Download MBBS Physical Medicine and Rehabilitation Presentations 12 Neurogenic Bladder Management After Spinal Cord Injury Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Physical Medicine and Rehabilitation 12 Neurogenic Bladder Management After Spinal Cord Injury PPT-Powerpoint Presentations and lecture notes


Neurogenic Bladder

Management After Spinal

Cord Injury

Department of PMR

Overview

A. Introduction

B. Functional anatomy of the lower urinary tract

C. Bladder impairment following spinal cord injury

D. Bladder management

E. Recommendations for bladder evaluation and follow-up


Introduction

Neurogenic bladder is a general term applied to a malfunctioning

urinary bladder due to neurologic dysfunction, or insult, resulting
from internal or external trauma, disease or injury.

The majority of people with spinal cord injury (SCI), even those who

have very incomplete impairment, have abnormalities in bladder
function which may cause upper and lower urinary tract complications.
Functional anatomy of LUT

Bladder filling and emptying involve the bladder (detrusor muscle) and its

outlet (bladder neck, proximal urethra and striated muscles of pelvic
floor) acting reciprocally.

During storage of urine, the bladder neck and proximal urethra are closed

to provide continence with the detrusor relaxed to allow low pressure
filling.

During voiding initial relaxation of the pelvic floor with opening of the

bladder neck is followed by detrusor contraction until the bladder is
completely emptied.

Innervation of the bladder

Sympathetic nerve supply

L

S

1

2

L

S3

2

S

Pelvic nerve

L

4

3

Sympathetic
chain

Hypogastric
ganglion

Hypogastric
nerve

Pudendal nerve
Autonomic control of micturition

Type of nerve

Name of nerve Spinal

Action

Innervation

Somatic

Pudendal

S2-4

Sensory and voluntary

nerves

motor to external

Nerve to the

sphincter PFM

levator ani

Sympathetic

Hypogastric

T11-L2

Detrusor relaxation

nerves

Internal sphincter

contraction

Parasympathetic

Pelvic nerves

S2-4

Inhibit sympathetic system

causing detrusor contraction

Internal sphincter

relaxation

Micturition centers

Co-ordination of micturition involves three main centers:

1. The sacral micturition center, located in the sacral spinal cord ( S3?S4
levels), which is a reflex center in which efferent parasympathetic impulses to
the bladder cause a bladder contraction and afferent impulses provide
feedback on bladder fullness.

2. The pontine center in the brainstem, which is responsible for
coordinating relaxation of the external sphincter with bladder contractions

3. The cerebral cortex, which exerts the final control by directing
micturition centers to initiate or delay voiding, depending on the social
situation.
The micturition reflex

Excitation of stretch

Pelvic nerves

Relayed to

receptors when

parasympathetic

~300ml of urine.

System

Pelvic nerves

Bladder outlet

micturition

pulled open,

Contraction of

increase in

bladder

Pudendal

pressure

impulses

nerve

inhibited

Definitions and terminology

Intermittent catheterisation: as drainage or aspiration of the bladder or a
urinary reservoir with subsequent removal of the catheter either performed by
the person or an attendant.

Bladder reflex triggering: maneuvers performed in order to elicit reflex
detrusor contraction by exteroceptive stimuli Like.. suprapubic tapping, thigh
scratching and anal/rectal manipulation.

Bladder expression: manoeuvres aimed at increasing intravesical pressure in
order to facilitate bladder emptying Like.. abdominal straining, Valsalva's
manoeuvre and Crede manoeuvre.
Definitions and terminology

Urodynamic studies: Normally take place in the laboratory and usually

involve artificial bladder filling and measurements of various bladder

parameters such as intra-vesical pressure.

Detrusor overactivity: Is a urodynamic observation characterized by

involuntary detrusor contractions during the filling phase which may be

spontaneous or provoked.

Detrusor underactivity: Is defined as a contraction of reduced strength

and/or duration, resulting in prolonged bladder emptying and/or a failure to

achieve complete bladder emptying within a normal time span.

Definitions and terminology

Bladder compliance: Describes the relationship between change in

bladder volume and change in detrusor pressure.

Detrusor sphincter dyssynergia: Is defined as a detrusor contraction

concurrent with an involuntary contraction of the urethral and/or peri
-urethral striated muscle. Occasionally, flow may be prevented
altogether.

Indwelling catheterisation: An indwelling catheter remains in the

bladder, urinary reservoir or urinary conduit for a period of time
longer than one emptying.


Bladder impairment following

spinal cord injury

SCI disrupts descending motor

and ascending sensory pathways,

preventing normal control of micturition

Types of Neurogenic Bladder Impairment

Suprasacral (Infrapontine) Bladder

An upper motor neuron lesion results in:

? detrusor hyperreflexia (overactivity).

? detrusor-external sphincter dyssynergia (DESD), inappropriate co-contraction

of the external urethral sphincter (EUS) with voiding detrusor contraction.

Mixed Neurogenic Bladder (Type A)

A lesion in the conus medullaris with damage to detrusor (parasympathetic) nucleus
causes:

? detrusor hyporeflexia (underactivity) with external sphincter hyperreflexia.

? characteristically large volume with overflow incontinence.


Types of Neurogenic Bladder Impairment

Mixed Neurogenic Bladder (Type B)
A lesion in the conus medullaris involving pudendal (somatic) nucleus

causes:

? Detrusor hyperreflexia with external sphincter hypotonia.

? Small volume, high frequency, incontinence.

Infrasacral Bladder
A Lower Motor Neurone lesion from conus medullaris and/or cauda equina

damage results in:

? Areflexia of detrusor with atonia of pelvic floor muscles.

? May have isolated increase in bladder neck/internal sphincter

resistance (intact T11-L2 sympathetics).

? Non-contractile bladder with leakage from overflow.

Madersbacher functional classification

system
Functional Classification

Failure to store

Because of bladder

Because of outlet

Failure to empty

Because of bladder

Because of outlet

Bladder Management

Goals:

Protecting upper urinary tracts from sustained high filling and voiding

pressures (i.e. >40cm water)

Achieving regular bladder emptying, avoiding stasis and bladder

overdistension and minimising post-voiding residual volumes.

Preventing and treating complications such as urinary tract infections

(UTIs), stones, strictures and autonomic dysreflexia

Maintaining continence and avoiding frequency and urgency

Choosing a technique which is compatible with person's lifestyle
Management methods

Any type of neurogenic bladder management can be divided into four

parts:

Behavioral

Pharmacological

Surgical

Supportive

Behavioral

Timed voiding: Pts are told to void before they reach their full

capacity.

Individuals with cognitive deficits are helped by timed voiding.

Bladder training: Progressively increasing the time between voiding by

10 to 15 minutes every 2 to 5 days.

Helpful in persons recovering from head injury/ stroke
Pharmacological

Main goal is to block the AcH receptors on the bladder wall there by reducing

the uninhibited contractions.

ORAL AGENTS

Anticholinergic drugs such as Propantheline, Oxybutynin, Tolteridone,

Tropsium etc can be used orally

Oxybutynin has some local smooth ms. relaxing and local anesthetic effect

Tolterodine (comp. antagonist) & Tropsium (selective antagonist) have fewer

anticholinergic adverse effects

TCAs- They have additional effect on the internal sphincter by preventing

NER reuptake- Caution AD

Darifenacin- Muscarinic receptor antagonist

Contd.

INTRAVESICAL DRUGS

Lidocaine- Short duration of action

Oxybutynin- Effective for 4-6 hours, still lobour intensive.

Capsiacin- C-fibre neurotoxin. Effect can last upto several months

A/E- suprapubic pain, haematuria, urgency, AD can last upto 2 wks

Resiniferatoxin- 1000 times more potent than Capsiacin longer acting.

Minimal side effects due to rapid onset of action.
Surgical

Bladder augmentation- to create a large bladder capacity with low

intravesical pressure. Distal ileum is commonly used

INDICATIONS

1.

Inability to tolerate/ unwillingness for drugs

2.

Detrusor hyperreflexia or low compliance

3.

Recurrent UTIs or AD

4.

Upper tract damage

Supportive

1.

Diapers

2.

External condom catheter

3.

Indwelling catheters

Diapers- one of the easiest methods mainly for back up. They have

many disadvantages like.. Expenses, potential skin breakdowns


External Condom Catheters

Men with detrusor hyperreflexia

Normal bladder function with incontinence secondary to

mobility or cognitive factors.

Major drawbacks:

leg bag, penile skin breakdown,

condom catheter falling off

slight increase in bladder infections.

Intermittent Catheterisation

During the first few weeks after injury, over

distension of the bladder should be avoided by
continuous drainage (usually 7-10 days after injury).

After this period, regular intermittent

catheterization.

Long term in both male and female patients with

paraplegia or males with tetraplegia and sufficient
hand function, clean intermittent self catheterization
(CISC) is the preferred method.
Clean intermittent self catheterization

Perform every 4-6 hours

Prerequisites: well-controlled detrusor activity, include good bladder

capacity, adequate bladder outlet resistance, absence of urethral
sensitivity to pain with catheterization and patient motivation.

Contraindications: abnormal urethral anatomy such as stricture, false

passages, and bladder neck obstruction, poor cognition, little
motivation, unwillingness to adhere to the catheterisation time
schedule.

CISC has the lowest complication rate.

Reflex Voiding and Bladder Expression

Techniques

In males with tetraplegia and insufficient hand dexterity to perform

CIS, drainage by reflex voiding with triggering maneuvers and use of an
external urinary collection device is possible.

Valsalva or Crede (pressing over the bladder) are discouraged as they

may produce high intra-vesical pressure, increasing the risk for long-
term complications.

However, this technique is generally no longer recommended.


Indwelling Catheterisation

In long-term use a suprapubic catheter is generally

preferred to avoid creation of fistulous tracts, damage
to the sphincter muscles, dilation of the urethra, penile
tip erosion and splitting of the penis, called traumatic
hypospadias.

Female patients with tetraplegia generally use either a

suprapubic or an indwelling urethral catheter, suitable
in some women with paraplegia also.

Males with tetraplegia suprapubic catheters are being

recommended.

Evaluation and Follow-up

There is no clear consensus on the appropriate urological follow-up of

individuals after spinal cord injury.

Upper tract evaluations include tests that evaluate function such as

renal scans, ultrasound, CT scan and intravenous pyelogram (IVP).

Lower tract evaluations include urodynamics to determine bladder

and sphincter function, cystograms to evaluate for vesicoureteral
reflux and cystoscopy to evaluate bladder anatomy.

This post was last modified on 08 April 2022