1. Dr,mohamed fawzi alshahwani
Neurogenic bladder
Dr,mohamed fawzi alshahwani

2. 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

3. 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.

4. 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

5. 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

6. 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

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

9. UDS

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

11. 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

12. - 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

13. 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 hr

14. 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

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

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