bladder and its dysfunction
Transcript of bladder and its dysfunction
INERVATION OF BLADDER AND ITS
DYSFUNCTION
OVERVIEW
Anatomy and physiology CNS centers Arcs and loops Spinal tracts Basic concepts of neurourological
function Reflexes Dysfunction Pharmacological management
Anatomy and physiology
Upper urinary tract dysfunction is rare due to neurological disease
Lower urinary tract is richly supplied with both autonomic and somatic nervous system
Bladder anatomy
Three anatomical layersInner mucosal layerMuscular middle layer
○ Outer and inner longitudinal layer○ Middle circular layer
Outer adventitial layer Functinally bladder is divided in to parts
Body Trigone
Receptors of the bladder
Parasympathetic (musacrinic) Sympathetic
Dual actionBeta adrenargicAlpha adrenergic
CNS centers
PONSPontomesencephalic reticular formationAfferents from bladder receptors of
distensionSphincter detrusor synergesiaReticulospinal tracts spincter and detrusor
centers of the spinal cord
Cortex, basal ganglia and cerebellumParacentral lobule involved in voluntary
initiation of micturition and inhibition of reflex voiding
Lesions results in frequency and urgencyDirect control of voluntary micturition
influencing the onufs nucleus through CSTPontine micturition center
Spinal cord centersSympathetic anteriomediolateral gray
column thoracolumbar cord T9-L1Parasympathetic nuclei intermediolateral
region of sacral cord S2-S4Onuf’s nucleus anterior horn of sacral cord
Arcs and Loops
Supra spinal arcParasympathetic afferent input from tension
receptor in the bladder wall to pontine micturition centers
Reticulospinal tracts to centers to sacral cord
3 to 4 yrs of age voiding is a reflex processLesions above the brain stem manifested
clinically by frequency and urgency with preserved detrusor sphincter synergesia
Sympathetic nervous system arcEfferent sympathetic innervation T9-L1
through ventral routes, sympathetic ganglia in the para vertebral chain preaortic and parvertebral chains
Touch, pain, and temperature from bladder through spinothalamic tract
Parasympathetic nervous system arcEfferents originate in the sacral cord travels
throgh ventral spinal roots and pelvic nerves and joins with sympathetic nerves to create a large autonomic plexus
Proprioceptive information of bladder sensation and pain through posterior columns and spinothalamic centers to PMC and supraspinal centers
Pudendal system arcsEfferent somatic innervation of ext sphincter
from the onufs nucleus through pudendal nerves
Afferent carry exteroceptive and proprioceptive sensation from pelvic floor
Afferent fibers from the ext sphincter and pelvic floor synapse with pudendal motor neurons in ventral horns of the spinal cord and helps in voluntary and reflex activity
LOOPS
Loop 1Pathways between frontal cortex, basal ganglia,
thalamic nuclei, cerebellum and pontomesencephalic reticular formation
Predominantly inhibitoryInterruption leads to loss of volitional control of
micturition reflex – uninhibited detrusor CVA, brain tumor, head injury, multiple sclerosis,
Parkinson’s disease.
LOOP 2Sensory afferent neurons from detrusor –
posterior and lateral columns, ‘’long routing’’ in spinal cord - pontomesencephalic portion in brain stem
Efferent neurons from micturition center travel down in reticulospinal tract ‘’long routing’’ to detrusor without any synapse in spinal cord
Required to establish an adequate magnitude and duration of detrusor reflex to accomplish complete bladder emptying
contdInterruption – hyper-reflexic detrusor –
unable to produce a voluntary voiding contraction
Spinal cord trauma, multiple sclerosis, spinal cord tumor, arachnoiditis
LOOP 3Detrusor and pudendal motor nuclei and
their interneurons in sacral cordCoordination between detrusor contraction
and striated urethral sphincter relaxation during voiding
LOOP 4Motor cortex in frontal lobe – traverse via
pyramidal tract in lateral columns of spinal cord, synapse on pudendal sphicter nucleus.
Voluntary control over striated muscle of the urethral sphincter during bladder storage and voiding
Spinal tracts
Corticospinal tract Reticulospinal tract Spinothalamic tract Posterior columns
Basic concepts of neurourological function Two phases
Low pressure insensanate filling and storage of urine
Efficient evacuation under voluntary control Filling and storage of urine
Passive filling phase initial phase occurs till proxim al urethral pressure > exceeds the bladder
Continence reflex phase bladder pressure > urethral pressure
Frontal micturition center by bladder distension enhances sympathetic activity and external sphincter
MicturitionNormal urinary voiding is voluntary
disinhibition of pontine and sacral reflex activity in response to bladder distension
REFLEXES
Superficial anal reflexAnal reflex or anal wink consists contraction
of anal sphincter in response to stroking or pricking the skin of perianal region
Inferior haemarhoidal nerve (S2-S5)Caudaequina or conus medullaris lesions
Bulbocavernosus reflexStimulating the skin of glans or penis
response is felt by placing a gloved finger in rectum
Neurogenic bladder dysfunction
5 types (2 UMN; 3LMN) Uninhibited Reflex Autonomous Motor paralytic Sensory paralytic
Nomenclature Urgency is the complaint of a sudden and
compelling desire to pass urine that is difficult to defer.
Urge incontinence is the complaint of involuntary leakage accompanied by urgency. Leakage may range from drops to soaking
Retention bladder is unable to empty itself to a point that there is over 100 cc's (3.5 ounces) of urine left over in the bladder after urinating*
Uninhibited bladder
Lesion affecting the second frontal gyrus and the pathways leading from it down to the pontine centre
Frontal lobe tumours, parasagittal meningiomas, anterior communicating artery aneurysms, normal perssure hydrocephalus, Parkinson’s disease and multisystem atrophy
Uninhibited bladder
Features are: Urgency at low bladder volumes
(detrusor hyperreflexia) Sudden uncontrollable evacuation No residual urine - little risk of infection If severe intellectual deterioration occurs
urine may be passed at random, without appropriate concern.
Spinal bladder Damage to spinal cord by trauma, tumor, multiple sclerosis Fullness is not appreciated Intravesical pressure may only be indicated by sweating,
pallor, flexor spasms, dramatic rise in blood pressure Reflex emptying without warning Incomplete evacuation may improve with practice and may
be performed at will if massaged and suprapubic pressure applied
Detrusor – sphincter dyssynergia . Evidence of bilateral pyramidal lesion – enhanced reflexes
and extensor plantar response Bladder is small and contracted, can hold maximum of 250ml
Autonomous bladder(subsacral lesions)
Damage to sensory and motor components in cauda equina or pelvis
Cauda equina lesions, Pelvic surgery, pelvic malignant lesions, spina bifida and high lumbar disc lesions
MRI or myelogram is obligatory to exclude high disc lesions
Autonomous bladder(subsacral lesions) contd
Features Continual dribbling incontinence Considerable residual urine with high
infection risk No sensation of bladder fullness- large
atonic bladder May be associated with perineal
numbness and loss of sexual function
Sensory bladder
Similar to autonomous bladder Anatomical explanation is uncertain Primary problem is sensory denervation Ultimately overdistension, myogenic
damage and contractile failure Rare disorders : Tabes dorsalis, SACD
and Multiple sclerosis, Diabetes mellitus
Sensory bladder contd..
Features : Massive retention of urine in litres – high
risk of infection Dribbling incontinence of sufficiently
large volumes Voiding possible with considerable
straining but evacuation is incomplete
Motor paralytic
Areflexic detrusorMarked by painful distention
Inability to initiate urination
Difficulty initiating urination, straining, decreased size and force of stream, interrupted stream, and recurrent urinary tract infection.
Pharmacological methods Urinary retention
Cholinergic agents to increase detrusor motor function○ Bathnechol improves detrusor funtion
particularly in denervation and selectively affects bladder and gut
Alpha adrenergic blockers such as prazosin
Urinary incontinenceInhibition of detrusor activity and
increase functional capacity of bladderAnticholinergics such as propanthalineAnticholinergic with smooth muscle
relaxing properties such as oxybutininTCA such as imipramine with
anticholinergic activity
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