Neurogenic bladder in SCI

Receptors
1. Cholinergic muscarinic receptors: M2 and M3 body of the bladder, trigone, bladder neck and urethra nicotinic receptors: striated sphincter muscle 2. Adrenergic receptors: predominately 1: trigone, bladder neck and urethra 2, 3: bladder neck, body
Braddom 3rd&4th Edition

Braddom 3rd&4th Edition

Main effector transmitters

1. Storage: Ach: smooth muscle relaxation NE: urethral contraction 5-HT: - urethral muscle contraction - might have inhibitory detrusor effects at the midbrain level 2. Voiding: PG: urethral relaxation

Peripheral innervation
1. Sym: T10-L2hypogastric n. 2. Parasym: S2-4 pelvic n. 3. Somatic: S2-4 pudendal n. external urethral sphincter

Braddom 3rd&4th Edition

Central control

Reflex center of bladder

Pudendal nerve Inh. Pelvic floor activity during voiding Braddom 3rd&4th Edition

Classification

Braddom 3rd&4th Edition

Hx. taking
How to urinate? (CIC, CISC, ID, spontaneous voiding) Frequency of urination, vol. per time, PVR? Incontinence? Disturb function? Fluid input/output UTI? Previous voiding habit, changing of bladder function Satisfaction Medication Present function: transfer, toileting Underlying dis: DM Hx. of AD
Braddom 3rd&4th Edition, .

Physical exam
ASIA: neurological level Reflex: - BCR: S4-5 - Anal reflex: S4-5 VAC: S2-4 Big/Long toe flexors (S2) Sphincter tone Sensory: perianal and deep anal sensation Prostate gland hypertrophy Others: consciousness, leg spasticity, seeing function, pressure ulcer
Braddom 3rd&4th Edition, .

Investigation
U/A, U/C, urine strip BUN/Cr Cr clearance: gold standard for assess renal function Urodynamic study/ uroflowmetry PVR (Balance bladder?)

Braddom 3rd&4th Edition

Balance bladder: PVR

UMNL: PVR < 20-25% of bladder capacity LMNL: PVR < 10-20% of bladder capacity acceptable bladder capacity > 300 ml in adult In practice acceptable low PVR ranges from 50-100 ml; the lower, the better

Ref: Slide lecture .

Investigation
U/S kidney: chronic obstruction, dilatation, mass, stone, cyst Plain KUB: radiopaque calculi in kidney/ureter/ bladder VCUG: detect VUR Others: CT, CT-IVP, DMSA scan, MAG-3 scan, urethral pressure profiles, bethanechol stimulation test
Braddom 3rd&4th Edition

Uroflowmetry
Normal value: - max flow rate (Q max) 25 ml/sec - mean flow rate 14 ml/sec - void vol 250 ml, time <30 sec void: Qmax/Vvoid/Vres > 150 ml Qmax < 10 ml/sec

Ref: .

Urodynamic study: filling phase

Filling rate Ref: . - 20 ml/min (UMN) - 50 ml/min (LMN) Results BD sensation: normal, increased, reduced, absent, non-specific, bladder pain, urgency - 1st sensation (100-250 cc.) - 1st desire (300-400 cc.) - strong desire (400-500 cc.);

 Detrusor function: Normal, Overactivity/Phasic involuntary contraction/Terminal detrusor overactivity (>15 cmH2O) > 40 cm H2O upper tract Urethral function: Normal, Abnormal, incompetent, urethral relaxation incontinence, urodynamic stress incontinence
Ref: .

Urodynamic study: filling phase

Bladder capacity: maximal cystometric capacity - Normal: 400-500 ml - Small: < 350 ml - Average: 350 ml - Large: > 650 ml Bladder compliance: = V/Pdet ( P det = Pves P abd) - Normal > 20 ml/ cmH2O - Borderline 10-20 ml/ cmH2O - Low < 10 ml/ cmH2O
Ref: .

Urodynamic study: voiding phase

Detrusor function: Overactivity Normal Underactivity Acontractile

> 60 cmH2O 40-60 cmH2O < 40 cmH2O < 15 cmH2O

Ref: .

Urodynamic study: voiding phase

Urethral function: Normal DSD type I (Initial) II (Intermittent) III Sustained Non-relaxing urethral sphincter obstruction Bladder outlet obstruction Volume: Void (by straining, tapping, expression), Leak, PVR, Cystometric capacity
Ref: .

Interpretation
Bladder capacity Bladder compliance Pdet in filling and voiding phase Sphincter EMG

UMN lesion

LMN lesion

Mixed UMN-LMN lesion

Ref: Slide lecture .

Management

Braddom 4th Edition

Management

Braddom 4th Edition

1. Detrusor overactivity with hyperreflexic sphincter

Goal: no urinary retention, no incontinence, no upper tract/lower tract complication Management: - Detrusor - Sphincter

Braddom 3rd&4th Edition, .

Detrusor: overactivity
1. Medication: anticholinergic drug ex. Oxybutynin HCl, imipramine 2. TENs: pudendal afferent stimulation for reflex inhibition (5Hz, 20-30 min, twice/d) 3. Sx: - sacral deafferentation (SDAT): posterior root rhizotomyflaccid bladder - combined with sacral anterior root stimulation (SARS): bladder
Braddom 3rd&4th Edition, .

Hyperreflexic sphincter
1. Time voiding: for incontinence person - Pt. urinate before detrusor contraction - Restrict oral fluid< 2 L/d keep urine output> 1.5 L/d - IC PVR 2. Trigger reflex voiding: suprapubic tapping if Pdet is acceptable, thigh scratching 3. Medication: - alpha blocker ex. Prazosin, phenoxybenzamine internal sphincter - Diazepam/baclofen: external sphincter 4. Sx.: sphincterotomy+bladder neck incision
Braddom 3rd&4th Edition, .

2. Detrusor underactivity with hyporeflexic sphincter

Goal: Improve storing function, decreased incontinence, no complication
Management: - Detrusor - Sphincter

Braddom 3rd&4th Edition, .

Detrusor underactivity
1. Time voiding: - Restrict oral fluid - Credes or valsavas maneuvers - IC PVR 2. Medication: cholinergic drugs (bethanechol hydrochloride )

Hyporeflexic sphincter
1. Medication: alpha agonist (ephedrine, phenylpropanolamine) 2. Kegels exercise: effective only in female with stress incontinence due to pelvic floor descent 3. Sx: urethral suspension, artificial sphincter, Teflon injection therapy

Bladder training: ID/CISC/CIC

Bladder training requires. Cognitive intact, Motivation, Independent toileting, Adherence to the scheduled voiding regimen, fluid intake

Bladder training regimen IC 4-6 /day (vol/cath < 500 ml) try voiding q 2 hr during the day and before IC Strictly follow fluid regimen (1.5-2.5 l/d) and record voiding diary Preferred urine / d = 1.5-2 L PVR vol IC frequency
> 200 ml < 200 < 150 < 100 < 50 IC 4-6 times/ day IC 3 times/day IC 2 times/day IC daily IC 2-3 times/wk until 2 wk, if < 50 ml balanced bladder off IC

Medication

Patient education
ID CISC Condom catheter

Grades of vesicoureteral reflux (VUR)

Classification of grades of vesicoureteral reflux

Adopted by the International Reflux Study Committee