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

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

3. 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

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

5. 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

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

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

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

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

13. 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

14. 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

15. 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

16. 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

17. 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.

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

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

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

21. NEUROGENIC BLADDER
NEUROLOGIC DISEASES

22. 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

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

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

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

26. 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

27. 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

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

29. 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

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

31. 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

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

33. 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)

34. 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 .

35. 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

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

37. 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

39. 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.

40. 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.

41. 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…??

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

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

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

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

46. 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

47. 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

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

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