NEUROGENIC BLADDER. Dr Harriet Grubb Dr Alison Seymour Dr Alexander Joseph
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1 NEUROGENIC BLADDER Dr Harriet Grubb Dr Alison Seymour Dr Alexander Joseph
2 OUTLINE Definition Anatomy and physiology of bladder function Types of neurogenic bladder Assessment and management Complications of neurogenic bladder
3 NEUROGENIC BLADDER Disorder of the lower urinary tract Caused by central and/or peripheral nervous system damage or disease
4 SCHEMATIC DIAGRAM OF THE LOWER URINARY TRACT Ureter Detrusor Muscle of the Bladder Internal Urethral Sphincter External Urethral Sphincter
5 STORAGE VOIDING
6 AREAS OF THE NERVOUS SYSTEM INVOLVED WITH MICTURITION BRAIN BRAINSTEM CERVICAL SPINAL CORD C1-C8 THORACIC SPINAL CORD T1-T12 LUMBAR SPINAL CORD L1-L5 SACRAL SPINAL CORD S1-S5 BRAIN PONTINE MICTURITION CENTRE THORACOLUMBAR REGION T11-L2 SACRAL MICTURITION CENTRE S2-S4
7 NERVES ORIGINATING FROM SACRAL MICTURITION CENTRE Pelvic nerve Parasympathetic Acetylcholine SMC S2-S4
8 NERVES ORIGINATING FROM SACRAL MICTURITION CENTRE Pudendal nerve Somatic Acetylcholine SMC S2-S4
9 NERVES ORIGINATING FROM THORACOLUMBAR REGION T11-L2 Hypogastric nerve Sympathetic Noradrenaline Thoraco -lumbar region T11- L2
10 NERVES ORIGINATING FROM THORACOLUMBAR REGION T11-L2 Hypogastric nerve Sympathetic Noradrenaline Thoraco -lumbar region T11-L2
11 PMC PONTINE MICTURITION CENTRE
12 BRAIN
13 BRAIN
14 BLADDER STORAGE
15 VOIDING
16 TYPES OF NEUROGENIC BLADDER LESIONS ABOVE THE PONTINE MICTURITION CENTRE Uninhibited bladder Cortex no longer has inhibitory control of PMC Frequency Reduced awareness of bladder fullness Uncontrolled and potentially socially unacceptable voiding
17 TYPES OF NEUROGENIC BLADDER LESIONS BETWEEN PMC AND SMC Upper motor neurone bladder Loss of inhibition from higher centres Emptying via spinal reflex
18 Spinal Reflex of bladder emptying following spinal cord lesion SMC
19 TYPES OF NEUROGENIC BLADDER LESIONS BETWEEN PMC AND SMC Lack of inhibition from brain and PMC leads to overactivity and hyper-reflexive Urgency Frequency Incontinence Reduced bladder capacity
20 TYPES OF NEUROGENIC BLADDER LESIONS BETWEEN PMC AND SMC Initial spinal shock (typically 6-12 weeks) Areflexia Urinary retention No awareness of bladder filling
21 TYPES OF NEUROGENIC BLADDER LESIONS BETWEEN PMC AND SMC Detrusor Sphincter Dyssynergia (DSD) Pudendal nerves also involved in spinal reflex contraction of external urethral sphincter (EUS) Loss of co-ordination between detrusor muscle and EUS If simultaneous contraction high bladder pressures Voiding interrupted or incomplete Incontinence Complications vesico-ureteric reflux
22 TYPES OF NEUROGENIC BLADDER LESIONS BELOW THE SPINAL CORD The nerves roots are affected causing a lower motor neurone lesion Pelvic nerve damage inhibits contraction of the detrusor muscle Hypogastric nerves are still intact also having a relaxing affect on the detrusor Internal sphincter is still contracted from the hypogastric nerve Flaccid/areflexic bladder Bladder distension and overflow incontinence
23 TYPES OF NEUROGENIC BLADDER In practice many patients have a mixed picture of bladder problems, particularly if the injury is around sacral/conus regions of the spinal cord
24 ASSESSMENT
25 ASSESSMENT AND MANAGEMENT OF NEUROGENIC BLADDER
26 ASSESSMENT History should include: Urinary tract symptoms storage/emptying/both Neurological symptoms and diagnosis Bowel symptoms Examination: Blood pressure Abdominal examination External genitalia Focused neurological examination
27 RED FLAG SYMPTOMS Haematuria Recurrent UTIs Loin pain Recurrent catheter blockages Hydronephrosis or kidney stones Deterioration in kidney function Urgent urology referral
28 INVESTIGATIONS Urine dip +/- MSU or CSU Bladder diary Post void bladder scan If high risk of renal complications: Renal ultrasound Urodynamics Cystoscopy
29 MANAGEMENT OF STORAGE SYMPTOMS
30 MANAGEMENT General advice: Avoidance of bladder irritants Maintaining good fluid intake Avoiding constipation Medications
31 Medications for neurogenic bladder Beta 3 agonist STORAGE Hypogastric nerve Sympathetic Noradrenaline Antimuscarinics Thoraco -lumbar region T11- L2 VOIDING Alpha blockers
32 ANTIMUSCARINICS Main medications used are: Solifenacin Oxybutinin Tolderidone Darifenacin Trospium Fesoterodine
33 BOTULINUM TOXIN Licenced for use if antimuscarinic treatment has failed Patients may require a catheterisation regime following treatment as bladder emptying impaired Injected directly into bladder wall under cystoscopy guidance
34 MANAGEMENT OF VOIDING SYMPTOMS
35 FAILURE OF BLADDER EMPTYING Intermittent self-catheterisation Indwelling urethral catheter Suprapubic catheter
36 COMPLICATIONS OF NEUROGENIC BLADDER
37 URINARY TRACT INFECTIONS Most common cause of sepsis in patients with spinal cord injury More likely if: Infrequent ISC Assisted intermittent catheterisation Indwelling catheter Avoid treating asymptomatic bacteriuria
38 URINARY CALCULI Suspect if: Recurrent UTIs Recurrent catheter blockages Haematuria Can lead to ureteral obstruction and hydronephrosis
39 VESICOURETERAL REFLUX Due to persistently high bladder pressures and detrusorsphincter dyssynergia Can lead to pyelonephritis, hydronephrosis and renal impairment
40 BLADDER CANCER Those at risk include those with long-standing symptoms or recurrent UTI Patients with red-flag symptoms should be referred for urgent urology assessment
41 THANK YOU FOR LISTENING
42 REFERENCES Wein AJ, Rackley RR. Overactive bladder a better understanding of Pathophysiology, Diagnosis and Management. Journal of Urology 2006:175;S5-S10 Abrams GM, Wakasa M. Chronic complications of spinal cord injury and disease. Available from URL: National Institute of Health and Care Excellence Urinary incontinence in neurological disease: assessment and management. Available from URL: Fowler CJ, O Malley KJ. Investigation and Management of Neurogenic Bladder Dysfunction. J Neurol Neurosurg Psychiatry 2003;74:iv27-iv31
43 REFERENCES Neurogenic Bladder Review Article - Peter Dorsher and Peter McIntosh Advances in Urology Vol Article ID Neuro-urology guidelines - European association of Urology The Epidemiology and Pathophysiology of Neurogenic Bladder - David Ginsberg International Continence Society Fact sheets - August 2015 Physiology of Micturition - Armando Hasudungan The prognosis and Management of Neurogenic Bladder University of Michigan Health System Management of Neurogenic Bladder for Adults with Spinal Cord Injuries ACI NSW Agency for Clinical Innovation
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