neurogenic bladder dr. sh. alaie neurologist. neurogenic bladder definition is a malfunctioning...

NEUROGENIC BLADDERNEUROGENIC BLADDER

Dr. sh. AlaieDr. sh. Alaie

NeurologistNeurologist


DefinitionDefinition

Is a malfunctioning bladder due to any Is a malfunctioning bladder due to any type of neurologic disordertype of neurologic disorder..


VoidingVoiding::11))Filling = storage :bladder acts as low Filling = storage :bladder acts as low

pressure receptacle pressure receptacle Sphincter high resistanceSphincter high resistance

22))Voiding = Emptying :Bladder contractsVoiding = Emptying :Bladder contracts Sphincter opensSphincter opens

Both Should be done in Normal PressureBoth Should be done in Normal Pressure

Normal Voiding:1)Normal DetrusorNormal Voiding:1)Normal Detrusor

4-84-8/ / day 2)Normal Sphincterday 2)Normal Sphincter

33))SynergySynergy

44))VoluntrilyVoluntrily

Normal PressureNormal Pressure

AnatomyAnatomy

BRAINBRAINMaster control of the entire Urinary Master control of the entire Urinary systemsystemMedial aspect of Medial aspect of Precentral gyrusPrecentral gyrusInhibitoryInhibitory signal to detrussor until a signal to detrussor until a suitable time &placesuitable time &placeInjury :1)Injury :1)UnawarenessUnawareness to entire voiding to entire voiding

process process 22 ) )Spastic bladderSpastic bladder

ANATOMYANATOMYPONSPONS

PMC:coordinating Bladder &Urethral PMC:coordinating Bladder &Urethral Sphincter = Sphincter =SynergySynergy

Facilitate Urination 1)detrussur Facilitate Urination 1)detrussur contractioncontraction

22))sphincter relaxationsphincter relaxation

Ingury :1)Ingury :1)Spastic bladderSpastic bladder

22))DSDDSD

ANATOMYANATOMYSPINAL CORDSPINAL CORD

Supra sacral:intermediary between Supra sacral:intermediary between PMC &Sacral cordPMC &Sacral cord

Lat.CorticoSpinal &ReticuluSpinalLat.CorticoSpinal &ReticuluSpinal

Injury: 1)Injury: 1)Spastic BladderSpastic Bladder

22))DSDDSD

ANATOMYANATOMYSacral cordSacral cord

Primitive Voiding Center for Reflex ArcPrimitive Voiding Center for Reflex Arc

S2,S3,S4S2,S3,S4

Injury :Detrusor Injury :Detrusor AreflexiaAreflexia

ANATOMYANATOMYPeripheral nervesPeripheral nerves

11))Sympathetic :bladder & internal Sympathetic :bladder & internal sphinctersphincter

22))parasympathetic: bladderparasympathetic: bladder

33))Somatic:Onuf neucleus: Ex.sphincterSomatic:Onuf neucleus: Ex.sphincter

Injury:Injury:Areflexic bladderAreflexic bladder:sensory /motor:sensory /motor

PhysiologyPhysiology

1)Filling1)Filling accumulation of urine while the pressure is accumulation of urine while the pressure is

lowlow If Pv >Pu : Urine LeackageIf Pv >Pu : Urine Leackage RefluxRefluxSympathetic :1)inhibit parasympatheticSympathetic :1)inhibit parasympathetic 2)relaxation &expansion of 2)relaxation &expansion of

detrussor detrussor 3)close the bladder neck3)close the bladder neckPudendal : contraction of the Ex.SphincterPudendal : contraction of the Ex.Sphincter Pu>PvPu>Pv

NEUROGENICNEUROGENIC BLADDERBLADDER Physiology Physiology

22))EmptyingEmptying:: Bladder filling to capacity: stretch Bladder filling to capacity: stretch

receptors:pelvic nervereceptors:pelvic nerve & & Hypogastric nerveHypogastric nerve Sacral cord:voidingSacral cord:voiding

After 3-4 Yr old:sympathetic : relaxes in. sphincterAfter 3-4 Yr old:sympathetic : relaxes in. sphincter Ps: detrusor contractionPs: detrusor contraction

Pudendal: relaxation of ex.sphincterPudendal: relaxation of ex.sphincter

Pv>Pu: voidingPv>Pu: voiding

TYPES of NEUROGENIC TYPES of NEUROGENIC BLADDERBLADDER

11))Detrusor :Overactive:Impaired filling Detrusor :Overactive:Impaired filling Underactive:Impaired Underactive:Impaired EmptyingEmptying

22))Sphincter:Overavtive:Impaired Sphincter:Overavtive:Impaired EmptyingEmptying

Underactive:LeackageUnderactive:Leackage

33))Loss of coordination:Impaired Loss of coordination:Impaired EmptyingEmptying

Types of Bladder Types of Bladder DysfunctionDysfunction

11 - -Failure of Storage (Detrusor Hyperreflexia)Failure of Storage (Detrusor Hyperreflexia)

22 - -Failure of EmptyingFailure of Emptying

a) a) Detrusor HypoactivityDetrusor Hypoactivity

b) b) Detrusor Detrusor ––Sphincter dyssynergia=DSDSphincter dyssynergia=DSD

33 - -Mixed typeMixed type

All can be dangerous to upper All can be dangerous to upper tracttract

SYMPTOMSSYMPTOMS Storage FailureStorage Failure

a) frequency / nocturiaa) frequency / nocturia Urination>8 times a dayUrination>8 times a day

oror > > 22 times over nighttimes over night

b) urgency: extreme desire to voidb) urgency: extreme desire to voidc) Incontinency : urge in continencec) Incontinency : urge in continenced) hesitancy,intermittency,straining to d) hesitancy,intermittency,straining to

void,terminal dribbling void,terminal dribbling . .

SYMPTOMSSYMPTOMS Emptying FailureEmptying Failure

a) feeling of incomplete emptyinga) feeling of incomplete emptying

b) frequency , urgencyb) frequency , urgency

c) incontinency (overflow)c) incontinency (overflow)

d) hesitancy,intermittency,straining to d) hesitancy,intermittency,straining to void,terminal dribblingvoid,terminal dribbling..

Symptoms are the same in Symptoms are the same in all typesall types!!

70%70% mismanagement mismanagement based on history alonebased on history alone!!

COMPLICATIONSCOMPLICATIONS

11))rise in rise in Pv:REFLUX:Hydroureter/HydronephrosPv:REFLUX:Hydroureter/Hydronephrosisis

22))Retention:Frequent UTI Retention:Frequent UTI (+reflux:Pyelonephritis) (+reflux:Pyelonephritis)

33))Urinary stonesUrinary stones

44))Impaired social & personal lifeImpaired social & personal life


NEUROLOGIC DISEASESNEUROLOGIC DISEASES

Voiding dysfunction is Voiding dysfunction is important in multiple sclerosisimportant in multiple sclerosis

Because ofBecause of::

11 - -Frequency (up to 90% of patients)Frequency (up to 90% of patients)

22 - -Serious complications: 55% Serious complications: 55% → 5%→ 5%

33 - -Impairment of social &personal life Impairment of social &personal life & sexual activity& sexual activity

44 - -Could be successfully managedCould be successfully managed

55 - -Social & cultural aspectsSocial & cultural aspects

MSMSSYMTOMSSYMTOMS

- -Voiding dysfunction may be the sole Voiding dysfunction may be the sole initial complaint ( initial complaint ( 2.3%2.3% ) )..

- -Or part of the presenting symptoms Or part of the presenting symptoms ( 10% ) ( 10% )

NEUROLOGIC DISEASESNEUROLOGIC DISEASESCVACVA

Cerebral Shock:Det.Cerebral Shock:Det.AreflexiaAreflexia:Retention:Retention

Afew weeks/months Afew weeks/months later:later:Det.HyperreflexiaDet.Hyperreflexia

NEUROLOGIC DISEASESNEUROLOGIC DISEASESMSAMSA

Urinary symptoms are commonUrinary symptoms are common

Come early (60% before or associated Come early (60% before or associated withwith

other symptomsother symptoms

Even Even 4yr before diagnosis4yr before diagnosis

AUTONOMIC DYSREFLEXIAAUTONOMIC DYSREFLEXIA

Is a lethal emergencyIs a lethal emergency

Acute massive disorderd autonomic(S) Acute massive disorderd autonomic(S) response to specific stimuli in SC response to specific stimuli in SC injury above T6- T8injury above T6- T8

More common in cervicalMore common in cervical

After shock period but up to yrs after After shock period but up to yrs after injuryinjury

Stimuli below level of the lesionStimuli below level of the lesion


Headache/HTN(even ICH or sezure)Headache/HTN(even ICH or sezure)Flashing of face,body above the lesionFlashing of face,body above the lesionSweatingSweatingUsually bradycardia,maybe Usually bradycardia,maybe tachycardia/arrhytmiatachycardia/arrhytmiaStimulus from: bladder/rectum: Stimulus from: bladder/rectum: distention,manipulation distention,manipulationGI/bone FX /sexual activity /bed soreGI/bone FX /sexual activity /bed sore


Endoscopic procedure: spinal/ general Endoscopic procedure: spinal/ general anesthesia anesthesia

SL niphedipin/ oral niphedipin/ trazocinSL niphedipin/ oral niphedipin/ trazocin

Significant rise in BP without other Significant rise in BP without other symptomssymptoms

DiagnosisDiagnosis

11 - -History: ask strictly about voiding History: ask strictly about voiding symptoms and feeling of symptoms and feeling of incomplete emptying incomplete emptying

22 - -exam: pelvic examexam: pelvic exam Sacral reflex examSacral reflex exam

Signs of spinal cord involvmentSigns of spinal cord involvment33 - -Lab : U/A, U/C, BUN, CrLab : U/A, U/C, BUN, Cr

DiagnosisDiagnosis

44 - -Imaging : sonographyImaging : sonography

a) Anatomya) Anatomy

b) Residue b) Residue ( up to 100( up to 100CCCC))

DiagnosisDiagnosis

55 - -In In –– out catheter method out catheter method::

a) Well hydrated for 48 hra) Well hydrated for 48 hr

b) Drink 2 glasses of water, before examb) Drink 2 glasses of water, before exam

c) First desire to void = capacity(c) First desire to void = capacity(300300 –– 500cc500cc))

d) Measure residue after voidingd) Measure residue after voiding

DiagnosisDiagnosis Urodynamic studyUrodynamic study

A general term for the study of the A general term for the study of the storage and voiding functionstorage and voiding function

DiagnosisDiagnosisUrodynamic studyUrodynamic study

a) Bladder eapacity (300 a) Bladder eapacity (300 –– 500cc) 500cc)

b) Detrussor pressure, Max 10 Cm H2ob) Detrussor pressure, Max 10 Cm H2o

c) DSDc) DSD

d) Detressor instabilityd) Detressor instability

e) L.P.P (leak point pressure)e) L.P.P (leak point pressure)

DiagnosisDiagnosisUrodynamic studyUrodynamic study

Indication Indication - -urologic problems: Contraversyurologic problems: Contraversy

- -Neurologic problemsNeurologic problems::

All with neurogenic bladderAll with neurogenic bladder should undergo urodynamic study should undergo urodynamic study to characterize the nature of the to characterize the nature of the problem and to determine problem and to determine prognosis and prognosis and managementmanagement. .

MANAGEMENTMANAGEMENTGOALSGOALS

11 - -upper tract preservationupper tract preservation

22 - -absence or control of infectionabsence or control of infection

33 - -adequate storage at low I.V.Padequate storage at low I.V.P

44 - -adequate emptying at low I.V.Padequate emptying at low I.V.P

55 - -adequate controladequate control

66 - -no catheterno catheter

77 - -social acceptabilitysocial acceptability

MANAGEMENTMANAGEMENTSTORAGE FAILURESTORAGE FAILURE

11 ) )Non surgicalNon surgical::

a) Non pharmacologica) Non pharmacologic

b) Pharmacologicb) Pharmacologic

22 ) )surgicalsurgical


NON PHARMACOLOGICNON PHARMACOLOGIC

11 - -voiding diaryvoiding diary: 3-5 days: 3-5 days

a) Total 24hr urinary outputa) Total 24hr urinary output

b) Number of voidsb) Number of voids

c) Voiding intervalc) Voiding interval

d) Diurnal distributiond) Diurnal distribution

e) Timing and triggers for e) Timing and triggers for incontinenceincontinence


Bladder training programBladder training program: : 11 - -lengthen the amount of time lengthen the amount of time

between voidingbetween voiding..22 - -increase the amount of urine the increase the amount of urine the

bladder can holdbladder can hold. . 33 - -improves the control over the urgeimproves the control over the urge..

44 - -patient gives voiding program to his patient gives voiding program to his bladder bladder..

11 - -Kegel exerciseKegel exercise..22 - -delaying urination,5 min delaying urination,5 min → 10 min→ 10 min

Walk instead of running at urgeWalk instead of running at urge Relaxation techniquesRelaxation techniques

33 - -sheduled bathroom tripssheduled bathroom trips::Every 1hr initiallyEvery 1hr initially..

44 - -irritating factors: Alcohol, caffeine, acidic irritating factors: Alcohol, caffeine, acidic foods (tomatoes, grapefruit)foods (tomatoes, grapefruit)

55 - -change of temperaturechange of temperature..66 - -bio feedback and acupuncturebio feedback and acupuncture . .


BLADDER TRAINING PROGRAMBLADDER TRAINING PROGRAM

11 - -anti cholinergicsanti cholinergics::

a) Tolterodine 1-2 mg/bida) Tolterodine 1-2 mg/bid

b) Oxybutinine 5 mg/TDSb) Oxybutinine 5 mg/TDS

22 - -TCA: imipramin 25 mg/dayTCA: imipramin 25 mg/day

33 - -desmopressin , spray, 1-2 puffdesmopressin , spray, 1-2 puff

44 - -Ca antagonists/potassium channel Ca antagonists/potassium channel openers/prostaglandin openers/prostaglandin

inhibitorsinhibitors……????


pharmacologicpharmacologic

WarningWarning!!!!!!

AnticholinergicAnticholinergic : :

11 - -check for residue beforecheck for residue before

22 - -check for pharmacologic retention check for pharmacologic retention afterafter


pharmacologicpharmacologic


SURGICALSURGICAL11 - -intravesical injection of botolinum intravesical injection of botolinum

toxin toxin oxybutinin oxybutinin capsaicin capsaicin??

22 - -electrical stimualtionelectrical stimualtion

33 - -denervation techniquesdenervation techniques

44 - -augmentation cystoplastyaugmentation cystoplasty

MANAGEMENTMANAGEMENTEMPTYING FAILUREEMPTYING FAILURE

11 - -Non surgicalNon surgical

a) Non pharmacologica) Non pharmacologic

b) Pharmacologicb) Pharmacologic

22 - -surgicalsurgical


NON PHARMACOLOGICNON PHARMACOLOGIC11 - -Valsalva Valsalva –– crede manuver: crede manuver:

Increase I.V.P Increase I.V.P

22 - -trigger voidtrigger void

33 - -clean intermittent clean intermittent catheterization( catheterization( CICCIC ) )


NON PHARMACOLOGICNON PHARMACOLOGICCICCIC

11 - -safesafe22 - -extremely effectiveextremely effective

33 - -most practical means of attaining catheter most practical means of attaining catheter - free state- free state

44 - -preserves the independencepreserves the independence55 - -protects the kidneysprotects the kidneys

66 - -prevents incontinenceprevents incontinence77 - -decrease infectionsdecrease infections

88 - -non expensivenon expensive


NON PHARMACOLOGICNON PHARMACOLOGICCICCIC

99 - -can be used in all types of dysfunctioncan be used in all types of dysfunction

1010 - -decrease residue after a whiledecrease residue after a while

- -If the patient can eat or write can do CICIf the patient can eat or write can do CIC

Cornerstone of treatmentCornerstone of treatment

MANAGEMENTMANAGEMENTEMPTYING FAILUREEMPTYING FAILURE PHARMACOLOGICPHARMACOLOGIC

11 - -bethanecholbethanechol??

22 - -baclofenbaclofen

33 - -prosteglandinprosteglandin????

MANAGEMENTMANAGEMENT EMPTYING FAILUREEMPTYING FAILURE

SURGICALSURGICAL11 - -electrical stimulationelectrical stimulation

22 - -bladder myoplstybladder myoplsty

33 - -reduction cytoplastyreduction cytoplasty

neurogenic bladder dr. sh. alaie neurologist. neurogenic bladder definition is a malfunctioning...

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