Neurogenic
Bladder
Any condition that impairs bladder and bladder outlet, afferent and efferent
signaling can cause neurogenic bladder
Causes:
1- May involve the CNS (eg, stroke, spinal injury, meningomyelocele,
amyotrophic lateral sclerosis),
2-peripheral nerves (eg, diabetic, alcoholic, or vitamin B12 deficiency
neuropathies; herniated disks; damage due to pelvic surgery),
3- both (eg, Parkinson's disease, multiple sclerosis, syphilis).
Types:
1-In flaccid (hypotonic) neurogenic bladder, volume is large, pressure is low,
and contractions are absent. It may result from peripheral nerve damage or
spinal cord damage at the S2 to S4 level. After acute cord damage, initial
flaccidity may be followed by long-term flaccidity or spasticity, or bladder
function may improve after days, weeks, or months.
2-In spastic bladder, volume is normal or small, and involuntary contractions
occur. It usually results from brain damage or spinal cord damage above T12.
Precise symptoms vary by site and severity of the lesion. Bladder contraction
and external urinary sphincter relaxation are typically uncoordinated (detrusor-
sphincter dyssynergia).
3-Mixed patterns (flaccid and spastic bladder) may be caused by many
disorders, including syphilis, diabetes mellitus, brain or spinal cord tumors,
stroke, ruptured intervertebral disk, and demyelinating or degenerative
disorders (eg, multiple sclerosis, amyotrophic lateral sclerosis).
Symptoms and Signs:
Overflow incontinence is the primary symptom in patients with a flaccid or
spastic bladder. Patients retain urine and have constant overflow dribbling. Men
typically also have erectile dysfunction. Patients with spastic bladder may have
frequency, nocturia, and urgency or spastic paralysis with sensory deficits.
Complications:
1-recurrent UTIs and urinary calculi. Hydronephrosis with vesicoureteral reflux
may occur because the large urine volume puts pressure on the vesicoureteral
junction, causing dysfunction with reflux and, in severe cases, nephropathy.
2-Patients with high thoracic or cervical spinal cord lesions are at risk of
autonomic dysreflexia (a life-threatening syndrome of malignant hypertension,
bradycardia or tachycardia, headache,and sweating due to unregulated
sympathetic hyperactivity). This disorder may be triggered by acute bladder
distention (due to urinary retention) or bowel distention (due to constipation or
fecal impaction).
Diagnosis:
Postvoid residual volume
Renal ultrasonography
Serum creatinine
Usually cystography, cystoscopy, and cystometrography with urodynamic testing
Treatment:
1-General treatment
2- flaccid bladder,.Clean Intermittent self-catheterization(CIC) is preferable
Suprapubic catheterization may be used if patients cannot self-catheterize .
3- spastic bladder :trigger voiding (eg, applying suprapubic pressure, scratching
the thighs); anticholinergics may be effective. Sphincterotomy, . Sacral (S3 and
S4) rhizotomy Urinary diversion may involve an ileal conduit or ureterostomy
artificial, mechanically controlled urinary sphincter