Neurogenic bladder

Clinic

• Neurogenic bladder, refers to urinary bladder problems due to
  • CNS trauma or peripheral nerves involved in the control of urination.
  • Spinal cord injury, Peripheral nerve damage
  • MS
  • Stroke
  • Spina bifida
  • Parkinson's disease or other neurodegenerative diseases.
• There are multiple types of neurogenic bladder

Symptoms

• Overactive bladder
• Urinary urgency
• Frequency
• Incontinence or difficulty passing urine

Classification

Uninhibited

• Uninhibited bladder is usually due to damage to the brain from a Stroke / Tumor.
• This can cause
  • Reduced sensation of bladder fullness
  • Low capacity bladder
  • Urinary incontinence (Inability to hold urine)
• Does not lead to high bladder pressures that can cause kidney damage.
• It is characterized by urge incontinence, frequency, enuresis, and recurrent urinary tract infections.

Uninhibited bladder	STLE	HTLV-1
Urinary incontinence	+++	+++
Urgency	+++	+++
Frequency	+++	+

Spastic

• It is also known as upper motor neuron or hyper-reflexive bladder
• Detrusor and urethral sphincter do not work together and are usually tightly contracted at the same time.
• This phenomenon is also called detrusor external sphincter dyssynergia (DESD).
• This leads to
  • Urinary retention
  • High pressures in the bladder that can damage the kidneys.
• The bladder volume is usually smaller than normal due to increased muscle tone in the bladder.
• Spastic neurogenic bladder is usually caused by damage to the spinal cord above the level of T10.

Entity / Miasm

Bladder/ Detrusor overactivity: HTLV-1

Flaccid

• t is also known as lower motor neuron or hypotonic bladder
• The muscles of the bladder lose ability to contract normally.
• This can cause the inability to void urine even if the bladder is full and cause a large bladder capacity.
• The internal urinary sphincter can contract normally, however urinary incontinence is common.
• This type of neurogenic bladder is caused by damage to the peripheral nerves that travel from the spinal cord to the bladder.

Entity / Miasm

Bladder / Paralysis: PLV

Mixed

• Mixed type of neurogenic bladder can cause a combination of the above presentations.
• In mixed type A, the bladder muscle is flaccid but the sphincter is overactive.
• This creates a large, low pressure bladder and inability to void, but does not carry as much risk for kidney damage as a spastic bladder.

• Mixed type B is characterized by a flaccid external sphincter and a spastic bladder causing problems with incontinence.
• Miasm:

Signs and symptoms[edit]

Neurogenic bladder can cause a range of urinary symptoms including urinary urgency, urinary incontinence or difficulty urinating (urinary retention). The first sign of bladder dysfunction may be recurrent urinary tract infections (UTIs).^{[citation needed]}

Complications[edit]

Neurogenic bladder can cause hydronephrosis (swelling of a kidney due to a build-up of urine), recurrent urinary tract infections, and recurrent kidney stones which may compromise kidney function. This is especially significant in spastic neurogenic bladder that leads to high bladder pressures. Kidney failure was previously a leading cause of mortality in patients with spinal cord injury but is now dramatically less common due to improvements in bladder management.

Causes[edit]

Urine storage and elimination (urination) requires coordination between the bladder emptying muscle (detrusor) and the external sphincter of the bladder. This coordination can be disrupted by damage or diseases of the central nervous system, peripheral nerves or autonomic nervous system. This includes any condition that impairs bladder signaling at any point along the path from the urination center in the brain, spinal cord, peripheral nerves and the bladder.

Central nervous system[edit]

Damage to the brain or spinal cord is the most common cause of neurogenic bladder. Damage to the brain can be caused by stroke, brain tumors, multiple sclerosis, Parkinson's disease or other neurodegenerative conditions. Bladder involvement is more likely if the damage is in the area of the pons. Damage to the spinal cord can be caused by traumatic injury, demyelinating disease, syringomyelia, cauda equina syndrome, or spina bifida. Spinal cord compression from herniated disks, tumor, or spinal stenosis can also result in neurogenic bladder.

Peripheral nervous system[edit]

Damage to the nerves that travel from the spinal cord to the bladder (peripheral nerves) can cause neurogenic bladder, usually the flaccid type. Nerve damage can be caused by diabetes, alcoholism, and vitamin B12 deficiency. Peripheral nerves can also be damaged as a complication of major surgery of the pelvis, such as for removal of tumors.

Pathophysiology of Neurogenic Bladder

Many classifications have been used to group neurogenic bladder dysfunction. Each has their merits and clinical utility. These classifications may be based on urodynamic findings (e.g., Lapides [6], Krane, and Siroky [7]), neurourologic criteria (Hald and Bradley [8], Bors and Comarr [9]), or on bladder and urethral function (International Continence Society [10], Wein [11]).

A popular classification of neurogenic bladder dysfunction based on the location of the neurologic lesion can help guide pharmacologic and surgical therapies, with the voiding abnormalities seen clinically following from disruptions of the normal urinary physiology described above and shown in Figure 1. In this classification, neurogenic bladder arises from

1. lesions above the pontine micturition center (e.g., stroke or brain tumor) producing an uninhibited bladder,
2. lesions between the pontine micturition center and sacral spinal cord (e.g., traumatic spinal cord injury or multiple sclerosis involving cervicothoracic spinal cord) producing an upper motor neuron bladder,
3. sacral cord lesions that damage the detrusor nucleus but spare the pudendal nucleus producing a mixed type A bladder,
4. sacral cord lesions that spare the detrusor nucleus but damage the pudendal nucleus producing a mixed type B bladder,
5. lower motor neuron bladder from sacral cord or sacral nerve root injuries.

Neurogenic Bladder

Entities/ Miasms	Name	Lesion	Sign / Symptom	Pathology
Urine involuntary + Enuresis HSV-1	Uninhibited bladder	Lesions above the pontine micturition center	Reduced awareness of bladder fullness Low capacity bladder Urinary incontinence	Reduction of inhibition of pontine micturition center (PMC) by cortical / Subcortical structure damage. Brain lesions occurring above PMC, especially with bilateral lesions. Since PMC is intact, the normal opposition of detrusor and internal/external sphincter tonus is maintained so there are no high bladder pressures
Myoclonus Incontinence HTLV-1 NVCJD	Upper motor neuron neurogenic bladder dysfunction= Detrusor-sphincter dyssynergia (DSD)	The spinal cord damage esp Above T10	Detrusor hyperreflexia Bladder hypertonicity Maybe incontinence	Simultaneous detrusor and urinary sphincter contractions produce high pressures in the bladder The spinal cord damage renders the bladder and sphincters spastic, especially if lesions are above the T10 level The bladder capacity is usually reduced due to the high detrusor tonus (neurogenic detrusor overactivity, or detrusor hyperreflexia). If detrusor pressure exceeds internal/external urinary sphincter pressure in the proximal urethra, then incontinence may occur.
Urinary retention HSV-1, 2	Mixed type A neurogenic bladder (the more common of the mixed type bladders)= Detrusor areflexia = Detrusor flaccid	Detrusor nucleus damage	Urinary retention Incontinence is uncommon.	Intact pudendal nucleus is spastic producing a hypertonic external urinary sphincter. The bladder is large and has low pressure, so the spastic external sphincter produces urinary retention. The detrusor pressure is low so upper urinary tract damage from vesicoureteral reflux does not occur, and incontinence is uncommon.
STLE HTLV-1	Mixed type B neurogenic bladder	Pudendal nucleus lesion	Incontinence Urgency Frequency	Flaccid external urinary sphincter Bladder is spastic due to the disinhibited detrusor nucleus. Thus, the bladder capacity is low but vesicular pressures are usually not elevated since there is little outflow resistance.
Bladder Paralysis Fasciculations Hyporeflexia PLV	Lower motor neuron neurogenic bladder	Lesion in sacral micturition centers or related peripheral nerves	Detrusor areflexia Incontinence	Thoracic sympathetic nervous system outflow to the lower urinary tract is intact. Bladder capacity is large since detrusor tone is low (detrusor areflexia) Internal urinary sphincter innervation is intact. Despite the low detrusor pressure, overflow urinary incontinence and urinary tract infections are not uncommon.
Bradikinesia Tremor (parkinsonism) STLE HTLV-1	Detrusor hyperactivity with impaired bladder contractility (DHIC)		Frequent but weak involuntary detrusor contractions causing incontinence despite incomplete bladder emptying	bladder trabeculation Slow bladder contraction velocity Elevated urinary residual volume after voiding attempts.