• Patients who possess any of these cutaneous
findings should undergo a MRI of the
lumbosacral spine.

• Examination of the male genitalia should
include palpation along the entire urethra.
• Induration may be a sign of urethral
inflammation and stricture.
• Position of the testicles should be noted
(cryptorchidism is common in
myelodysplasia.)

• The anus should be examined for Tone
and Position.
• Finally, any deficits in lower extremity
reflexes or motor strength should be
noted

• A urinalysis should be obtained
• The presence of red cells, white cells,
glucose, and protein should be noted.
• A low specific gravity may reflect poor
concentrating ability secondary to renal
dysfunction.

Radiographic and Dynamic
Assessment of Bladder
Dysfunction

BLADDER ULTRASOUND
• The bladder ultrasound can provide many
clues like
• Thickened bladder wall (UTI & BOO)
• Calculation of PVRU for assessing whether
the patient can efficiently empty the
bladder.
Bladder Ultrasound

VOIDING
CYSTOURETHROGRAPHY
• MCU provides information about
– Bladder neck, and urethral anatomy
– Trabeculations
– Diverticuli
– Vesicoureteral reflux is a common finding in both
anatomic and functional causes of bladder
dysfunction
VCUG

• The urodynamic evaluation provides indepth functional
information regarding the bladder.
• It establishes
• bladder capacity,
• bladder filling pressures,
• patient’s perception of bladder filling, and the ability to
empty efficiently and in proper coordination with EUS
UDS

• Neurologic modulation combined with the
viscoelastic properties of the healthy
detrusor muscle allow the bladder to maintain
fairly constant pressure throughout the filling
phase.
• As a result, intravesical pressures in the
healthy bladder remain at or below 5 to 10 cm
H2O pressure
UDS

• compliance can be adversely affected
(mechanical obstruction or by U & LMN
lesions) resulting in increased intravesical
storage pressures.
• Storage pressures higher than 40 cm
H2O, lead to renal injury.
UDS

Neuropathic Causes of
Bladder Dysfunction

Neuropathic bladder secondary
to myelodysplasia
• Myelodysplasia, defined as abnormal development
of the spinal canal and spinal cord
• It is the most common etiology of NB in children.
• Workup is done in the neonatal period, usually
after the surgical closure of the defect.
• workup will include RBUS, urodynamic study &
MCU

• This baseline information can identify
children at risk for urinary tract
deterioration (poor compliant or overactive detrusor or
outflow obstruction as a part of DSD.)
• In such cases proactive approach is
necessary.
Myelodysplasia

• The neurological lesion produced by
MMC can be variable.
• The vertebral level provides little or no
clue to the exact neurologic level or lesion
produced.
Myelodysplasia

• MMC influences lower urinary tract function in
a variety of ways and cannot be predicted
by spinal anomalies or the neurogenic function
of the lower extremities.
• The neurologic lesion in MMC is a dynamic
disease process in which changes take place
throughout childhood.
Myelodysplasia

• Three categories of lower urinary tract
dynamics may be detected:
– synergic (26%)
– dyssynergic with and without poor detrusor
compliance (37%) and
– complete denervation (36%).
Myelodysplasia

• Dyssynergy:
• When the external sphincter fails to decrease
or actually increases in its activities during a
detrusor contraction
• It is associated with a poorly compliant
bladder with high pressures. This results in a
bladder that empties only at high pressures.
Myelodysplasia

• Synergy is characterized by complete
silencing of the sphincter during a
detrusor contraction
• Voiding pressures are usually within
normal range.
Myelodysplasia

• Complete denervation: is noted when no
bioelectric potentials are detectable in the
region of the EUS at any time during
micturition cycle.
Myelomeningocele

• Within the first 3 years of life urinary tract
deterioration is seen in
• 71% of newborn with DSD
• 17% of synergic children and
• 23% of completely denervated patients.
Myelomeningocele

• Outlet obstruction is a major contributor to the
development of urinary tract deterioration.
• Leak point pressure and detrusor filling
pressure both are significant markers to predict
upper tract deterioration.
• Detrusor filling pressures should be
maintained lower than 30 cm H2O.
Myelomeningocele

• clean intermittent catheterisation (CIC) is
indicated when
– detrusor filling pressures exceed 30 cm H2O and
– voiding pressure exceeds 100 cm H2O, is
necessary.
• Sequential urodynamic studies, on a yearly
base during the first 5 years of life, provide a
safe monitoring of these children.
Myelomeningocele

Occult Spinal Dysraphisms
• Affects the formation of the spinal
column but does not result in an open
vertebral canal.
• In children younger than 3 months the
vertebral bones have not ossified, thus a
window exists for ultrasound to screen
spinal cord lesions.
Occult spinal dysraphism

• 90% of children with various occult
dysraphic status have cutaneous lesions.
– small dimple
– skin tag
– tuft of hair
– dermal vascular malformation,
– subcutaneous lipoma
– asymmetrically curving gluteal cleft.

• On careful inspection of the lower extremities,
we can detect a
– high arched foot,
– alteration of configuration of toes, or
– pressure zones on the feet with atrophic lesions
on the skin.
• Lower urinary tract function is abnormal in 40–
90% of affected elder children.

• In most of the children lower extremity
examination is normal
• Patients become symptomatic during
pubertal Growth spurt
• During pubertal growth spurt differential
growth of spinal cord and vertebral bodies
produces compression of nerve roots

• Lipomeningocele, intradural lipoma, and
other anomalies of filum terminale may be
present.
• Urodynamic evaluation reveals abnormalities in
one third
• These congenital anomalies produce different
neurologic findings.

• Lipomas cause UMN lesion alone or in
combination with LMN lesion.
• The reason to consult a specialist may be
– difficulty in toilet training,
– urinary incontinence after an initial period of
successful dryness
– recurrent UTI, and
– fecal soiling.

• In such lesions
• RBUS, MRI studies are needed and a full
urodynamic evaluation with EMG should be
done.
• The therapeutic measures should be discussed
with a neurosurgeon.
• MCU is warranted when the urodynamics
parameters suggest risk to the upper urinary tract

Sacral Agenesis
• Defined as the partial or complete absence of lowermost
vetebral bodies
• There may be
– absence of just two or three vetebral bodies or
– Absence of scaral and several lumbar bones
• These children appear normal with no lower extremity
abnormality
• Usually failed toilet training brings the child to consult
his paediatrician.
Sacral agenesis

• Patient has flat bottom, and even absent vertebrae in
palpating the coccyx.
• The pathognomic sign is absence of the upper end of
the gluteal cleft, with flattened buttocks.
• The diagnosis can be confirmed by
– a simple lateral plain x-ray of the sacral area.
– spinal ultrasound in infants
• A spinal MR reveals a sharp cut off to the cord at
about T-12, with nerve roots streaming from it.
Sacral agenesis

• Urodynamic Study may show either
– overactive detrusor with sphincter dyssynergy (UMN)
– acontractile detrusor with complete denervation in the
urethral sphincter (LMN)
• UM lesions are characterized by an overactive
detrusor, exaggerated sacral reflex and DSD
• The VCUG shows thick trabeculated bladder with
closed bladder neck.
Sacral agenesis

• Lower motor lesions show an
acontractile detrusor with open bladder
neck
• VCUG shows small thin walled bladder.
• Management will depend mainly on the
urodynamic findings and the
morphological aspect on the VCUG.
Sacral agenesis

Anorectal Malformations (ARM)
• Spinal cord anomalies (tethered cord, filum terminale anomalies, and a lipoma)
may be found in up to 50% of cases of ARM, specially in
high type ARM.
• Neurogenic bladder dysfunction is a frequent finding
• Bladder dysfunction can be either due to the congenital
spinal anomalies or secondary to the surgical trauma.

• Most common finding on urodynamic studies
is an upper motor lesion with DSD
• Currently urodynamic studies are reserved to
children
– who have symptoms or
– Who have abnormalities on the simplified
urodynamic studies (flowmetry, EMG, postvoid
residual).
Anorectal Malformations (ARM)

Cerebral Palsy
• Cerebral palsy is a non progressive injury of
the brain occurring in the perinatal period.
• Most children with cerebral palsy develop total
urinary control.
• Incontinence is a feature in some
• Overactive detrusor with DSD is the most
common finding.
Cerebral palsy

• Most common injuries are of the cervical and high
thoracic regions.
• The high spinal lesions will produce an UMN lesion
with overactive detrusor and DSD
• Urodynamic studies are done after stabilisation
of the spinal trauma, usually 2 months after the
injury and to be repeated 6–9 months after.
Traumatic Injuries of the Spine

• sacral spinal injuries cause acontractile
detrusor with inactive external sphincter.
• There is low risk for the urinary tract
deterioration but need specific measures for
incontinence.
Traumatic Injuries of the Spine

Management of
Neurogenic Bladder
in children

Management of a child with a neurogenic
bladder
• the main objective
– to preserve a normal upper urinary tract.
• The second main objective is
– to improve the social life and the quality of life of
these children, giving them urinary and fecal
continence

• These goals need a reservoir (the bladder)
with adequate capacity and low storage
pressure, able to empty itself with a normal
micturation pressure.
Management of NB

• The management will have to be tailored
according to
• urodynamic results and
• motor and intellectual capacities of the
patient.
Management of NB

• to achieve a complete emptying of the
bladder
• to maintain or restore an adequate
bladder capacity and compliance, and
• to reinforce the sphincter outlet
resistance when needed.
Goals of treatment

Clean Intermittent Catheterization (CIC)
• CIC was introduced by Lapides in 1971
• Remains the most important tool in the
management NB.
• As fewer than 10% of children with congenital NB
will develop satisfactory bladder control,
• Parents are reminded at periodic follow-ups to
expect this intervention by the age of toilet
training

• Some authors prefer early institution of CIC
because
– by the age of 3 years, CIC will be required in
all for achieving continence,
– starting CIC in toddlers is difficult.
• CIC may be realized with classical Nelaton
catheter kept in an antiseptic solution.

• It allows a complete emptying of the bladder
– lowers the risk of UTI
– protects the upper urinary tract against high
bladder pressure
– Is a valuable tool to keep child dry

• CIC is a clean but not sterile procedure.
• Starting CIC will frequently result in chronic
colonization of the bladder by bacteria.
• These bacteria are generally of low clinical
significance
• Antibiotic use should be reserved only for a
symptomatic episode of UTI & pseudomonas and
proteus.

• CIC should be started as soon as possible to avoid UTI
and deterioration of the bladder.
• CIC may be realized through the urethra or through a
continent cystostomy (the Mitrofanoff principle).

• In cases where despite CIC urinary tract
deterioration occurs, the overnight catheter
drainage of the bladder may be tried.
• Overnight drainage may increase bladder
compliance and capacity

Pharmacologic Treatment of NB
• Aim of the pharmacotherapy is
– Decrease detrusor over activity
– Increase bladder capacity
– Increase bladder outlet resistance ( in incontinence)
– Dercrease bladder outlet resistance (in DSD)

• Oxybutinin remains the gold standard of treatment
of bladder overactivity.
• It is as an anticholinergic agent acts on M3
muscarinic receptors.
• It decreases intravesical pressures and uninhibited
contractions and
• indirectly increases bladder capacity.
Oxybutynin

• It also has an
– anti-spasmodic,
– local anaesthetic and
– Calcium channel blocking
• It converts overactive detrusor into an inactive
reservoir
Oxybutynin

• It is administered orally in the dose of 0.2-0.4
mg/kg/day in 2-3 divided doses.
• side effects of altered thermoregulation and
constipation.
• These side effects may be reduced by direct
instillation of the oxybutinin in the bladder.
Oxybutynin

• Other bladder relaxant drugs include
• propiverine (0.8mg/kg/day),
• trospium, and tolterodine.
• The current experience with these compounds is still
limited
Other bladder Relaxants

• Madersbacher et al* concluded that long-term
efficacy and tolerability of propiverine in
children is promising with clinically
relevant improvements in key urodynamic
outcomes.
*Madersbacher H, Mürtz G, Alloussi S, Domurath B,Henne T, Körner I et al. Propiverine vs oxybutynin for treating
neurogenic detrusor overactivity in children and adolescents: results of a multicentre observational cohort study.
BJU Int 2009;103:776-81.
Propiverine

• Another study evaluated long-term efficacy and
safety of tolterodine in 30 children with neurogenic
detrusor overactivity.
• They concluded that tolterodine was effective and
well tolerated in children with neurogenic detrusor
overactivity
• *Reddy PP, Borgstein NG, Nijman RJ, Ellsworth PI. Longterm efficacy and safety of tolterodine in children with
neurogenic detrusor overactivity. J Pediatr Urol 2008;4:428-33.
Tolterodine

α - Blocker
• For children with DSD, one may try alpha-blocker therapy
such as tamsulosin, prazosin or doxazosin.
• These have achieved success, are low risk to try,
• They can be followed for effectiveness by
– symptomatic improvement, as well as with a noninvasive
uroflow study with postvoid residue

Antibiotics
• The problem of daily antibiotics is the risk of developing
antibiotic-resistant organisms
• Low dose, low efficacy antibiotics such as
cotrimoxazole and nitrofurantoin should be used in an
alternative fashion for prophylaxis and
• High-efficacy full dose drugs are used for an active
infection.

Botulinum toxin A
• BOTOX results in decreased muscle activity by
blocking the release of acetylcholine from the neuron
• This effectively weakens the muscle for a period of three
to four months
• It increases bladder capacity, decreased pressures,
decreased incidence of reflux and improves
continence.

• Botulinum toxin A is injected in the detrusor muscle
under cystoscopic guidance
• 5 IU/kg body weight with a maximum dose of 300 IU.
• The sites of injection are spread through the
bladder except the trigone not to induce reflux.
• The effect lasts between 6 to 9 months.
• This minimally invasive procedure, may be
repeated.
Botulinum toxin A

• It is useful to consider strategies of scheduled
evacuation.
• This includes healthy
• Toilet trainaing
• dietary fiber intake and a
• daily stool softener, coupled with a
• method of daily evacuation to achieve effective
bowel management.
Bowel management
Mineral Oil 2-4 ml/kg/day
Milk of Magnesia 1-3 ml/kg/day
Polyethylene glycol 0.5-1.5 g/kg/day
Sorbitol or lactulose 1-2 ml/kg/day

• A number of surgical options are available
should a combination of pharmacotherapy and
CIC prove inadequate in halting the progression
of urinary tract damage.
• It is imperative that one must have a mechanism
of satisfactory bladder emptying.
Bladder Augmentation

The goal of bladder augmentation is
• to protect the upper urinary tract when
the less invasive procedures are ineffective,
and
• to induce dryness in children where the
incontinence is related to low compliance
and capacity.
.

• Bladder augmentation should only be
realized in a patient when CIC is impossible
by the urethra, sensitive or technically
impossible
• Bladder augmentation is usually kept low on
the list of surgical options due to long-term
morbidity of these procedures

The augmentation induces many complications
• Infections
• stone formation
• metabolic complications
• perforation and
• cancer.

• Enterocystoplasty and clam cystoplasty are
good alternatives to autoaugmentation
when the surgeon is faced with a small,
scarred bladder.
• It is often associated with the construction
of a catheterizable channel (Mitrofanoff
principle)

• The choice of surgery leans towards continent
urinary diversion and bladder augmentation in the
event of
– intractable incontinence,
– diminishing renal functions and
– hypertension following long-term renal damage.

• Neuromodulation therapy aims to treat the
abnormal innervation of the bladder
• It tries to "re-train" the nerve-muscle interaction to
attain more normal bladder function.
Neuromodulation

• The available treatments include
– transurethral electrical bladder stimulation
– implantation of a sacral neuromodulation
pacemaker device; and
– operative procedures that reconfigure sacral
nerve root anatomy
Neuromodulation

• Sacral neuromodulation by a reversible implantable
device (Medtronic,USA), is thought to improve bladder
function either
– by consistent stimulation of the efferent fibers of the
sacral nerve roots or
– by providing rhythmic contractions of the pelvic floor
Neuromodulation

• Another method of counteracting a small, hyperactive bladder
is the intradural transection of the S2-S4 nerve roots
• Guys et al studied the results of sacral nerve stimulation
(SNS) therapy in children with neurogenic bladder
dysfunction.
• They did not find significantly better results in the SNS group
Neuromodulation

• In case of Incompetent Bladder Outlet, bladder
neck procedures are the way to achieve
continence.
• Agents like Durasphere (zirconium oxide beads) & Deflux
(hyaluronic acid polymer) have been employed for this
purpose
• The main disadvantage with this approach is the
difficulty in CIC which follows.
Bladder Neck Bulking Agents

• Neel et al have introduced the concept of TEM in children
with noncompliant NB to address continence and treatment of
VUR.
• Ten children with NB were treated with cystoscopic injection
of botulinum-A toxin in the detrusor and subureteric injection
of Deflux.
• There was significant increase in BC and decrease in max.
detrusor pressure. VUR was successfully treated in 15 of 16
ureters
Total endoscopic management (TEM)

Outlet Resistance
• In other patients the outlet resistance may be obtained by
the
1. open cervicoplasty
2. sling suspension of the bladder neck
3. artificial urinary sphincter
4. bladder neck closure with mitrofanoff.

• Bladder neck sling is considered by many as the procedure of
choice in females and
• it has also been advocated in male patients by some.
• The sling is made of autologous material in most cases (rectus
fascia).
• Castellan et al. report good continence with a mean follow-up
of 4 years in 58 patients.

• Artificial Urinary Sphincter (AUS) is considered
by many as the procedure of choice in boys when
a reinforcement of outlet resistance is needed to
gain adequate continence.
• Continence rates between 80% and 90% are
reported among children.
• AUS may be associated with erosion, sepsis or
dysfunction.

• Children with AUS undergo many procedures
due to device technical problems.
• In one French multi-institutional study 63/107
children had to be re-operated on and 42 of
them more than once.
• Most do not recommend implantation of an AUS
device before puberty

,
• Bladder neck closure was initially proposed by
Mitrofanoff in the management of children with a
neuropathic bladder.
• it exposes the bladder and upper urinary tract to a
high risk of deterioration in case of bad
compliance to CIC.

Procedures Increasing the Outlet Resistance
• Any of these procedures imply the risk of bladder
and upper urinary tract deterioration with renal
insufficiency.
• A close follow-up is mandatory to detect any
change in the urodynamic profile and any dilation
of the upper urinary tract.

• The management of a child with a
neurogenic bladder needs a
multidisciplinary team
• Treatment and has to be tailored to each
child with respect to his familial
environment, and his orthopedic and or
mental limitations.
Conclusion

• CIC is the most important part of the treatment
and should be started as early as possible
after birth and repair of the spinal defect.
• It will not always be sufficient to gain
continence but it is mandatory to protect the
upper urinary tract which is the main goal of
the treatment.
Conclusion

Neurogenic bladder

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