Definition: Neurogenic bladder Neurogenic bladder is a type of dysfunction of the bladder due to neurological disorder. Types: Nervous system diseases: Congenital: like myelodysplasia like meningocele. Acquired: like Parkinson & the spinal cord trauma Metabolic diseases: Like DM that causes peripheral neuropathy especially sympathetic & parasympathetic of the bladder. Detrusal muscle disease: That includes any neuropathy in the detrusal muscle esp. the fibrotic disease or fibrosis due to chronic inflammation. Classification: - Hyperactive or overactive - Hypoactive Manifestations: From the symptoms we have incontinence or urinary retention; these are the main imp. Symptoms. Also there is the Lower urinary tract symptoms like: suprapubic pain, pain in micturation, frequency, urgency, urge incontinence, difficulty in urination, poor stream and nocturia. Sometimes we will have added complications associated with these symptoms like infections due to stasis of the urine.
Let us take incontinence as it s the main symptom. Incontinence : Involuntary loss of urine. Types: - Stress incontinence: Due to weakness of the pelvic floor muscles and sometimes intrinsic deficiency of the urethra and not related to neurogenic bladder. (eg: when coughing, sneezing) - Urge incontinence: It's the strong desire to void (eg: when you are outside) It is one of the main symptoms of the neurogenic bladder. We have two types of urge: motor(involuntary contraction of detrusor muscle). sensory (it's a feeling, any inflammatory process can cause it like cystitis) and the two are related to the nervous system. -Mix (stress + Urge) - Overflow incontinence: Sometimes it is related and sometimes it is not. If we take prostate it is due to obstruction (the urine will accumulate in the bladder then there is leaking- not related to neurogenic bladder. Sometimes if there is increasing in the resistance of the flow due to neurogenic bladder then we will have filled bladder and the emptying will be difficult and sometimes it is due to organic disease like strictures, bladder neck contracture or prostatic diseases like BPH or cancer. It can cause acute or chronic retention. - True incontinence: Not related to the neurogenic bladder and it is due to defect in the external sphincter from trauma or iatrogenic then leaking occurs. - Psychogenic incontinence: Also not related it is due to alteration to the psych of the patient.
To differentiate between Urgent, Stress, Overflow and True: Urgent not palpable either if it's full or empty. Stress you use cystogram produces dye contrast picture (make patient cough for angle measurement, u will be able to know if the bladder neck is hyper/hypo mobile) Functional study of LUT ( urodynamic study) is better. Overflow always palpable. Any mass in abdomen think of neurogenic bladder. If mass below abdomen think of uterus in female & in male think of bladder. True find the scar, on palpation or percussion the bladder will be empty, cystoscopy enable to see the sphincter. *Mixed: difficult TT, do surgery if not diagnosed early no benefit. Diagnosis: - From the history it is easy to decide the cause of the incontinence, sometimes he had a prostate operation then a trauma may occur to the sphincter so it is true incontinence. So history is very imp from the patient profile to the social history, for example if a child has urine incontinence it is mostly neurogenic bladder. If an old male patient in the 70s it is mostly from the prostate. How to differentiate between hyper and hypo-active, if for example he had a lumbar spine disc prolapsed hypoactive, DM-hypoactive. The history will not lead us exactly to the diagnosis. - From physical examination like feeling the anal tone, feel bladder if full. - Investigations: other than regular urine analysis and urine culture as if we have infection, urodynamic studies specific for function disorder of the LUT. Causes Neurogenic Bladder: - Trauma - Disease - Tumor
- Upper motor neuron disease ( hypertonic, hyperreflexia ) *Complications: 1) increase intravesical pressure or overflow incontinence. Both can lead to renal failure. 2) Infections. -Lower motor neuron (atonic) Both can do urge or overflow incontinence Investigation for any incontinence: CBC, LFT, urine culture, urine analysis, ultrasound. These are a group of tests: Ultrasound: Is the simplest one that used to decide if there is any residual volume in the bladder. The normal residual volume in the adults is up to 50 cc (< 10% of bladder capacity). The normal residual volume differ according to the age we have a formula *{age x 30 ± 30}. Uroflowmetry: A device like the bathroom to measure the flow rate. We concerned with the maximum flow rate (Q-max), average flow rate, voiding volume, time of voiding and the shape of the curve. 1) The shape of the uroflowmetry curve, normally it is bell shape. 2) Qmax: normally it is 3-5 sec. more than 5 it is abnormal. Maximum flow rate differ from males and females. Normal value 20-25 ml/sec in males, 25-30 ml/sec in females. The critical value is 15 ml/sec. Average flow rate is 2/3 of the maximum flow rate.
3) Residual volume: measured by catheter or ultrasound, Normal is <10% (<50cc) If between 10 50% there is significant residual volume. If > 50% chronic retention. 2 to 3 second to initiate urine " if greater its hesitancy" Abnormal uroflowmetry curve shapes like: 1- Intermittent shape that is caused by straining
2- Box shape uroflowmetry occur usually in strictures. 3- And in this shape Qmax is lower than normal, poor stream and a big tail "long term "usually seen in benign prostate hyperplasia. 4- detrusor underactivity. Poor contractility of the bladder >> interrupted flow; because the pt is straining. Cystometry Is the more sophisticated one that measure the detrusal pressure and its relation to the volume. It is an invasive procedure and we enter urethral catheter to measure the vesical pressure and enter a rectal catheter to measure the abdominal pressure. Normally, the cystometry is composed of 2 phases: the filling phase and the voiding phase.
It has a sensor that measure and records it on a diagram that has four lines: 1- Abdominal pressure. 2- intravesical pressure. 3- Detrusal pressure. 4- Flow rate. Pressure Volume Detrusor P = intravesical P Abdominal P Ex; when u cough a peak appear in P abd and P vesical but has no effect on P detrusor. If u see a peak in flow rate line it means stress incontinence. Another ex; detrusor muscle involuntary contraction leading to peak appearing in intr vesical pressure line. Last ex; if u see peaks in p vesical, p detrusor (involuntary contraction) & flow rate lines this mean urge incontinence.
Filling 1) Filling pressure: normal 0-10cm/H2O Cystometry 2 phases: Voiding 1) Q max 2) Volume capacity: 400-500ml in adult 3) Sensation -First desire to void 50% from volume capacity. -Normal desire 70% -Strong desire 90% -Urgent >90% For any of this sensation if its lower than this value hypersensitive. But if its greater hyposensitive. 4) Detrusor activity: mostly relax 2)Residual volume 3)Voiding pressure: normal 40-70cm/H2O 5) Compliance = ( V / P) normal greater than 40 END Nobody can go back and start a new beginning, but anyone can start today and make a new ending. Maria Robinson Done By: Arowa Basim Subha & Sirine Beleid from A5