Dr. sh. Alaie Neurologist NEUROGENIC BLADDER Dr. sh. Alaie Neurologist

NEUROGENIC BLADDER Definition Is a malfunctioning bladder due to any type of neurologic disorder.

NEUROGENIC BLADDER Voiding: 1)Filling = storage :bladder acts as low pressure receptacle Sphincter high resistance 2)Voiding = Emptying :Bladder contracts Sphincter opens Both Should be done in Normal Pressure

Normal Voiding:1)Normal Detrusor 4-8 /day 2)Normal Sphincter 3)Synergy 4)Voluntrily Normal Pressure

Anatomy BRAIN Master control of the entire Urinary system Medial aspect of Precentral gyrus Inhibitory signal to detrussor until a suitable time &place Injury :1)Unawareness to entire voiding process 2) Spastic bladder

ANATOMY PONS PMC:coordinating Bladder &Urethral Sphincter =Synergy Facilitate Urination 1)detrussur contraction 2)sphincter relaxation Ingury :1)Spastic bladder 2)DSD

ANATOMY SPINAL CORD Supra sacral:intermediary between PMC &Sacral cord Lat.CorticoSpinal &ReticuluSpinal Injury: 1)Spastic Bladder 2)DSD

ANATOMY Sacral cord Primitive Voiding Center for Reflex Arc S2,S3,S4 Injury :Detrusor Areflexia

ANATOMY Peripheral nerves 1)Sympathetic :bladder & internal sphincter 2)parasympathetic: bladder 3)Somatic:Onuf neucleus: Ex.sphincter Injury:Areflexic bladder:sensory /motor

Physiology 1)Filling accumulation of urine while the pressure is low If Pv >Pu : Urine Leackage Reflux Sympathetic :1)inhibit parasympathetic 2)relaxation &expansion of detrussor 3)close the bladder neck Pudendal : contraction of the Ex.Sphincter Pu>Pv

NEUROGENIC BLADDER Physiology 2)Emptying: Bladder filling to capacity: stretch receptors:pelvic nerve & Hypogastric nerve Sacral cord:voiding After 3-4 Yr old:sympathetic : relaxes in. sphincter Ps: detrusor contraction Pudendal: relaxation of ex.sphincter Pv>Pu: voiding

TYPES of NEUROGENIC BLADDER 1)Detrusor :Overactive:Impaired filling Underactive:Impaired Emptying 2)Sphincter:Overavtive:Impaired Emptying Underactive:Leackage 3)Loss of coordination:Impaired Emptying

Types of Bladder Dysfunction 1- Failure of Storage (Detrusor Hyperreflexia) 2- Failure of Emptying a) Detrusor Hypoactivity b) Detrusor –Sphincter dyssynergia=DSD 3- Mixed type All can be dangerous to upper tract

SYMPTOMS Storage Failure a) frequency / nocturia Urination>8 times a day or > 2 times over night b) urgency: extreme desire to void c) Incontinency : urge in continence d) hesitancy,intermittency,straining to void,terminal dribbling.

SYMPTOMS Emptying Failure a) feeling of incomplete emptying b) frequency , urgency c) incontinency (overflow) d) hesitancy,intermittency,straining to void,terminal dribbling.

Symptoms are the same in all types! 70% mismanagement based on history alone!

COMPLICATIONS 1)rise in Pv:REFLUX:Hydroureter/Hydronephrosis 2)Retention:Frequent UTI (+reflux:Pyelonephritis) 3)Urinary stones 4)Impaired social & personal life

NEUROGENIC BLADDER NEUROLOGIC DISEASES

Voiding dysfunction is important in multiple sclerosis Because of: 1- Frequency (up to 90% of patients) 2- Serious complications: 55% → 5% 3- Impairment of social &personal life & sexual activity 4- Could be successfully managed 5- Social & cultural aspects

MS SYMTOMS - Voiding dysfunction may be the sole initial complaint ( 2.3% ). - Or part of the presenting symptoms ( 10% )

NEUROLOGIC DISEASES CVA Cerebral Shock:Det.Areflexia:Retention Afew weeks/months later:Det.Hyperreflexia

NEUROLOGIC DISEASES MSA Urinary symptoms are common Come early (60% before or associated with other symptoms Even 4yr before diagnosis

AUTONOMIC DYSREFLEXIA Is a lethal emergency Acute massive disorderd autonomic(S) response to specific stimuli in SC injury above T6- T8 More common in cervical After shock period but up to yrs after injury Stimuli below level of the lesion

AUTONOMIC DYSREFLEXIA Headache/HTN(even ICH or sezure) Flashing of face,body above the lesion Sweating Usually bradycardia,maybe tachycardia/arrhytmia Stimulus from: bladder/rectum: distention,manipulation GI/bone FX /sexual activity /bed sore

AUTONOMIC DYSREFLEXIA Endoscopic procedure: spinal/ general anesthesia SL niphedipin/ oral niphedipin/ trazocin Significant rise in BP without other symptoms

Diagnosis 1- History: ask strictly about voiding symptoms and feeling of incomplete emptying 2- exam: pelvic exam Sacral reflex exam Signs of spinal cord involvment 3- Lab : U/A, U/C, BUN, Cr

Diagnosis 4- Imaging : sonography a) Anatomy b) Residue ( up to 100CC)

Diagnosis 5- In – out catheter method: a) Well hydrated for 48 hr b) Drink 2 glasses of water, before exam c) First desire to void = capacity(300 – 500cc) d) Measure residue after voiding

Diagnosis Urodynamic study A general term for the study of the storage and voiding function

Diagnosis Urodynamic study a) Bladder eapacity (300 – 500cc) b) Detrussor pressure, Max 10 Cm H2o c) DSD d) Detressor instability e) L.P.P (leak point pressure)

Diagnosis Urodynamic study Indication - urologic problems: Contraversy - Neurologic problems: All with neurogenic bladder should undergo urodynamic study to characterize the nature of the problem and to determine prognosis and management .

MANAGEMENT GOALS 1- upper tract preservation 2- absence or control of infection 3- adequate storage at low I.V.P 4- adequate emptying at low I.V.P 5- adequate control 6- no catheter 7- social acceptability

MANAGEMENT STORAGE FAILURE 1) Non surgical: a) Non pharmacologic b) Pharmacologic 2) surgical

MANAGEMENT STORAGE FAILURE NON PHARMACOLOGIC 1- voiding diary: 3-5 days a) Total 24hr urinary output b) Number of voids c) Voiding interval d) Diurnal distribution e) Timing and triggers for incontinence

MANAGEMENT STORAGE FAILURE Bladder training program : 1- lengthen the amount of time between voiding. 2- increase the amount of urine the bladder can hold . 3- improves the control over the urge. 4- patient gives voiding program to his bladder.

MANAGEMENT STORAGE FAILURE BLADDER TRAINING PROGRAM 1- Kegel exercise. 2- delaying urination,5 min → 10 min Walk instead of running at urge Relaxation techniques 3- sheduled bathroom trips: Every 1hr initially. 4- irritating factors: Alcohol, caffeine, acidic foods (tomatoes, grapefruit) 5- change of temperature. 6- bio feedback and acupuncture.

MANAGEMENT STORAGE FAILURE pharmacologic 1- anti cholinergics: a) Tolterodine 1-2 mg/bid b) Oxybutinine 5 mg/TDS 2- TCA: imipramin 25 mg/day 3- desmopressin , spray, 1-2 puff 4- Ca antagonists/potassium channel openers/prostaglandin inhibitors…??

MANAGEMENT STORAGE FAILURE pharmacologic Warning!!! Anticholinergic: 1- check for residue before 2- check for pharmacologic retention after

MANAGEMENT STORAGE FAILURE SURGICAL 1- intravesical injection of botolinum toxin oxybutinin capsaicin? 2- electrical stimualtion 3- denervation techniques 4- augmentation cystoplasty

MANAGEMENT EMPTYING FAILURE 1- Non surgical a) Non pharmacologic b) Pharmacologic 2- surgical

MANAGEMENT EMPTYING FAILURE NON PHARMACOLOGIC 1- Valsalva – crede manuver: Increase I.V.P 2- trigger void 3- clean intermittent catheterization( CIC )

MANAGEMENT EMPTYING FAILURE NON PHARMACOLOGIC CIC 1- safe 2- extremely effective 3- most practical means of attaining catheter - free state 4- preserves the independence 5- protects the kidneys 6- prevents incontinence 7- decrease infections 8- non expensive

MANAGEMENT EMPTYING FAILURE NON PHARMACOLOGIC CIC 9- can be used in all types of dysfunction 10- decrease residue after a while - If the patient can eat or write can do CIC Cornerstone of treatment

MANAGEMENT EMPTYING FAILURE PHARMACOLOGIC 1- bethanechol? 2- baclofen 3- prosteglandin??

MANAGEMENT EMPTYING FAILURE SURGICAL 1- electrical stimulation 2- bladder myoplsty 3- reduction cytoplasty