Bladder dysfunction in different neurological diseases

Dr. Subhasish Deb
Dept. of General Medicine
Burdwan Medical College
Dr Subhasish Deb, BMCH, General Medicine

 Pyramidal shaped when empty
 Ovoid when full
 Parts:
1. Superior surface
2. 2 Inferolateral surf
3. Apex
4. Base
5. Neck
 Transitional
Epithelium

TRIGONE :
• Triangular area in post surface immediately above
bladder neck
• Identified by absence of rugae, i.e mucosa is
smooth here
INTERNAL SPHINCTER:
• At bladder neck, made of detrusor muscle and
elastic tissue
• ABSENT IN FEMALES
EXTERNAL SPHINCTER:
• Skeletal muscle, voluntary control
• In urogenital diaphragm

Superior and Inferior vesical artieries,
branches of ant. trunk of internal iliac
Veins form a plexus in the infero-lat
surface and drain in internal iliac vein
Most of the lymph in external iliac nodes

1. Pelvic Nerve: (parasympathetic)
• Motor + sensory
• From sacral plexus S2,3,4 (Detrusor centre
intermediolateral column of grey matter)
• Motor part = parasympathetic fibres
• Expels urine
2. Pudental Nerve: (Somatic)
• Voluntary control
• External urinary sphincter
• S2,3,4 (nucleus of Onuf) – antero lateral horns of S2,3,4
3. Hypogastric nerve: (Sympathetic)
• T11,T12,L1, L2
• Stores urine

1) M3 – Bladder wall (Detrusor contr.)
2) B3 - bladder wall (Detrusor relax.)
3) a1 – internal sphincter
4) Nicotinic – external sphincter

 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 relax. (B3) + int sphicn contric (a1)
• The pons also stimulates the hypogastic nrv and
inhibits the pudental ner  external sphic contraction.
• Thus urine is not expelled.

When Bladder is Full:
• Streching of bladder  pelvic sensory n sends
FAST signals.
• This is directly carried to the PONTINE
MICTURATION CENTRE, bypassing the thoraco
lumbar regions.
• The Pons:
1. Inhibits hypogastric nv (symp)
a) No relaxation of detrusor (B3)
b) Relaxation of internal shpincter (a1)
2. Stimulates Pelvic efferent nv  contr of detrusor
(M3)
3. Inhibits Pudental nv  relax. of ext. sphincter
(N)

Empty bladder
Full bladder response
L L
SS

NEUROLOGIC DISORDERS
CAUSING
BLADDER DISTURBANCES

AUTONOMOUS BLADDER
Etiology:
•Conus lesion:
•Trauma, tumour, myodysplasia, necrotizing myelitis,
venous agiomas
Features:
-Bladder paralyzed for sensory and reflexive activity
-No awareness of state of fullness
-Voluntary initiation of micturation impossible
-Detrusor tone lost  bladder distends
 Overflow incontinence
-voiding possible by CREDE’s maneuverDr Subhasish Deb, BMCH, General Medicine

Other features:
• Anal sphincter and colon are similarly affected
• Saddle anesthesia
• Abolition of bulbocavernosus and anal reflex and
tendon reflexes in leg
Cystometrogram: low pressure and no emptying
contractions
T/T : Catheterization and anticholinergics

Crede’s manouver : (MASS REFLEX)
technique for manual expression of urine
from the bladder used in BLADDER TRAINING
for paralyzed patients.
The hands are held flat against the abdomen,
just below the umbilicus. A firm downward
stroke toward the bladder is repeated six
or seven times, followed by pressure from
both hands placed directly over the
bladder to manually remove all urine.

 ATONIC bladder (motor)
 Structure affected:
• sacral root or
• peripheral nv
 Etiology:
• lumbosacral meningomyelocele,
• tetherd cord syndrome
• Cauda equina: compression m/c- epidural tumour, disc,
radiculitis from herpes or CMV
 Features:
• LMN paralysis of bladder
• Sacral and bladder sensations are intact
• Voluntary initiation of micturation lost-loss of cortical fibres
• Overflow incontinence

ATONIC BLADDER (sensory)
DM & tabes dorsalis
Motor fibres intact
Small fibres – DM
Also seen in acute neuropathies like GB
synd
t/t – intermittent self catheterization

SPASTIC BLADDER
Etiology:
• m/c multiple sclerosis, traumatic myelopathy
• Myelitis
• Spondylosis
• AVM
• Syringomyelia
• Tropical spastic paraperesis

 If cord lesion is sudden onset  detrusor
suffers spinal shock  distension and
overflow
 When spinal shock subsides  Detrusor
overactivity (hyperreflexia)  +pt 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 o voluntary
micturation impared.
 Cystometrogram: uninhibitted contractions of
detrusor in response to small volmes of fluid

Dangerous syndrome due to spinal cord
injury at or above T6
Uncontrolled HTN due to reflex
sympathetic discharge
Pathophysiology:
• A noxious stimulus at t6 excessive symp
discharge  HTN (by splanchnic and peripheral
vasoconstriction)
• Baroreceptors react by sending strong vagal
response  bradycardia

• lack of spinal cord continuity
• descending inhibitory response only travels as far
as the level of neurologic injury
• does not cause the desired response in the
sympathetic fibers below the injury therefore, the
hypertension remains uncontrolled.
Above level of injury:
• Bradycardia, nasal congestion, pupilary
constriction, sweating.
Below level of injury:
• Pale, cool skin, pilo erection, distended bladder

In diseases such as MS, SACD, tethered
cord and syphylitic meningomyelitis
Lesions at multiple levels ie spinal roots,
sacral neurons, their fibres and higher
spinal segments.
Resultant picture is a combination of
sensory, motor and spastic type of bladder

Confused mental state
Ignores desire to void
Subsequent incontinence
No warning signs of fullness- suddenly wet
Supranuclear type of hyperactivity and
precipitant evacuation
Post part of superior frontal gyrus and
cingulate gyrus

TYPE LESION SITE
1. Uninhibited bladder Cortico regulatory tracts
2. Reflex bladder Spinal cord above T12
3. Autonomous bladder S2 S3 S4
4. Motor Atonic bladder Motor efferents
5. Sensory atonic
bladder
Sensory afferents

Neurogenic bladder
Flaccid Mixed Spastic
- Vol. large - Small volume
- Pressure low - involuntary cont.
- Contraction absent - Bladder detrusor
- In: peripheral nv damage dyssynergia
or lesion at S2-S4 - in lesions above
T12

THANK YOU

Bladder dysfunction in different neurological diseases

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Bladder dysfunction in different neurological diseases