Dr,mohamed fawzi alshahwani Neurogenic bladder Dr,mohamed fawzi alshahwani

The urinary bladder is probably the only visceral smooth muscle that is under complete voluntary control from cerebral cortex It has both somatic & autonomic innervations The functional features include: A normal capacity of 400 – 500 ml Sensation of fullness Volume change without change in intraluminal pressure Initiation & maintenance of contraction until bladder is empty Voluntary initiation or inhibition of voiding

Innervation The sphincteric unit In both male & females : two sphincters Internal involuntary SM sph. at bladder neck External voluntary striated M. sph. from the prostate to membranous urethra in males & at mid urethra in females Innervation Parasympathetic : S 2 – 4 Symp. : T10 – L 2 Somatic motor innervation :S 2 – 3 though the pudendal N.

Classification of neurogenic bladder Upper motor neuron , spastic , uninhibited : injury above spinal cord micturition center Lower motor neuron, flaccid , atonic, areflexic : injury in the pelvic nerves or spinal micturition center

N.B. Spinal shock Immediately after injury, regardless of the level, there is a stage of flaccid paralysis with numbness below the level of the injury that lead to bladder overfilling to the point of overflow incontinence & rectal impaction. It last few weak up to 6 months during this ti;e bladder should be drained by a catheter

Clinical picture UMNL : reduced capacity , involuntary detrusor contraction , high intravesical detrusor pressure , spasticity of pelvic striated M. , autonomic dysreflexia in cervical cord lesions LMNL : large bladder capacity, lack of voluntary detrusor contraction, low intravesical pressure, deceased tone in external sph. N.B.: full neurologic exam. Is required for those patients

Investigations Urinalysis Renal function test Imaging study Instrumental exam. Cystoscopy Urodynamic studies

UDS

Differential diagnosis Cystitis Chronic urethritis Vesical irritation 2ry to psychic disturbance Interstitial cystitis Cystocele Infravesical obstruction

Treatment : -Spinal shock The treatment is guided by the need to restore low pressure activity to the bladder in order to preserve renal function, continence, & control infection -Spinal shock bladder drainage is required by intermittent catheterisation , indwelling catheter or suprapubic cystostomy Increase fluid intake to 2 – 3 l/day

- Spastic neuropathic bladder Voiding by trigger tech. Anticholinergic medications (parasympatholytic drugs) like oxybutynin(ditropan) 5mg 2-3 times /day Indwelling catheter or CIC Condom catheter & leg bag Sphincterotomy Sacral rhizotomy at S 3-4 Neurostimulation Urinary diversion

Flaccid neuropathic bladder - Crede maneuver ( manual suprapubic pressure) accompanied by straining Bladder training & care , voiding every 2hr CSIC every 3-6 hr TUR in hypertrophied bladder neck or BPH parasympathmimetic drugs like bethanecol chloride( Urecholine) 5 – 50 mg every 6-8hr

complications Infection : cystitis, periurethritis, prostatitis, epididymoorchitis, pyelonephritis Hydronephrosis Calculus Renal imperment Autonomic dysreflexia: , dramatic elevation in systolic &/or diastolic pressure, increase pulse pressure, bradycardia, headache, piloerection. brought by over distention of the bladder in patients with cord lesion above T1

Treatment of autonomic dysreflexia immediate catheterisation oral nifedipine (20mg) 30 min before cystoscopy as prophylaxis alpha adrenergic blockers

calculosis, hydronephrosis prognosis The greater threat to those pt is progressive renal damage caused by pyelonephritis , calculosis, hydronephrosis