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