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See all Premium member Presentation Transcript NEUROGENIC BLADDER : Dr Rahul Chakor MD.,DM Lecturer – Dept of Neurology T N Medical College B Y L Nair Hospital Mumbai NEUROGENIC BLADDER Outline : Outline Applied anatomy Common symptoms of neurogenic bladder Levels of bladder dysfunction Investigations Treatment available Part I : Applied anatomy Part I Bladder functions : Bladder functions Storage - at low pressure until such time as it is convenient and socially acceptable to void Voiding - initiated by inhibition of the striated sphincter and pelvic floor, followed some seconds later by a contraction of the detrusor muscle. Innervation of male lower urinary tract : Detrusor - innervated by S2,3,4 parasympathetic (muscarinic M2 receptors) intermediolateral gray column –pelvic n External urethral sphincter - innervated by somatomotor S2,3,4 nucleus (Onuf’s Nucleus)-pudendal n Trigone and internal sphincter innervated by Sympathetic T10,11,12 (less important) Afferent sensation through pelvic n and pudendal n, hypogastric n (Ad and C fibers) to Periaqueductal gray matter pontine micturition center S 2,3,4 S 2,3,4 Innervation of male lower urinary tract Pontine Micturition Center : Pontine Micturition Center Pontine Micturition Center (PMC)/Barrington’s nucleus Lateral region, continence, storage urine - stimulation results in a powerful contraction of the urethral sphincter Medial region, micturition center - stimulation results in decrease in urethral pressure and silence of pelvic floor EMG signal, followed by a rise in detrusor pressure. Micturition reflex : Micturition reflex Fibers in pelvic nerves – - Afferent limb of voiding reflex (sensation of fullness and urge) - Parasympathetic fibers to bladder efferent limb of the reflex Internal sphincter - no important role in micturition, prevents leakage during filling and prevents reflux of semen into bladder during ejaculation Sympathetic nerves - no part in micturition The micturition reflex : The micturition reflex Sensation of bladder fullness via pelvic and pudendal nerves to S 2,3,4 Periaqueductal gray matter Medial Pontine micturition center Frontal lobe decides social appropriateness Onuf’s nucleus to pudendal nerves Detrussor center (S 2,3,4) to pelvic nerves RECIPROCAL ACTIVITY BETWEEN SPHINCTER & DETRUSSOR Micturition Neuraxis involved : Neuraxis involved For storage and voiding Frontal lobe, PMC Sacral center, Nerves i.e Complex & extensive innervation needed – Bladder symptoms are common Part II : Part II Symptoms Symptoms : Symptoms Incontinence - involuntary loss of urine is objectively demonstrable and is a social or hygienic problem Urinary urge incontinence - involuntary loss of urine that follows an uninitiated, uninhibitable detrusor contraction and is generally associated with a sensation of urinary urgency Detrusor hyperreflexia (DH), Detrussor Instability (DI) - Involuntary detrusor contraction Detrusor sphincter dyssenergia (DSD) Overflow incontinence (OI) - disorder of bladder emptying and the capacity of an insensate, hypotonic bladder is exceeded. DH,DI : DH,DI Detrussor Sphincter Dyssynergia Detrussor Hypereflexia Poorly sustained hyperreflexic bladder contraction and DSD Raised post voiding residual (PVR) (>100ml) Exacerbation of urgency . Slide 13: Neuropathy Long history of neuropathic symptoms, Stocking glove anesthesia Absent knee and ankle jerks will be absent Small fiber sensory impairment demonstrable to the level of the ankles Other features of autonomic involvement Sexual dysfunction Cauda equina Bladder, sexual & bowel dysfunction S 2, 3, 4 sensory loss Lax anal sphincter Bulbocavernosus (sacral reflexes) reflex lost +/- Foot deformities, lower limb abnormalities Cutaneous markers over the back & sacrum Slide 14: Spinal Cord Signs of upper motor neuron lesion in the lower limbs (unless the lesion is central intramedullary and small) Erectile dysfunction in men +/- Paraparesis Brainstem Marked neurological deficits dorsal and discreet lesion defect of bladder function MLF lesion Internuclear ophthalmoplegia Slide 15: Extrapyramidal diseases Extrapyramidal features MSA, Parkinsons disease Autonomic dysfunction Cerebellar signs Suprapontine Frontal lobe disorders Dementia, personality change Aware about incontinence unless extensive lesions Severe urgency, frequency & urge incontinence without dementia, socially aware and embarrassed by incontinence Urinary retention Part III : Part III Levels of bladder dysfunction Levels of bladder dysfunction : Levels of bladder dysfunction Suprapontine Severe urgency, frequency and urge incontinence without dementia, socially aware and embarrassed by their incontinence. Pontine Detrussor hyperreflexia, arreflexia in pts with INO Spinal Most important disorders of storage and emptying DSD DH Slide 18: Suprapontine Causes Stroke Tumors Dementia (AD,FTD) Causes of various levels of dysfunction Part IV : Part IV Investigations Slide 20: Noninvasive bladder investigations Post void residual volume – In out catheterization, Ultrasound ( N is <100ml) Uroflowmetry Voided volume ( >100ml) Maximal flow, maximal and average flow rate (M > 20ml/sec F > 15ml/sec) Slide 21: Cystometry * Measure detrusor pressure (Intravesical presure – Rectal pressure) * Bladder infused till 400 to 600ml – Pressure should not rise to >15cm water (Stable bladder) * Neurogenic detrusor overactivity – Involutary detrusor contraction during filling phase * Voiding phase – Detrusor pressure M < 50cm water F < 30cm water Slide 22: Sphincter EMG – Reinnervation with prolonged duration of MUAPs Neuroimaging – Cauda equina & conus lesions, spinal, supra pontine and pontine lesions Part V : Part V Treatment Detrusor overactivity : Detrusor overactivity Anticholinergics - Oxybutynin, tolterodine - M3 blockers darifenacin Tricyclic antidepressants - Imipramine Desmopressin intranasally – once in 24 hrs Botulinum toxin A Intravesical capsaicin – instilled with a balloon catheter Neurogenic Detrusor overactivity : Neurogenic Detrusor overactivity Treatment : Urinary Retention If residual volume > 100ml Clean intermittent self catheterisation (CISC) Permanent indwelling catheter Detrusor overactivity and Retention Anticholinergic drugs CISC Treatment Treatment : Treatment External device – condom catheter Sacral nerve stimulators – for DI Nerve root stimulators – S 2,3,4 for voiding assisting defecation Surgery – Augmentation cystoplasty, artificial sphincter, urinary diversion with stoma collection bag THANK YOU : THANK YOU You do not have the permission to view this presentation. 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