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Neurogenic Bladder. Ayman Mahdy,MD, PhD Associate Professor of Surgery Division of Urology Director Voiding Dysfunction and Female Urology UC. Anatomy and physiology . Bladder wall : smooth muscle/3 layers Urethral sphincter: Internal/involuntary /smooth part: BN

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Neurogenic bladder

Neurogenic Bladder

Ayman Mahdy,MD, PhD

Associate Professor of Surgery

Division of Urology

Director Voiding Dysfunction and Female Urology

UC


Anatomy and physiology
Anatomy and physiology

  • Bladder wall : smooth muscle/3 layers

  • Urethral sphincter:

    • Internal/involuntary /smooth part: BN

    • External/voluntary/striated part: mid urethra

  • Spinal cord ends at L1/L2 vertebral level

  • Lower urinary tract nerve supply:

    • Parasympathetic : S2-S4 spinal segments

    • Sympathetic: T10-L2 spinal segments

    • Somatic: S2-4 (Pudendal N)

  • Two types of the afferent nerves within the pelvic nerves: A and C (Morrison JW 1986).


Urine storage
Urine Storage

Sensory perception

Inhibition

Medial pontine micturation center

Lateral pontine micturation center

Lateral Spinothalamic tract

Stimulation of sympathetic neurons

Sacral cord

Inhibit sacral parathympathetic

Stimulate sacral somatic

Contraction SS and bladder outlet

Dorsal ganglion

Contraction of sphincter

Relaxation of detrusor

Receptors in muscle wall and mucosa


Micturation reflex
Micturation reflex

Sensory perception

facilitation

Medial pontine micturation center

Medial pontine micturation center

Lateral Spinothalamic tract

Stimulate sacral parathympathetic

Inhibit sacral somatic

Sacral cord

Dorsal ganglion

Receptors in muscle wall and mucosa

Contraction of detrusor

Relaxation of sphincter


What is ngb
What is NGB?

Any bladder abnormality of micturation caused by neuromuscular disease, injury or dysfunction




Obstructive luts
Obstructive LUTS disease

  • Hesitancy

  • Slow stream

  • Intermittency

  • Straining to void

  • Spraying (splitting) of urinary stream

  • Feeling of incomplete (bladder) emptying

  • Need to immediately re-void

  • Post-micturition leakage

  • Position-dependent micturition

  • Dysuria

  • Urinary retention


Storage luts
Storage LUTS disease

  • Urinary frequency

  • Urinary urgency

  • Nocturia

  • OAB , urgency syndrome


Urinary incontinence
Urinary incontinence disease

  • Stress UI

  • Urgency UI

  • Postural UI

  • Nocturnal enuresis

  • Mixed UI

  • Continuous UI

  • Insensible UI

  • Coital UI


Dynamics of voiding dysfunction
Dynamics of voiding dysfunction disease

  • Bladder

  • Bladder outlet

  • Both

Male

Female


Dynamics of obstructive luts
Dynamics of obstructive LUTS disease

  • Bladder:

    • Weak or absent detrusor contraction e.g. diabetic cystopathy

  • Bladder outlet:

    • Bladder outlet obstruction e.g. DESD

  • Combination


Dynamics of storage symptoms ui
Dynamics of storage symptoms/UI disease

  • Bladder:

    • Detrusor overactivity (overactive bladder)

  • Bladder outlet:

    • Intrinsic sphincter deficiency

  • Combination

Normal sphincter

Incompetent

sphincter



History
History disease

  • Urinary tract symptoms

  • Neurological symptoms and diagnosis (if known)

  • Clinical course of the neurological disease

  • Bowel symptoms

  • Sexual function

  • Comorbidities

  • Use of prescription and other medication and therapies.


History cont
History disease(Cont.)

  • Acute (reversible) UI:

    • Acute onset and subsides with underlying condition

    • Causes outside the urinary tract

    • DRIP:

      • Delirium

      • Restricted mobility/Retention

      • Infection/Inflammation/Impaction

      • Polyuria/Pharmaceuticals


Evaluation of voiding dysfunction in the elderly patient cont
Evaluation of voiding dysfunction in the elderly patient disease(Cont.)

  • Neurologic history:

    • Duration (MS and Parkinsonism)

    • Back surgery patients: time, level, type of lesion and affected sensation

    • CVA: UI before or after the onset of CVA

    • MS: duration, onset of exacerbations, motor deficits


P/E disease

  • Assess the impact of the underlying neurological:

    • Mobility

    • Hand function

    • Cognitive function


Initial management1
Initial management disease

  • Assure bladder emptying:

    • CIC

    • Urethral Foley

  • Assure hyegenic measures:

    • Palliative

    • Antimuscarinics

    • Timed void


Initial management cont
Initial management disease(Cont.)

  • Refer:

    • Hematuria

    • Reurrent urinary tract infections

    • Hydronephrosis

    • kidney stones on imaging

    • biochemical evidence of renal deterioration.


Clean intermittent catheterization cic
Clean Intermittent Catheterization (CIC) disease

  • First introduced in 1972 by Lapides et al

  • Proffered treatment if patient has the manual dexterity

  • Staff support

  • 4-6/day

  • With or without anti-muscarinic use

  • Poor candidates:

    • Cognitive and physical factors

    • Lack of support

    • Deformities

    • Anatomical


Clean intermittent catheterization cic1
Clean Intermittent Catheterization (CIC) disease

  • Incidence of bacteruria 1-3% catheterization

  • 1-4 Bacteruria/100 catheterization

  • Use of antibiotic prophylaxis is controversial


Indwelling catheter
Indwelling catheter disease

  • Higher risk for:

    • Renal failure

    • Bladder stones

    • UTIs

    • Bladder cancer


Suprapubic tube versus urethral foley
Suprapubic tube versus urethral Foley disease

  • Easy to exchange

  • Avoid urethral trauma

  • Sexual function

  • Less EO in male


Autonomic dysrelflexia
Autonomic Dysrelflexia disease

  • SCI above T6

  • Loss of supraspinal inhibition of throaco-lumbar sympathetic outflow

  • Massive discharge of the sympathetic system

  • Clinically:

    • Sweating and cutaneous flushing

    • Pounding H/A, nasal congestion, piloerection

    • HTN (may be life threatening)

    • Bradycardia


Autonomic dysrelflexia1
Autonomic Dysrelflexia disease

Textbook of NGB 2008


Autonomic dysrelflexia treatment
Autonomic Dysrelflexia: Treatment disease

  • Remove the stimulus!!

  • Other:

    • Nifedipine



Long term management1
Long term management disease

  • Usually 3 months after the episode

  • Sooner if:

    • Renal function deterioration

    • Hematuria

    • Hydronephrosis

    • Renal stones

    • Recurrent UTIs


Goals of evaluation management
Goals of Evaluation/Management disease

  • Prevent upper tract deterioration

  • Restore hygiene and social acceptance (UI)

  • Assure efficient bladder emptying

  • Avoid NGB bladder related complications


Complications of ngb
Complications of NGB disease

  • UTI

  • VURD

  • STONES

  • Renal amyloidosis (rare)

  • ED

  • Autonomic dysreflexia


Office requirements
Office Requirements disease

  • Handicap accessibility

  • Cystoscopy

  • VUDS

  • EMG

  • Crash Cart

  • Ostomy care

  • Multi-team members


Work up
Work up disease

  • History

  • Voiding diary

  • QOL assessment

  • PE

  • Neurological exam

  • Urine bacteriologic studies

  • RFTs

  • Radiologic evaluation

    • Upper tract

    • Lower tract

  • UDS/VUDS

  • Endoscopic examination


VUDS disease



Filling
Filling disease

No leak

Stop filling

Resume filling

No leak


Voiding
Voiding disease


Post void
Post-void disease



VCUG disease





Antimuscarinics
Antimuscarinics disease

  • *Benefits:

    • Improve compliance

    • Relieve frequency, urgency and UUI

    • Decrease intra-vesical pressure

    • Decrease DO

    • Helps protect the upper tract from deterioration

      *(Storher M et al 2007, Amend B et al 2008 and Kim YH et al 1997)


Antimuscarinics cont
Antimuscarinics disease(Cont.)

  • Higher doses are usually needed in NGB population compared with non neurogenic OAB

    • Constipation

    • Dry mouth

  • Patients with CNS disease (impaired cognition with oxybutinin):

    • Darifenacin

    • Trospium


Treatment algorithm of oab uui
Treatment algorithm of OAB/UUI disease

Initial

Screening

Voiding Diary

Urodynamic Workup

R/O Obstruction

Interstim

Interstim

Behavioral Techniques

Biofeedback

Medications

-

Botox

Neurostimulators

Other

Surgical Intervention

Botox

Urgent PC


Botulinum toxin a botox
Botulinum toxin A (Botox) disease

  • FDA approved 2011 for 200 unites

  • In patient with neurogenic detrusor overactivity

  • Indications:

    • Antimuscarinic drugs ineffective or poorly tolerated.

    • Medication cost

    • Compliance

  • Two RCT proved efficacy

  • Mean duration of effect 36-42 weeks


Surgical treatment
Surgical treatment disease

  • Sphicterotomy

  • Bladder augmentation

  • Urinary diversion:

    • Continent

    • Incontinent



Female sui treatment
Female SUI: Treatment disease

  • Guidelines defined the five major types of procedures:

    • Injectables

    • Laparoscopic suspensions

    • Midurethral slings

    • Pubovaginal slings

    • Retropubic suspensions

Bulking agent

TOT Sling


Sui in men
SUI in men disease

  • Less common

  • After prostate surgery

  • Treatments:

    • Conservative

    • Male sling

    • Artificial urinary sphincter (AUS)

Male sling

AUS


Surveillance
Surveillance disease

  • Indications

    • Spinal cord injury or spina bifida

    • Impaired bladder compliance

    • Detrusor-sphincter dyssynergia

    • Vesico-ureteric reflux.

  • Methods:

    • Upper tract function: renal scans/serum creatinine)

    • Lower tract function: urodynamics

    • Anatomy: ultrasound or CT scan/cystogram/cystoscopy


Conclusion
Conclusion disease

  • NGB management is a complex process and should be approached in a multidisciplinary fashion

  • Goals should address bladder emptying and storage and to avoid complications and assures QOL

  • NGB patients should obtain baseline anatomical and functional evaluation

  • Surveillance should be offered especially for high risk patients


Questions
Questions? disease


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