Department of PMR
Overview
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A. Introduction
B. Functional anatomy of the lower urinary tract
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C. Bladder impairment following spinal cord injuryD. Bladder management
E. Recommendations for bladder evaluation and follow-up
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Introduction
Neurogenic bladder is a general term applied to a malfunctioning
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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
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have very incomplete impairment, have abnormalities in bladder
function which may cause upper and lower urinary tract complications.
Functional anatomy of LUT
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Bladder filling and emptying involve the bladder (detrusor muscle) and itsoutlet (bladder neck, proximal urethra and striated muscles of pelvic
floor) acting reciprocally.
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During storage of urine, the bladder neck and proximal urethra are closedto provide continence with the detrusor relaxed to allow low pressure
filling.
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During voiding initial relaxation of the pelvic floor with opening of thebladder neck is followed by detrusor contraction until the bladder is
completely emptied.
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Innervation of the bladderSympathetic nerve supply
L
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S
1
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2L
S3
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2
S
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Pelvic nerveL
4
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3
Sympathetic
chain
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Hypogastric
ganglion
Hypogastric
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nervePudendal nerve
Autonomic control of micturition
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Type of nerveName of nerve Spinal
Action
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Innervation
Somatic
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PudendalS2-4
Sensory and voluntary
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nerves
motor to external
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Nerve to thesphincter PFM
levator ani
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Sympathetic
Hypogastric
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T11-L2Detrusor relaxation
nerves
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Internal sphincter
contraction
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ParasympatheticPelvic nerves
S2-4
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Inhibit sympathetic system
causing detrusor contraction
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Internal sphincterrelaxation
Micturition centers
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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
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the bladder cause a bladder contraction and afferent impulses providefeedback on bladder fullness.
2. The pontine center in the brainstem, which is responsible for
coordinating relaxation of the external sphincter with bladder contractions
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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
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Excitation of stretch
Pelvic nerves
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Relayed toreceptors when
parasympathetic
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~300ml of urine.
System
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Pelvic nervesBladder outlet
micturition
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pulled open,
Contraction of
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increase inbladder
Pudendal
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pressure
impulses
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nerveinhibited
Definitions and terminology
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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.
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Bladder reflex triggering: maneuvers performed in order to elicit reflexdetrusor contraction by exteroceptive stimuli Like.. suprapubic tapping, thigh
scratching and anal/rectal manipulation.
Bladder expression: manoeuvres aimed at increasing intravesical pressure in
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order to facilitate bladder emptying Like.. abdominal straining, Valsalva'smanoeuvre and Crede manoeuvre.
Definitions and terminology
Urodynamic studies: Normally take place in the laboratory and usually
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involve artificial bladder filling and measurements of various bladder
parameters such as intra-vesical pressure.
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Detrusor overactivity: Is a urodynamic observation characterized byinvoluntary detrusor contractions during the filling phase which may be
spontaneous or provoked.
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Detrusor underactivity: Is defined as a contraction of reduced strength
and/or duration, resulting in prolonged bladder emptying and/or a failure to
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achieve complete bladder emptying within a normal time span.Definitions and terminology
Bladder compliance: Describes the relationship between change in
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bladder volume and change in detrusor pressure.
Detrusor sphincter dyssynergia: Is defined as a detrusor contraction
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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
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bladder, urinary reservoir or urinary conduit for a period of time
longer than one emptying.
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Bladder impairment followingspinal cord injury
SCI disrupts descending motor
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and ascending sensory pathways,
preventing normal control of micturition
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Types of Neurogenic Bladder ImpairmentSuprasacral (Infrapontine) Bladder
An upper motor neuron lesion results in:
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? detrusor hyperreflexia (overactivity).
? detrusor-external sphincter dyssynergia (DESD), inappropriate co-contraction
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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
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causes:? detrusor hyporeflexia (underactivity) with external sphincter hyperreflexia.
? characteristically large volume with overflow incontinence.
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Types of Neurogenic Bladder Impairment
Mixed Neurogenic Bladder (Type B)
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A lesion in the conus medullaris involving pudendal (somatic) nucleuscauses:
? Detrusor hyperreflexia with external sphincter hypotonia.
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? Small volume, high frequency, incontinence.
Infrasacral Bladder
A Lower Motor Neurone lesion from conus medullaris and/or cauda equina
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damage results in:
? Areflexia of detrusor with atonia of pelvic floor muscles.
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? May have isolated increase in bladder neck/internal sphincterresistance (intact T11-L2 sympathetics).
? Non-contractile bladder with leakage from overflow.
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Madersbacher functional classification
system
Functional Classification
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Failure to store
Because of bladder
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Because of outletFailure to empty
Because of bladder
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Because of outlet
Bladder Management
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Goals:Protecting upper urinary tracts from sustained high filling and voiding
pressures (i.e. >40cm water)
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Achieving regular bladder emptying, avoiding stasis and bladder
overdistension and minimising post-voiding residual volumes.
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Preventing and treating complications such as urinary tract infections(UTIs), stones, strictures and autonomic dysreflexia
Maintaining continence and avoiding frequency and urgency
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Choosing a technique which is compatible with person's lifestyle
Management methods
Any type of neurogenic bladder management can be divided into four
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parts:
Behavioral
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PharmacologicalSurgical
Supportive
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Behavioral
Timed voiding: Pts are told to void before they reach their full
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capacity.Individuals with cognitive deficits are helped by timed voiding.
Bladder training: Progressively increasing the time between voiding by
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10 to 15 minutes every 2 to 5 days.
Helpful in persons recovering from head injury/ stroke
Pharmacological
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Main goal is to block the AcH receptors on the bladder wall there by reducing
the uninhibited contractions.
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ORAL AGENTSAnticholinergic drugs such as Propantheline, Oxybutynin, Tolteridone,
Tropsium etc can be used orally
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Oxybutynin has some local smooth ms. relaxing and local anesthetic effect
Tolterodine (comp. antagonist) & Tropsium (selective antagonist) have fewer
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anticholinergic adverse effectsTCAs- They have additional effect on the internal sphincter by preventing
NER reuptake- Caution AD
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Darifenacin- Muscarinic receptor antagonist
Contd.
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INTRAVESICAL DRUGSLidocaine- Short duration of action
Oxybutynin- Effective for 4-6 hours, still lobour intensive.
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Capsiacin- C-fibre neurotoxin. Effect can last upto several months
A/E- suprapubic pain, haematuria, urgency, AD can last upto 2 wks
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Resiniferatoxin- 1000 times more potent than Capsiacin longer acting.Minimal side effects due to rapid onset of action.
Surgical
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Bladder augmentation- to create a large bladder capacity with lowintravesical pressure. Distal ileum is commonly used
INDICATIONS
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1.
Inability to tolerate/ unwillingness for drugs
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2.Detrusor hyperreflexia or low compliance
3.
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Recurrent UTIs or AD
4.
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Upper tract damageSupportive
1.
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Diapers
2.
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External condom catheter3.
Indwelling catheters
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Diapers- one of the easiest methods mainly for back up. They have
many disadvantages like.. Expenses, potential skin breakdowns
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External Condom Catheters
Men with detrusor hyperreflexia
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Normal bladder function with incontinence secondary tomobility or cognitive factors.
Major drawbacks:
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leg bag, penile skin breakdown,
condom catheter falling off
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slight increase in bladder infections.Intermittent Catheterisation
During the first few weeks after injury, over
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distension of the bladder should be avoided by
continuous drainage (usually 7-10 days after injury).
After this period, regular intermittent
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catheterization.
Long term in both male and female patients with
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paraplegia or males with tetraplegia and sufficienthand function, clean intermittent self catheterization
(CISC) is the preferred method.
Clean intermittent self catheterization
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Perform every 4-6 hoursPrerequisites: well-controlled detrusor activity, include good bladder
capacity, adequate bladder outlet resistance, absence of urethral
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sensitivity to pain with catheterization and patient motivation.Contraindications: abnormal urethral anatomy such as stricture, false
passages, and bladder neck obstruction, poor cognition, little
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motivation, unwillingness to adhere to the catheterisation timeschedule.
CISC has the lowest complication rate.
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Reflex Voiding and Bladder ExpressionTechniques
In males with tetraplegia and insufficient hand dexterity to perform
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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
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may produce high intra-vesical pressure, increasing the risk for long-
term complications.
However, this technique is generally no longer recommended.
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Indwelling Catheterisation
In long-term use a suprapubic catheter is generally
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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.
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Female patients with tetraplegia generally use either a
suprapubic or an indwelling urethral catheter, suitable
in some women with paraplegia also.
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Males with tetraplegia suprapubic catheters are being
recommended.
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Evaluation and Follow-upThere is no clear consensus on the appropriate urological follow-up of
individuals after spinal cord injury.
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Upper tract evaluations include tests that evaluate function such as
renal scans, ultrasound, CT scan and intravenous pyelogram (IVP).
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Lower tract evaluations include urodynamics to determine bladderand sphincter function, cystograms to evaluate for vesicoureteral
reflux and cystoscopy to evaluate bladder anatomy.
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