bladder dysfunction in different neurological diseases

BLADDER DYSFUNCTION IN DIFFERENT NEUROLOGICAL DISEASES

BLADDER DYSFUNCTION IN DIFFERENT NEUROLOGICAL DISEASES

Dr. Subhasish DebDept. of General MedicineBurdwan Medical College

Dr Subhasish Deb, BMCH, General Medicine

ANATOMYPyramidal shaped when emptyOvoid when fullParts: Superior surface2 Inferolateral surfApexBaseNeck

Transitional Epithelium


TRIGONE :Triangular area in post surface immediately above bladder neckIdentified by absence of rugae, i.e mucosa is smooth here

INTERNAL SPHINCTER:At bladder neck, made of detrusor muscle and elastic tissueABSENT IN FEMALES

EXTERNAL SPHINCTER:Skeletal muscle, voluntary controlIn urogenital diaphragm



BLOOD SUPPLYSuperior and Inferior vesical artieries, branches of ant. trunk of internal iliac

Veins form a plexus in the infero-lat surface and drain in internal iliac vein

Most of the lymph in external iliac nodesDr Subhasish Deb, BMCH, General Medicine

INNERVATION OF THE BLADDERPelvic Nerve: (parasympathetic)Motor + sensoryFrom sacral plexus S2,3,4 (Detrusor centre intermediolateral column of grey matter)Motor part = parasympathetic fibresExpels urine

Pudental Nerve: (Somatic)Voluntary controlExternal urinary sphincterS2,3,4 (nucleus of Onuf) antero lateral horns of S2,3,4

Hypogastric nerve: (Sympathetic)T11,T12,L1, L2Stores urineDr Subhasish Deb, BMCH, General Medicine


RECEPTORSM3 Bladder wall (Detrusor contr.)B3 - bladder wall (Detrusor relax.)a1 internal sphincterNicotinic external sphincterDr Subhasish Deb, BMCH, General Medicine


MICTURATION REFLEXWhen bladder is empty:Little urine in bladder leads to SLOW sensory impulses in sensory pelvic nerve. (pelvic afferent)The pelvic nerve stimulates the hypogastric nerve at the thoracic level.

Detrusor relax. (B3) + int sphicn contric (a1)The pons also stimulates the hypogastic nrv and inhibits the pudental ner external sphic contraction.Thus urine is not expelled.


When Bladder is Full:Streching of bladder pelvic sensory n sends FAST signals.This is directly carried to the PONTINE MICTURATION CENTRE, bypassing the thoraco lumbar regions. The Pons:Inhibits hypogastric nv (symp) No relaxation of detrusor (B3)Relaxation of internal shpincter (a1)Stimulates Pelvic efferent nv contr of detrusor (M3)Inhibits Pudental nv relax. of ext. sphincter (N)


Empty bladderFull bladder responseLLSSDr Subhasish Deb, BMCH, General Medicine

NEUROLOGIC DISORDERS CAUSING BLADDER DISTURBANCESDr Subhasish Deb, BMCH, General Medicine

1.Complete destruction of Cord below T12AUTONOMOUS BLADDEREtiology:Conus lesion:Trauma, tumour, myodysplasia, necrotizing myelitis, venous agiomas

Features:-Bladder paralyzed for sensory and reflexive activityNo awareness of state of fullnessVoluntary initiation of micturation impossibleDetrusor tone lost bladder distends Overflow incontinence-voiding possible by CREDEs maneuver


Other features:Anal sphincter and colon are similarly affectedSaddle anesthesiaAbolition of bulbocavernosus and anal reflex and tendon reflexes in leg

Cystometrogram: low pressure and no emptying contractions

T/T : Catheterization and anticholinergics


Credes manouver : (MASS REFLEX) technique for manual expression of urine from the bladder used in bladder training for paralyzed patients.The hands are held flat against the abdomen, just below the umbilicus. A firm downward stroke toward the bladder is repeated six or seven times, followed by pressure from both hands placed directly over the bladder to manually remove all urine.Dr Subhasish Deb, BMCH, General Medicine

2. Disease of Sacral Motor Neurons in spinal Grey MatterATONIC bladder (motor)Structure affected: sacral root or peripheral nvEtiology: lumbosacral meningomyelocele,tetherd cord syndromeCauda equina: compression m/c- epidural tumour, disc, radiculitis from herpes or CMVFeatures:LMN paralysis of bladderSacral and bladder sensations are intactVoluntary initiation of micturation lost-loss of cortical fibresOverflow incontinence


3.Interruption of sensory afferentsATONIC BLADDER (sensory)DM & tabes dorsalisMotor fibres intactSmall fibres DMAlso seen in acute neuropathies like GB syndt/t intermittent self catheterization


4.Upper spinal cord lesionsSPASTIC BLADDEREtiology:m/c multiple sclerosis, traumatic myelopathyMyelitisSpondylosisAVMSyringomyeliaTropical spastic paraperesis


If cord lesion is sudden onset detrusor suffers spinal shock distension and overflowWhen spinal shock subsides Detrusor overactivity (hyperreflexia) +pt cannot control external sphincter incontinence Other features: Bulbocavernosus and anal reflex presentBladder sensation depends on extent of involvement of sensory tractsBladder capacity reduced and initiation o voluntary micturation impared.Cystometrogram: uninhibitted contractions of detrusor in response to small volmes of fluidDr Subhasish Deb, BMCH, General Medicine

Autonomic DysreflexiaDangerous syndrome due to spinal cord injury at or above T6Uncontrolled HTN due to reflex sympathetic dischargePathophysiology:A noxious stimulus at t6 excessive symp discharge HTN (by splanchnic and peripheral vasoconstriction)Baroreceptors react by sending strong vagal response bradycardia


lack of spinal cord continuitydescending inhibitory response only travels as far as the level of neurologic injury does not cause the desired response in the sympathetic fibers below the injury therefore, the hypertension remains uncontrolled.Above level of injury:Bradycardia, nasal congestion, pupilary constriction, sweating.Below level of injury:Pale, cool skin, pilo erection, distended bladderDr Subhasish Deb, BMCH, General Medicine

5.Mixed type of neurogenic bladderIn diseases such as MS, SACD, tethered cord and syphylitic meningomyelitis Lesions at multiple levels ie spinal roots, sacral neurons, their fibres and higher spinal segments.

Resultant picture is a combination of sensory, motor and spastic type of bladderDr Subhasish Deb, BMCH, General Medicine

6. Frontal IncontinenceConfused mental stateIgnores desire to voidSubsequent incontinenceNo warning signs of fullness- suddenly wetSupranuclear type of hyperactivity and precipitant evacuation Post part of superior frontal gyrus and cingulate gyrusDr Subhasish Deb, BMCH, General Medicine

Olden NomenclatureTYPELESION SITEUninhibited bladderCortico regulatory tractsReflex bladderSpinal cord above T123. Autonomous bladderS2 S3 S4

4. Motor Atonic bladderMotor efferents

Sensory atonic bladderSensory afferents


Neurogenic bladder

Flaccid Mixed SpasticVol. large - Small volume Pressure low - involuntary cont. Contraction absent - Bladder detrusorIn: peripheral nv damage dyssynergia or lesion at S2-S4 - in lesions above T12Dr Subhasish Deb, BMCH, General Medicine


THANK YOUDr Subhasish Deb, BMCH, General Medicine

bladder dysfunction in different neurological diseases

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