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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 α1: trigone, bladder neck and urethra

β2, β3: bladder neck, body

Braddom 3 rd &4 th Edition

Braddom 3 rd &4 th 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

Peripheral innervation 1. Sym: T10-L2  hypogastric n. 2. Parasym: S2-4  pelvic n. 3. Somatic:
  • 1. Sym:

T10-L2hypogastric n.

  • 2. Parasym:

S2-4pelvic n.

  • 3. Somatic:

S2-4pudendal n.external urethral sphincter

Braddom 3 rd &4 th Edition

Central control

Pudendal nerve Inh. Pelvic floor activity during voiding
Pudendal nerve
Inh. Pelvic floor
activity during
voiding

Braddom 3 rd &4 th Edition

Reflex center of bladder

Classification

Classification Braddom 3 &4 Edition

Braddom 3 rd &4 th 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 3 rd &4 th Edition, หนังสือ อ. อภิชนา

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 3 rd &4 th Edition, หนังสือ อ. อภิชนา

Investigation

U/A, U/C, urine strip BUN/Cr

Cr clearance: gold standard for assess renal function

Urodynamic study/ uroflowmetry PVR (Balance bladder?)

Braddom 3 rd &4 th 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 .อภิชนา

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 3 rd &4 th 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 เขียนรายงาน void: Qmax/Vvoid/Vres

ถ้าฉี่ได้ > 150 ml แต่ Qmax < 10 ml/sec ให้สงสัยว่า ผิดปกติ

Ref: หนังสือ อ. อภิชนา

Urodynamic study: filling phase

Filling rate

Ref: หนังสือ อ. อภิชนา

  • - 20 ml/min (UMN)

  • - 50 ml/min (LMN)

Results

BD sensation: normal, increased, reduced, absent, non-specific, bladder pain, urgency

  • - 1 st sensation (100-250 cc.)

  • - 1 st desire (300-400 cc.)

  • - strong desire (400-500 cc.);

Detrusor function: Normal, Overactivity/Phasic involuntary contraction/Terminal detrusor overactivity (>15 cmH 2 O) > 40 cm H2O เป็นอันตรายต่อ upper tract

Urethral function: Normal, Abnormal, incompetent, urethral relaxation incontinence,

urodynamic stress incontinence

Ref: หนังสือ อ. อภิชนา

Urodynamic study: filling phase

Bladder capacity: maximal cystometric capacity

  • - Normal: 400-500 ml

  • - Small: < 350 ml

  • - Average: 350 ml

  • - Large: > 650 ml

Bladder compliance: = ΔV/ΔPdet

( P det = Pves P abd)

  • - Normal

> 20

ml/ cmH 2 O

  • - Borderline

10-20 ml/ cmH 2 O

  • - Low

< 10

ml/ cmH 2 O

Ref: หนังสือ อ. อภิชนา

Urodynamic study: voiding phase

Detrusor function:

Overactivity

> 60

cmH 2 O

Normal

40-60 cmH 2 O

Underactivity

< 40

cmH 2 O

Acontractile

< 15

cmH 2 O

Ref: หนังสือ อ. อภิชนา

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: หนังสือ อ. อภิชนา

Interpretation

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

Mixed UMN-LMN lesion Ref: Slide lecture อ . อภิชนา
Mixed UMN-LMN lesion Ref: Slide lecture อ . อภิชนา
Mixed UMN-LMN lesion Ref: Slide lecture อ . อภิชนา

Mixed UMN-LMN lesion

Ref: Slide lecture .อภิชนา

Management

Braddom 4 th Edition

Management

Braddom 4 th Edition

1. Detrusor overactivity with

hyperreflexic sphincter

Goal: no urinary retention, no incontinence, no upper tract/lower tract complication

Management:

- Detrusor

- Sphincter

Braddom 3 rd &4 th Edition, หนังสือ อ. กิ่งแก้ว

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): กระตุ้นให้ bladder บีบตัว

Braddom 3 rd &4 th Edition, หนังสือ อ. กิ่งแก้ว

Hyperreflexic sphincter

  • 1. Time voiding: for incontinence person

    • - Pt. urinate before detrusor contraction

    • - Restrict oral fluid< 2 L/d หรือ keep urine output> 1.5 L/d

    • - IC ตามหลังถ้ามี PVR

  • 2. Trigger reflex voiding: suprapubic tapping if Pdet is acceptable, thigh scratching

  • 3. Medication:

    • - alpha blocker ex. Prazosin, phenoxybenzamine ลดการบีบ เกร็งของ internal sphincter

    • - Diazepam/baclofen: ลดการบีบเกร็งของ external sphincter

  • 4. Sx.: sphincterotomy+bladder neck incision

  • Braddom 3 rd &4 th Edition, หนังสือ อ. กิ่งแก้ว

    2. Detrusor underactivity with

    hyporeflexic sphincter

    Goal: Improve storing function, decreased incontinence, no complication

    Management:

    - Detrusor

    - Sphincter

    Braddom 3 rd &4 th Edition, หนังสือ อ. กิ่งแก้ว

    Detrusor underactivity

    • 1. Time voiding:

      • - Restrict oral fluid

      • - Crede’s or valsava’s maneuvers

      • - IC ตามหลังถ้ามี PVR

  • 2. Medication: cholinergic drugs (bethanechol hydrochloride ไม่ใช้แล้ว)

  • Hyporeflexic sphincter

    • 1. Medication: alpha agonist (ephedrine, phenylpropanolamine)

    • 2. Kegel’s 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

    IC 4-6 times/ day

    IC 2-3 times/wk until 2 wk, if < 50 ml

    < 200

    IC 3 times/day

    IC 2 times/day

    < 150 < 100

    < 50

    IC daily

    balanced bladderoff IC

    Medication

    Medication

    Patient education

    ID

    CISC Condom catheter

    Grades of vesicoureteral reflux (VUR)

    Classification of grades of

    vesicoureteral reflux

    Classification of grades of vesicoureteral reflux Adopted by the International Reflux Study Committee

    Adopted by the International Reflux Study Committee