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1 Bladder dysfunction Dr behnaz ansari

2 Anatomic Considerations: in the autonomic nervous system there are always two efferent neurons serving this function, one (preganglionic) arising from its nucleus in the brainstem or spinal cord and the other (postganglionic) arising from specialized nerve cells in peripheral ganglia

4 The autonomic nervous system, from an anatomic point of view, is divided into two parts: the craniosacral, or parasympathetic, and the thoracolumbar, or sympathetic The systems differ architecturally in that the ganglion in the sympathetic nervous system is located in a contiguous and interconnected, longitudinal chain (sympathetic chain) paravertebrally, whereas the parasympathetic ganglia are distributed in proximity to the structures they innervate. Moreover, the main neurotransmitter of the postganglionic connection to the end organ is norepinephrine in the case of the sympathetic nerves and acetylcholine for parasympathetic innervation. There are exceptions with regard to the sympathetic innervation of sweat glands (sudomotor), which are cholinergic.

6 The Parasym pathetic Nervous System: There are two divisions of the parasympathetic nervous system: cranial and sacral. The cranial division originates in the visceral nuclei of the midbrain, pons, and medulla. These nuclei include the Edinger-Westphal pupillary nucleus, superior and inferior salivatory nuclei, dorsal motor nucleus of the vagus, and adjacent reticular nuclei.

7 The preganglionic fibers from the Edinger-Westphal nucleus traverse the oculomotor nerve and synapse in the ciliary ganglion in the orbit; axons of the ciliary ganglion cells innervate the ciliary muscle and pupillary sphincter. The preganglionic fibers of the superior salivatory nucleus enter the facial nerve and, at a point near the geniculate ganglion, form the greater superficial petrosal nerve, through which they reach the sphenopalatine ganglion; postganglionic fibers from the cells of this ganglion innervate the lacrimal gland.

8 Other fibers originating in the saliva tory nuclei are carried in the facial nerve and traverse the tympanic cavity as the chorda tympani to eventually join the submandibular ganglion. Cells of this ganglion innervate the submandibular and sublingual glands. Axons of the inferior saliva tory nerve cells enter the glossopharyngeal nerve and reach the otic ganglion through the tympanic plexus and lesser superficial petrosal nerve; cells of the otic ganglion send fibers to the parotid gland. Preganglionic fibers, derived from the dorsal motor nucleus of the vagus and adjacent visceral nuclei in the lateral reticular formation (mainly the nucleus ambiguus), enter the vagus nerve and terminate in ganglia situated in the walls of many thoracic and abdominal viscera.

10 The sacral part of the parasympathetic system originates in the lateral horn cells of the second, third, and fourth sacral segments. Axons of these sacral neurons, constituting the preganglionic fibers, traverse the sacral spinal nerve roots of the cauda equina and synapse in ganglia that lie within the walls of the distal colon, bladder, and other pelvic organs

13 The Sympathetic Nervous System: The preganglionic neurons of the sympathetic division originate in the intermediolateral cell column of the spinal gray matter, from the eighth cervical to the second lumbar segments. The axons of the nerve fibers originating in the intermediolateral column are of small caliber and are myelinated; when grouped, they form the white comm unicating rami. These preganglionic fibers synapse with the cell bodies of the postganglionic neurons, which are collected into two large ganglionated chains or cords, one on each side of the vertebral column (paravertebral ganglia), and several single prevertebral ganglia. These constitute the sympathetic ganglia.

14 Axons of the sympathetic ganglion cells are also of small caliber but are unmyelinated. Most of the postganglionic fibers pass via gray communicating rami to their adjacent spinal nerves of T5 to L2; they supply blood vessels, sweat glands, and hair follicles, and also form plexuses that supply the heart, bronchi, kidneys, intestines, pancreas, bladder, and sex organs

15 The sympathetic innervation of the adrenal medulla is unique in that its secretory cells receive preganglionic fibers directly, via the splanchnic nerves. This is an exception to the rule that organs innervated by the autonomic nervous system receive only postganglionic fibers. This special arrangement can be explained by the fact that cells of the adrenal medulla are the morphologic homologues of the postganglionic sympathetic neurons and secrete epinephrine and norepinephrine (the postganglionic transmitters) directly into the bloodstream

16 There are 3 cervical (superior, middle, and inferior, or stellate), 11 thoracic, and 4 to 6 lumbar sympathetic ganglia. The head receives its sympathetic innervation from the eighth cervical and first two thoracic cord segments.

17 Postganglionic fibers from cells of the superior cervical ganglion follow the internal and external carotid arteries and innervate the blood vessels and smooth muscle, as well as the sweat, lacrimal, and salivary glands of the head. Included among these postganglionic fibers, issuing mainly from Tl, are the pupillodilator fibers and those innervating the Muller muscle of the upper eyelid. The arm receives its postganglionic innervation from the inferior cervical ganglion and uppermost thoracic ganglia (the two are fused to form the stellate ganglion). The cardiac plexus and other thoracic sympathetic nerves are derived from the stellate ganglion and the abdominal visceral plexuses, from the fifth to the ninth or tenth thoracic ganglia

20 The Central Regulation of Visceral Function: Integration of autonomic function takes place at two levels,the brainstem and the cerebrum. In the brainstem, the main visceral afferent nucleus is the nucleus tractus solitarius (NTS). The caudal NTS integrates these signals and projects to a number of critical areas in the hypothalamus, amygdala, and insular cortex The supranuclear regulatory apparatus of the hypothalamus includes three main cerebral structures: the frontal lobe cortex, the insular cortex, and the amygdaloid and adjacent nuclei

21 Sympathetic responses are most readily obtained by stimulation of the posterior and lateral regions of the hypothalamus, and parasympathetic responses from the anterior regions.

23 Regulation of Bladder Function: the main component of which is the large detrusor (transitional type) muscle; a functional internal sphincter composed of similar muscle; and the striated external sphincter or urogenital diaphragm. in the male, the internal sphincter also prevents the reflux of semen from the urethra during ejaculation.

24 Micturation: For micturition to occur, the sphincters must relax, allowing the detrusor to expel urine from the bladder into the urethra. This is accomplished by a complex mechanism involving mainly the parasympathetic nervous system (the sacral peripheral nerves derived from the second, third, and fourth sacral segments of the spinal cord and their somatic sensorimotor fibers) and, to a lesser extent, sympathetic fibers derived from the thorax. The vaguely localizable brainstem "micturition centers, with their spinal and suprasegmental connections, may contribute.

26 The detrusor muscle receives motor innervation from nerve cells in the intermediolateral columns of gray matter, mainly from the third and also from the second and fourth sacral segments of the spinal cord (the "detrusor center"). These neurons give rise to preganglionic fibers that synapse in parasympathetic ganglia within the bladder wall. There are also beta-adrenergic receptors in the dome of the bladder, which are activated by sympathetic fibers that arise in the intermediolateral nerve cells of TlO, Tll, and T12 segments. These preganglionic fibers pass via inferior splanchnic nerves to the inferior mesenteric ganglia ; pre- and postganglionic sympathetic axons are conveyed by the hypogastric nerve to the pelvic plexus.

27 The internal sphincter and base of the bladder (trigone), consisting of smooth muscle, are also innervated to some extent by the sympathetic fibers of the hypogastric nerves; their receptors are mainly of alpha-adrenergic type. The external urethral and anal sphincters are composed of striated muscle fibers. Their innervation, via the pudendal nerves, is derived from a densely packed group of somatomotor neurons (nucleus of Onuf) in the anterolateral horns of sacral segments 2, 3, and 4. Cells in the ventrolateral part of Onuf's nucleus innervate the external urethral sphincter, and cells of the mediodorsal part innervate the anal sphincter. The muscle fibers of the sphincters respond to the nicotinic effects of ACh.

29 According to Ruch, the descending pathways from the midbrain tegmentum are inhibitory and those from the pontine tegmentum and posterior hypothalamus are facilitatory. The pathway that descends with the corticospinal tract from the motor cortex is inhibitory. Thus the net effect of lesions in the brain and spinal cord on the micturition reflex, at least in animals, may be either inhibitory or facilitatory.

31 Neurogenic Bladder Dysfunction

33 The storage function of the bladder is affected following suprapontine or infrapontine/suprasacral lesions. This results in involuntary spontaneous or induced contractions of the detrusor muscle (detrusor overactivity), which can be identified during the filling phase of urodynamics. The voiding function of the bladder can be affected by infrapontine lesions. Following spinal cord damage, there is simultaneous contraction of the external urethral sphincter and detrusor muscle, detrusor-sphincter dyssynergia, which results in incomplete bladder emptying and abnormally high bladder pressures. Following lesions of the conus medullaris or cauda equina, voiding dysfunction can be due to poorly non-relaxing urethral sphincters and sustained detrusor contractions.

34 Cortical Lesions: Among patients with disturbed bladder control, various frontal lobe disturbances have been reported: intracranial tumors, damage after rupture of an aneurysm, penetrating brain wounds, and prefrontal lobotomy (leukotomy). The typical clinical picture of frontal lobe incontinence is a patient with severe urgency and frequency of micturition and urge incontinence but without dementia; the patient is Micturition is normally coordinated, indicating that the disturbance is in the higher control of these processes. Urinary retention also has been described in patients with brain lesions.

36 A much less common cause of dementia is normal- pressure hydrocephalus, where incontinence is a cardinal feature. Improvement in urodynamic function has been demonstrated within hours of lumbar puncture (LP) in patients with this disorder.

37 Basal Ganglia Lesions: Bladder symptoms in Parkinson disease (PD) correlate with neurological disability (Araki and Kuno, 2000) and stage of disease; both findings appear to support a link between dopaminergic degeneration and symptoms of urinary dysfunction. The most frequent complaints are of nighttime frequency, urgency, and difficulty voiding (Sakakibara et al., 2001a), and the most common abnormality in urodynamic studies is detrusor overactivity (Araki et al., 2000).

38 In a patient with severe urinary symptoms but mild parkinsonism, a diagnosis of multiple system atrophy (MSA) should be considered. The onset of urogenital symptoms in MSA may precede overt neurological involvement; ED and bladder symptoms begin on average 4 to 5 years before diagnosis and 2 years before more specific neurological symptoms appear.

39 It is thought that detrusor overactivity is caused by neuronal loss in the pontine region, whereas incomplete bladder emptying is caused by loss of parasympathetic innervation of the detrusor after neuronal degeneration in the intermediolateral cell columns of the spinal cord. In addition, anterior horn cell loss in the Onuf nucleus results in denervation of the urethral sphincter so that the patient has a combination of detrusor overactivity, incomplete bladder emptying, and a weak sphincter

40 Brainstem Lesions: Voiding difficulty is a rare but recognized symptom of a posterior fossa tumor and has been reported in series of patients with brainstem disorders (Fowler, 1999). The proximity in the dorsal pons between the pontine micturition center and medial longitudinal fasciculus means that a disorder of eye movements, such as an internuclear ophthalmoplegia (INO), is highly likely in patients with a pontine disorder causing a voiding difficulty.

41 Spinal Cord Lesions: Spinal cord disorders are the most common cause for neurogenic bladder dysfunction. Transspinal pathways connect the pontine micturition centers to the sacral cord. Intact connections are necessary to effect the reciprocal activity of the detrusor and sphincter needed to switch between storage and voiding. After disconnection from the pons, this synergistic activity is lost, resulting in detrusor-sphincter dyssynergia.

43 Initially after acute SCI, there usually is a phase of neuronal shock of variable duration, characterized clinically by complete urinary retention and urodynamics demonstrating an acontractile detrusor. Gradually over the course of weeks, new reflexes emerge to drive bladder emptying and cause detrusor contractions in response to low filling volumes.

44 Because bladder innervation arises more caudally than innervation of the lower limbs, any form of spinal cord disease that causes bladder dysfunction is likely to produce clinical signs in the lower limbs as well, unless the lesion is limited to the conus. This rule is sufficiently reliable to be of great value in determining whether a patient has a neurogenic bladder caused by spinal cord disease.

45 Spinal Cord Injury: After SCI, bladder dysfunction can be of such severity as to cause ureteric reflux, hydronephrosis, and eventual upper urinary tract damage. Before the introduction of modern treatments, renal failure was a common cause of death after SCI.

46 Multiple Sclerosis: The pathophysiological consequences of progressive MS affecting the spinal cord for the bladder are similar to those of SCI. 70% of a self-selected group of patients with MS responding to a questionnaire classified the impact bladder symptoms had on their life as high or moderate (Hemmett et al., 2004).

47 The most common urinary symptom is urgency; all series of urodynamic studies in patients with MS have shown that this is due to detrusor overactivity. Hesitancy of micturition may be a symptom patients volunteer or admit on direct questioning, but the more disabled may find themselves unable to initiate micturition voluntarily, emptying their bladders only with an involuntary hyperreflexic contraction and an interrupted urinary flow. A particular problem in MS is that neurological symptoms may deteriorate acutely when the patient has an infection and pyrexia, including urinary tract infection (UTI).

48 Conus and Cauda Equina Lesions: Impairment of bladder, bowel, and sexual function is particularly difficult for patients to bear psychologically when they are otherwise ambulant and mobile. Although a number of series have reported the urodynamic changes that can occur after a cauda equina lesion, no analysis has been performed to assess the effect of a cauda equina lesion on quality of life.

49 Disturbances of Peripheral Innervation: Diabetic Neuropathy: Urodynamic studies demonstrate impaired detrusor contractility, reduced urine flow, increased postmicturition residual volume, and reduced bladder sensation. It seems likely that vesical afferent and efferent fibers are involved, causing reduced awareness of bladder filling and decreased bladder contractility.

50 Amyloid Neuropathy: Lower urinary tract symptoms generally appear early on and are present in 50% of patients within the first 3 years of the disease. Patients most often complain of difficulty in bladder emptying and incontinence (Andrade, 2009). Immune-Mediated Neuropathies: Approximately one-fourth of patients with Guillain-Barré syndrome have bladder symptoms. These symptoms usually occur in those patients with more severe neuropathy and appear after limb weakness is established. Both detrusor areflexia and bladder overactivity have been described.

51 Autoimmune Autonomic Ganglionopathy Pure Autonomic Failure Myotonic Dystrophy

52 Urinary Retention in Young Women Fowler syndrome : Urinary retention or symptoms of obstructed voiding in young women in the absence of overt neurological disease have long puzzled urologists and neurologists alike, and in the absence of any convincing organic cause, the condition was once said to be hysterical. The typical clinical picture is that of a young woman in the age range of 20 to 30 years who presents with retention and a bladder capacity greater than 1 L.

53 MRI of the brain, spinal cord, and cauda equina are normal. The lack of sacral anesthesia makes a cauda equina lesion improbable. An association between this syndrome and polycystic ovaries was described in the original description of the syndrome. In some young women with urinary retention, concentric needle electrode examination of the striated muscle of the urethral sphincter reveals complex repetitive discharges and myotonialike activity, decelerating bursts. it could until recently only be managed symptomatically. However, it is now known that these patients respond particularly favorably to sacral neuromodulation.

55 Diagnostic Evaluation: History Bladder Diary Physical Examination Screening for Urinary Tract Infections Bladder Scan Ultrasound Scan Urodynamic Studies

56 Urodynamic Studies: Urodynamic studies examine the function of the lower urinary tract. Included in this aspect of evaluation are measurements of urine flow rate and residual volume, cystometry during both filling and voiding, videocystometry, and urethral pressure profilometry.

57 NONINVASIVE BLADDER INVESTIGATIONS: A commonly used design for a flow meter consists of a commode or urinal into which the patient passes urine as naturally as possible. In the base of the collecting system is a spinning disc. The urinary flow is calculated based upon the power necessary to maintain the rotation speed. A graphic printout of the urinary flow is obtained, and time taken to reach maximum flow, maximum and average flow rates, and voided volume are analyzed. It is important that the patient performs the test with a comfortably full bladder containing, if possible, a volume of at least 150 ml.

60 INVESTIGATIONS REQUIRING CATHETERIZATION: Cystometry evaluates the pressure/volume relationship during nonphysiological filling of the bladder and during voiding. The detrusor pressure is derived by subtraction of the abdominal pressure (measured using a catheter in the rectum) from the intravesical pressure (measured using a catheter in the bladder). The rate of filling is recorded by the machine, which pumps sterile water or saline through the catheter in the bladder. For speed and convenience, most laboratories use filling rates of between 50 and 100 ml/min. This nonphysiological rapid filling does mean that the full bladder capacity can be reached usually within 7 or 8 minutes. The first sensation of bladder filling may be reported at around 100 ml, and full capacity is reached between 400 and 600 ml. In healthy persons, the bladder expands to contain this amount of fluid without an increase of pressure more than 15 cm H2O.

61 When bladder filling has been completed, the patient voids into the flow meter, with the bladder and rectal lines still in place. Valuable information can be obtained by measuring detrusor pressure and urine flow simultaneously.

63 Electromyography: EMG has been used to demonstrate changes of reinnervation in the urethral or anal sphincter in a few neurogenic disorders. Lesions of the cauda equina Isolated urinary retention in young woman anterior horn cells in the Onuf nucleus are selectively lost in MSA, and this results in changes in the sphincter muscles that can be identified by EMG.

65 Management of Neurogenic Bladder Dysfunction: Voiding Dysfunction: Intermittent self-catheterization Reflex voiding using trigger techniques and the Credé maneuver (nonforceful, smooth, even pressure applied from the umbilicus toward the pubis) are usually not recommended, as they may result in high detrusor pressure and incomplete bladder emptying during voiding (Fowler et al., 2009). Suprapubic vibration using a mechanical buzzer has been demonstrated to be effective in patients with MS with incomplete bladder emptying and detrusor overactivity, but its effect is limited (Prasad et al., 2003). Alpha-blockers relax the internal urethral sphincter in menbladder outlet obstruction. Botulinum toxin injections

66 Storage Dysfunction: Antimuscarinic Medications Desmopressin Cannabinoids Botulinum Toxin Vanilloids Sacral Neuromodulation Nerve Root Stimulators Surgery

70 Case report: A 66-year-old woman suffered from severe stress incontinence which had gradually developed into continuous urinary incontinence. Video-urodynamic studies at the first presentation demonstrated an a contractile detrusor without bladder sensation (bladder sensation at first desire to void >600 ml) in cystometry and activity in the external-sphincter electromyography with a needle electrode. On standing up, almost all of her urine leaked without postvoid residual urine, with a Valsalva leak point pressure of less than 45 cm H 2 O, indicating an intrinsic sphincter deficiency (Fig. 1). There were no neurological abnormalities including touch, pain sensations and motor weakness, and the patella tendon reflex and Achilles tendon reflex were normal.

72 Two years later, the patient suddenly experienced syncope, and thus visited the emergency room. She underwent a tracheotomy because of bilateral paralysis of the vocal cords

73 Three years later, she had difficulty in using her hands and also experienced gait difficulty. She was hospitalized because she could no longer carry out intermittent self-catheterization and also had a urinary tract infection. A neurological examination revealed a weakness of the extensor and flexor muscle of the neck, and disproportionate antecollis, and orthostatic hypotension (blood pressure on supine position: 140/80 mmhg, on standing up: 100/70 mmhg). The Jaw reflex, Patella tendon reflex and Achilles tendon reflex was brisk, and rigidity and akinesia were noted. Cerebellar ataxia including a positive finger-nose test and knee-toe test was noted.

75 What guess?

Chapter 16. APR Enhanced Lecture Slides

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