1. NEUROGENIC
BLADDER

2. Outline of the presentation
• Applied physiology
• Symptomatology
• Types according to levels of bladder
dysfunction
• Investigations
• Treatment available

3. Bladder functions
• Storage - at low pressure until such time as it
is convenient and socially acceptable to void
• Voiding - initiated by inhibition of the striated
sphincter and pelvic floor, followed some
seconds later by a contraction of the detrusor
muscle.

4. 1.Cortical micturition centre
2.Pontine micturition centre
3.Spinal micturition
centre
4. Peripheral nerves
Sympathetic
(T11 –L2)
Parasympathetic
( S2,3,4)
(S2,3,4)
Control of micturition

5. Cortical micturation centre(CMC)
Location: Paracentral lobule in the medial aspect of the
frontoparietal cotex
Function: Inhibitory to PMC
Dysfunction – loss of social control of bladder
The brain’s control of the PMC is part of the social
training that children experience at age 2 - 4 years

6. Pontine Micturition Centre (PMC)
Also called Barrington’s nucleus
• Lateral region
Function - continence, storage urine
stimulation results in a powerful contraction
of the urethral sphincter
• Medial region
Function - micturition center
stimulation results in decrease in urethral
pressure and silence of pelvic floor EMG signal,
followed by a rise in detrusor pressure.

7. Sacral reflex or Sacral/Primitive
micturition centre (SMC/PMC)
1. Sacral parasympathetic nucleus
(SPN): S234- pelvic splanchnic
nerves (nervi erigentes) arise from
2. Somatic – Onufoid nuclei
Collection of external urethral
sphinter motoneurones
3. Levator Ani Motoneurones

8. Peripheral innervation

9. Stimulation Response
Parasympathetic
(S 2-4)
Excitatory to
detrusor, relaxes
sphincter - void
Sympathetic
(T11- L2)
Inhibitory to
detrusor, ↑trigone
& Urethral tone
Somatic ( S2 - 4) Excitatory to the
external sphincter

10. Micturition reflex
Internal sphincter –
no important role in micturition,
prevents leakage during filling and
prevents reflux of semen into bladder during
ejaculation
Sympathetic nerves –
no part in micturition

11. The Micturition Reflex
Sensation of bladder fullness via pelvic
and pudendal nerves to S 2,3,4
Periaqueductal gray matter
Medial Pontine micturition center
Frontal lobe decides social
appropriateness
Onuf’s nucleus to pudendal nervesDetrussor center (S 2,3,4) to pelvic nerves
RECIPROCAL ACTIVITY BETWEEN SPHINCTER & DETRUSOR
Micturition

13. On-off switch
Relay
center
Primitive
voiding
Cerebral
PMC
SMC

14. Symptomatology

15. Detrusor Hypereflexia

16. Detrusor Sphincter Dyssynergia

17. Resultant
Poorly sustained hyperreflexic bladder
contraction (DH) and (DSD)
Raised post voiding residual (PVR)
Exacerbation of urgency

18. Neuropathy
• Long history of
neuropathic symptoms,
• Stocking glove
anesthesia
• Absent knee and ankle
jerks will be absent
• Small fiber sensory
impairment
demonstrable to the
level of the ankles
• Other features of
autonomic involvement
• Sexual dysfunction
Cauda equina
• Bladder, sexual & bowel
dysfunction
• S 2, 3, 4 sensory loss
• Lax anal sphincter
• Bulbocavernosus (sacral
reflexes) reflex lost
• +/- Foot deformities, lower
limb abnormalities
• Cutaneous markers over the
back & sacrum

19. Spinal Cord
• Signs of upper motor
neuron lesion in the
lower limbs (unless the
lesion is central
intramedullary and small)
• Erectile dysfunction in
men
• +/- Paraparesis
Brainstem
• Marked neurological
deficits dorsal and
discreet lesion defect
of bladder function
• MLF lesion
Internuclear
ophthalmoplegia

20. Extrapyramidal diseases
• Extrapyramidal features
• MSA, Parkinsons disease
• Autonomic dysfunction
• Cerebellar signs
Suprapontine
• Frontal lobe disorders
• Dementia, personality
change
• Aware about incontinence
unless extensive lesions
• Severe urgency, frequency &
urge incontinence without
dementia, socially aware
and embarrassed by
incontinence
• Urinary retention

21. Types according to
the level of bladder
dysfunction

23. a) Suprapontine/cortical lesion –
“Uninhibited /Cortical bladder”
Severe urgency, frequency & urge incontinence
with dementia – incontinent and inappropriate
voiding
without dementia- socially aware & embarrassed
by their incontinence.

24. b) Pontine lesion –
“ Reflex / Automatic bladder”
DH,
Arreflexia in pts with INO
c) Spinal (subpontine/suprasacral)
“ Spastic Bladder”
Disorders of storage and emptying
DSD (true only if above T6 level), DH

25. d) Sacral and subsacral lesions
I) Afferent fibres involved only –
“Atonic /Areflexic bladder”
Overflow incontinence
Straining for micturition
No DSD, no DH
II) Both afferent and efferent involved –
“Autonomous bladder”
Small capacity , acting of its own. No DSD/DH

26. UMN-
SPASTIC
LMN-
FLACCID
AREFLEXIC
Cerebral
PMC
SMC

27. Causes of various levels of dysfunction
a) Suprapontine and Pontine Causes
• Stroke
• Tumors
• Dementia (AD,FTD)

28. Spinal causes (subpontine/suprasacral)

29. Sacral and Subsacral causes

30. Management- Investigations
Noninvasive bladder investigations-
Post void residual volume –
• In out catheterization,
• Ultrasound ( N is <100ml)
Uroflowmetry-
• Voided volume ( >100ml)
• Maximal flow, maximal and average flow rate
(M > 20ml/sec and F > 15ml/sec)

31. Cystometry-
• Measure detrusor pressure
(Intravesical presure – Rectal pressure)
• Bladder infused till 400 to 600ml – Pressure should
not rise to >15cm water (Stable bladder)
• Neurogenic detrusor overactivity – Involutary
detrusor contraction during filling phase
• Voiding phase – Detrusor pressure M < 50cm
water F < 30cm water

32. Sphincter EMG –
Reinnervation with prolonged duration of
MUAPs
Neuroimaging –
Cauda equina & conus lesions,
spinal,
supra pontine and pontine lesions

33. Treatment - Detrusor overactivity
• Anticholinergics
- Oxybutynin, tolterodine
- M3 blockers- darifenacin
• Tricyclic antidepressants
- Imipramine
• Desmopressin intranasally – once in 24 hrs
• Botulinum toxin A
• Intravesical capsaicin –
instilled with a balloon catheter

34. Neurogenic Detrusor overactivity

36. Treatment
Only Urinary Retention
(If residual volume > 100ml)
• Clean intermittent self
catheterisation (CISC)
• Permanent indwelling
catheter
Detrusor overactivity &
Retention
• Anticholinergic drugs
• CISC

37. Treatment
• External device – condom catheter
• Sacral nerve stimulators – for DI
• Nerve root stimulators – S 2,3,4 for voiding
assisting defecation
• Surgery – Augmentation cystoplasty, artificial
sphincter, urinary diversion with stoma
collection bag