Historical Importance:

- In world war I, 39% of pt with Spinal cord injury died

because of UTI resulting from neurogenic bladder. - In world war II, mortality decreased to 10% but still the most common was renal failure resulting from spinal injury.

 Currently, although UTIs occur frequently in those

with SCI, death from this cause is extremely unusual. And less than 3 percent of deaths following SCI are now attributable to chronic renal failure.
This dramatic decline in morbidity and mortality from

urological causes has been a result of the advent of antibiotics, effective bladder management, and frequent monitoring of the upper and lower urinary tracts.

Basic Anatomy
The main organs involved in urination are the urinary

bladder and the urethra. Bladder has mainly two parts: Body: The main area where urine is collected The smooth muscle of the bladder body is known as the Detrusor which is responsible for voiding of bladder. Neck: Lower and most depended part, from here the urethra starts. Capacity: Anatomical : 1500ml Physiological: 650ml bladder sensations felt: 200ml Ugre to urinate: 400 ml Uncontrollable urge: 650ml

 The interior of bladder shows irregular folds(rugae)

due to loose attachment of mucosa, exception to this is Trigone, smooth triangular part at the lower end of bladder where mucosa is firmly attached. Ureters opens on both the posterolateral angles of trigone
Smooth muscle bundles along with elastic fibers pass

on either side of the urethra, and these fibers are sometimes called the internal urethral sphincter, although they do not encircle the urethra completely. Hence it is not a true sphincter.

 Farther along the urethra is a sphincter of skeletal

muscle, the sphincter of the membranous urethra (external urethral sphincter), which is under voluntary control and supplied by the pudendal nerve.

Neuroanatomy of Micturition

Muscles of Bladder

Smooth (Involuntary)

Striated (Voluntary)
Ext. urethral sphincter.

Detrusor. Internal urethral Sphincter.

Nervous Innervation
Sympathetic (promotes filling)

Both afferent and efferent supply T11,T12,L1& L2 -action: trigone contraction. -action: Detrusor relaxation. No effect on micturation. Very important role in males in preventing the reflux of semen into the bladder during ejaculation.

 Parasympathetic (Promotes emptying)

Both efferent and afferent. S2,3,4. Acts via muscarinic receptors (Acetylcholine). Contracts detrusor and relaxes sphincter.

 Somatic

Pudendal nerve (S2,3,4). Efferents arises from nucleus of Onuf. Supplies the external sphincter which is under voluntary control. Gained usually by age of 5-7 yrs. Hence, it prevents bed wetting.

Physiology of Micturition
Micturition reflex center sacral cord 2-4
Higher centers

mainly Inhibitory
Paracentral lobule Others: Limbic system Thalamus

mainly Facilitatory
Pons post. hypothalamus

stretch receptors

Physiology of Micturation
350-400ml of urine

Increase in intra-vesical pressure ~25cm H2O- stimulation of stretch receptors. Afferents carried by pelvic parasymp. Nerve to sacral area of spinal cord and relayed to pons.
In cortex they are recorded as desire to micturate.

 If circumstances are:

Favorable Stimulation of parasymp. Inhibition of somatic N. Contraction of detrusor & relaxation of int. & ext. Sphincter.

Not favorable Social inhibition But this is only temporary.

Bladder Pressure-Volume Relationship

Few important definitions

Urinary hesitancy - difficulty in beginning the flow

of urine. Urinary urgency sudden compelling urge to urinate .when uncontrollable it causes urge incontinence Incontinence if bladder control is lost and urine leakage occurs it is called incontinence.

 Stress urinary incontinence: incontinence that

occurs as a result of external mechanical disturbances like Coughing, sneezing, lifting weight etc. Urge urinary incontinence: incontinence that occurs as a result of the uncontrollable urge to urinate Mixed urinary incontinence, a combination of the two types of incontinence.

 Overflow incontinence frequent dribble of urine as

a result of inefficient bladder emptying Functional incontinence- urine loss not associated with any pathology or problem in urinary system. Occurs in physical or cognitive impairment like Alzheimers or head injury.

Neurogenic Bladder
Bladder abnormalities resulting from diseases affecting the

innervation of bladder both peripheral or central. Lapides classification

Spastic bladder 1. Cortical / autonomic 2. Spinal / automatic

Flaccid bladder 1. Autonomous 2. Motor atonic 3. Sensory atonic

Cortical/Uninhibited/autonomic/ infantile bladder

Site of lesion: btw paracentral lobule to pons
Causes:

1. Frontal lobe tumors 2. Parasagital meningiomas 3. ACA aneurysm 4. Normal pressure hydrocephalus 5. Parkinsons disease 6. Multi-system atrophy

 C/F:

- Urgency at low bladder volume - loss of social inhibition i.e. pt. passes urine just like an infant without his knowledge. - No residual volume i.e. complete evacuation occurs on its own.

Spinal/Reflex/Automatic Bladder
Site: from Pons to S1
Causes:

- Acute transverse myelitis - Trauma - Neoplasm - Multiple Sclerosis

 C/F:

Depends on the extent of lesion

Incomplete If inhibitory fibers gone Urgency Eg: MS If excitatory fibers gone Hesitancy eg: tumors Complete Retention with overflow incontinence. f/b automatic bladder

 Automatic Bladder

- After recovery from stage of spinal shock, the activity of the bladder is controlled by the local reflex arc. - When a specific volume is reached(250ml), the bladder empties reflexly. - But contrary to CORTICAL BLADDER emptying is incomplete. - Evacuation can be improved by bladder massage or suprapubic pressure. N.B: Stage of spinal shock is seen only if the insult to spinal cord is acute

Autonomous/Atonic Bladder
Site: Sacral region(S2,3,4)

Hence, it affects both motor & sensory components Causes: - Cauda equina syndrome - Pelvic trauma/surgery/malignancy - Spina bifida/ meningomyocele - Sacral arachnoiditis

 C/F:

-loss of bladder sensation. -large, atonic bladder with painless retention of urine. -patient can evacuate the bladder by applying external pressure. -continuous overflow incontinence with stress incontinence. -high risk of UTI. -loss of potency & saddle anesthesia.

Motor paralytic bladder

Site: Efferent limb
Causes:

- Poliomyelitis - Polyradiculopathy - Pelvic tumor - trauma

 C/F:

- Painful distention of bladder. - Inability to initiate or continue micturition. - Narrow/interrupted stream of urine. - In later stages, compensatory distention bladder & overflow incontinence. Cystometry: No contractions of detrusor.

of

Sensory Paralytic bladder

Site: Afferent limb
Causes:

- Tabes dorsalis. - DM. - Multiple Sclerosis. - SACD. - Syringomyelia.

 C/F:

- Painless distention of the bladder. - very large & hypotonic bladder with massive retention of urine. - continuous overflow incontinence. - large residual volume. - Contrary to Autonomous bladder pt. can initiate micturition as the motor limb is normal

Questions to be asked in cases of neurogenic bladder

Do the pt. have sensation of the bladder? (rules out sensory and autonomous bladder) 2. Can they stop urine passing in mid-stream at will? (for cortical fn which innervates ext. sphincter) 3. Is there continuous leak(sensory/autonomous) or sudden passage of urine(automatic)? 4. Is there any numbness in perineum?
1.

5. Is there any associated rectal disorder? 6. Is there any associated disorder of potency?

Urologic Evaluation
Generally, a urologic evaluation is done every year,

although there is no consensus among doctors on the frequency this type of examination.
Upper tract evaluations

-B.U.N, S.creat. -renal scans -tests that evaluate anatomy, such as ultra-sound, CT scans, and intravenous pyelograms(IVP).

 Lower tract evaluations - Urine analysis - postvoid residual urine (PVR) PVR is high, the bladder

may be contractile or the bladder outlet may be obstructed. - Uroflow rate is a useful screening test used mainly to evaluate bladder outlet obstruction. Uroflow rate is a useful screening test used mainly to evaluate bladder outlet obstruction. - Filling cystometrogram (CMG) assesses the bladder capacity, compliance, and the presence of phasic contractions (detrusor instability). - Voiding cystometrogram (pressure-flow study) Pressure-flow study simultaneously records the voiding detrusor pressure and the rate of urinary flow. This is the only test able to assess bladder contractility and the extent of a bladder outlet obstruction.

- A voiding cystogram can assess bladder neck and urethral function (internal and external sphincter) during filling and voiding phases. A voiding cystogram can identify a urethral diverticulum, urethral obstruction, and vesicoureteral reflux. - Electromyography (EMG) helps to ascertain the presence of coordinated or uncoordinated voiding. Failure of urethral relaxation during bladder contraction results in uncoordinated voiding (detrusor sphincter dyssynergia). - Cystoscopy to evaluate bladder anatomy. - It should be noted that urodynamics is an important evaluation for determining bladder function as no clue about raised intravesical pressure can be obtained from history and clinical examination

General points in Mx of neurogenic bladder

A. Behavioural changes

Stop smoking: reduce chronic coughing

reduces downward pressure on the pelvic floor Weight reduction: Excessive body weight affects bladder pressure, blood flow, and nerves.
Avoid Caffine, chocolates, high K+

containing fruits, citrus fruits like grapes, lemon etc. beverages, beer, hot spicy food.

Life Style changes

6 steps for continence:
1. Drink less than 5 glasses/day (40 oz) 2. Stop drinking after dinner 3. Elevate legs 4. Timed voiding

5. Regular pelvic floor exercises

6. Voiding diary

Kegels exercise
1. Contract your pelvic floor muscles as hard as you can

and hold them (squeeze 3-5 sec and relax for 5 sec).
2. Do sets of repetitions of squeezing (start with 5

repetitions: squeeze, hold, relax).

3. Increase lengths, intensity, and repetitions

every couple of days.

4. Perform Kegel exercises 3-4x during the day.

Credes and Valsalva

Cred is a method of applying suprapubic pressure to

express urine from the bladder. Cred is usually used when the bladder is flaccid or a bladder contraction needs to be augmented. Valsalva manovure causes an increase in the abdominal pressure.Thus the individual uses the abdominal muscles and the diaphragm to empty the bladder.However,the bladder does not empty completely. Cred and Valsalva used in individuals who have lower motor neuron injuries with low outlet resistance or who have had a sphincterotomy.

Avoid Credes and Valsalva in:

Detrusor sphincter dyssynergia.

Bladder outlet obstruction.

Vesicoureteral reflux. Hydronephrosis.

Bladder Exexcise
Bladder training involves relearning how to urinate. This

method of rehabilitation most often is used for active women with urge incontinence and sensory urge symptoms. Bladder training generally consists of self-education, scheduled voiding with conscious delay of voiding, positive reinforcement, adjustment of fluid intake and avoidance of dietary stimulants. In addition, distraction and relaxation techniques allow delayed voiding to help distend the urinary bladder. The interval goal between each void usually is set between 2 and 3 hours.

Pharmacological options
For Spastic Bladder
1. Anti-cholinergics:

Mech: Blocks the muscarinic receptors and thus increases the capacity by relaxing the bladder.
- Propanthelien 10 - 15mg tid - Dicyclomine - Hyoscine

8 - 20mg tid 0.1 - 5mg 6hrly

 Side Effects - Dry mouth, - Tachycardia, - Constipation,

- Fatigue, - Blurred vision , - Dizziness, - Slow thinking

 Antispasmodics:

It also causes relaxation of detrusor but are more selective. Eg; Dorefenacin 7.5mg OD Solefenacin 5mg OD Oxybutinin 2.5mg OD Trospium 20mg OD
TCAS:

Block the serotonin and norepinephrine uptake and thus causing decreased cortical facilitatory impulses therby causing reduced frequency of contractions. It also has direct detrusor relaxing action. Eg; Imipramine 25mg BD Amytriptilline 10mg HS

Clean Intermittent self Catheterization(CISC)

The normal capacity of the bladder is less than 500 ml.

Catheterizing the bladder every 46 hours prevents overdistention of the bladder. If more then 500ml of fluid is drained at a particular time then the fluid intake must be decreased and the frequency of catheter should be increased. Avoid if: Inability to catheterize themselves. A caregiver who is unwilling to perform catheterization. Abnormal urethral anatomy such as stricture, false passages, and bladder neck obstruction. Bladder capacity less than 200 ml.

 Advantages of CISC over Indwelling Cathter:

- pts autonomy is maintained - Freedom from indwelling catheter.

- Less chances of infection.

Indwelling catheter

 Types

Urethral

Suprapubic

Because complete bladder filling often does not occur

and individuals who use indwelling catheterization tend to have uninhibited bladder contractions, bladder capacity and compliance tend to decrease overtime.

Indications
Acute central nervous system trauma( allows precise

monitoring of urinary output, especially when maintaining fluid balance is critical) Terminally ill pt. No care giver In chronic SCI who are unable to perform intermittent catheterization or reflex voiding, have uncontrollable urinary incontinence. Where other less invasive procedures have failed.

 Frequency of changing:

Every 3-4 weeks under all aseptic precautions preferably done by trained health professional.

Bacterial colonisation usually occurs by the end of 2

weeks.Usualy asymtomatic.

Catheter Care
Genitals and part of catheter outside the body must be kept

clean by soap water and disinfectants. Urine analysis every 2-3 months for asymptomatic bacteriuria. A belt, tape, or other device is used to secure the catheter to the abdomen or thigh. If concretions cause blockage and impede drainage, a silicone catheter can be used, or 30 mls of Renacidin can be instilled daily for 2030 minutes Daily irrigation of the catheter with betadine or sterile water is not recommended because irrigation denudes the uroepithe-lium (Elliot et al., 1989) If the catheter tip and balloon irritate the trigone of the bladder, an anticholiner-gic medication may be prescribed to prevent invol-untary detrusor contractions and urinary leakage. .

Complications: Encrusting around the catheter. Infection Hematuria Spasm of bladder Long term Cx: Stones Contracture of bladder Urethral stricture

Indications for Suprapubic Cathter

Urethral abnormalities, such as stricture, false

passages, bladder neck obstruction, or urethral fistula Recurrent urethral catheter obstruction. Perineal skin breakdown due to urine leakage secondary to urethral incompetence. A desire to preserve sexual genital function. Prostatitis, urethritis, or epididymo-orchitis.

 Advantages of suprapubic cathter:

1. 2.

3.
4.

No urethral Cx like stricture, trauma etc. Less irritation because it bypasses the trigone. Voiding can be tested(to look for recovery). Sexual activity preserved.

Botox
Neurotoxin, Clostridium botulinum Injections into the bladder under direct vision Blocks chemically nerve ends As early as 2 days after injections it improves urgency

and frequency

Duration between 3-6 months Not FDA-approved for neurogenic bladder, but is

widely used for failure of medical therapy

Not indicated in patients with difficulties to empty

their bladders

Local side effects: Excessive bladder muscle relaxation can cause urinary retention Pain Infections Bleeding

General side effects: Muscular weakness Less effective during prolonged time Some people build up a resistance

Sacral Neuromodulation
Pacemaker for the bladder
Treatment for urgency, frequency, urge incontinence,

and urinary retention

Proven efficacy in patients for whom more

Over 14 years FDA-approved

conventional therapy has been unsatisfactory

Neurologic diseases -like MS, Parkinson's disease and

SCI injuries- are undergoing sacral neuromodulation with good success

How does it work?

Leads float next to bladder

nerves Leads are connected to a battery placed at the buttocks Leads sent mild electrical impulses out to the sacral nerves Can be discontinued at any time

Other Interventions
Pessaries
Periurethral bulking agents (periurethral injection of

collagen, fat or silicone) Overdistention of bladder Central Neurological De-innervation: SA Block Artificial sphincter 5 reductase inhibitor(finasteride) BZD, Baclofen, dantrolene