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Neurogenic Bladder

is the loss of normal bladder function due


to damage to some of its nervous system.
The human bladder has two main functions, namely the storage
and emptying of urine. Physiologically, in the process of urination there
are four conditions that must be fulfilled to be normal, namely:
1. Adequate bladder capacity,
2. perfect bladder emptying,
3. takes place in good control, and
4. every filling and emptying of the bladder is not adversely affects the
upper urinary tract and kidneys.
Ethiology
There are 2 types of neurogenic bladder
1. Spastic
- Caused by lesions above the center of the micturition in the sacral.
- Loss of sensation to empty the bladder and lose motor control,
- Bladder can be atrophy, so bladder capacity decreases.
Clinical Appearance:
• Frequent urinary voiding
• Small capacity <300 cc
• Small amounts
2. Flaccid
- Lower motor neuron lesions
- Bladder continues to be filled and enlarged (extension)
- Urine is collected and can become empty but incomplete (overflow),
causing the amount of residual urine to trigger potential for infection.
Anormalities in the central nervous system:
• Alzheimer's disease
• Meningomielocele
• Brain tumor or spinal cord
• Multiple sclerosis

Disorders of the peripheral nervous system:


• Alcoholic neuropathy
• Diabetes neuropathy
• Nerve damage due to pelvic surgery
Patophysiology
Depending on the path affected, in general there are three main types of
interference
1. Supersons punch
The center of the micturition is the center of setting mycotic
reflexes and all of its activity is regulated mostly by inhibitory input
from the medial frontal lobe, basal ganglia and elsewhere. Damage in
general will result in loss of inhibition and cause hyperreflection
2. Lesions between the center of the micturition and the sac spinal
cord
Spinal cord lesions located between the center of the micturition
and the sacral portion of the spinal cord will interfere with the pathway
which inhibits detrusor contraction and the regulation of the detrusor
sphincter function. Some conditions that might occur include:
1. Vesica urinaria is hyperreflection
As with supra-ponsy lesions, the loss of the normal inhibitory mechanism
will lead to a hyperreflection bladder state that will cause pressure to increase in
small increments of the volume of the bladder.
2. Disinergia detrusor-sphingter (DDS)
Under normal circumstances, sphincter relaxation will precede detrusor
contractions. In the DDS state, there are contractions of the sphincter and detrusor
muscles simultaneously.
3. A weak detrusor contraction
Hyperreflection contractions that arise are often weak so that emptying the
bladder that occurs is not perfect. This situation when combined with disinergia
will cause an increase in residual volume after micturition.
4. Increasing the volume of residual post-injection
A large volume of residual after-injection in hyperreflection bladder
conditions requires a little additional volume for bladder contractions to occur.
Patients complain about frequent small amounts of micturition.
3. Lower Motor Neuron lesion (LMN)
Damage to the S2-S4 root in both the spinal and extradural
canals will cause LMN interference from the bladder function and loss
of bladder sensibility. The voluntary process of micturition is lost and
because the mechanism for causing detrusor contractions is lost, the
bladder becomes atonic or hypotonic when the damage to the damage
is partial.
Symptoms

• Neurogenic bladder is characterized by spontaneous voiding in small


amounts at frequent intervals. This voiding pattern reflects the
presence of upper motor neuron lesions (Engram, 1999)
• Symptoms vary based on whether the bladder becomes less active or
overactive. An underactive bladder is usually not empty and stretched
until it becomes very large. This enlargement usually does not cause
pain because stretching occurs slowly and because the bladder has
little nerve or does not have local nerves.
Diagnosis
• History
• Evaluation :
Physical examination included
> regular check-ups in bed
> careful evaluation of genitalia and prostate
> perineal sensation
> anal tone
There are several ways of evaluating reflexes that are useful for
determining the state of the patient
Ice Water Test:
• To test for bladder autonomic function through the pelvic nerves
• 3 ounces (150 cc) of saline liquid with a temperature of 380 F or 3.30
C is injected into a catheter in the bladder.
• If the saline solution comes out quickly, the test shows a description
of UMN's condition
Bulbocavernosus Reflex:
• This test is for the somatic function of the bladder through the pudendal
nerve.
• The finger is inserted into the rectum and the pensi gland or the clitoris
is pressed or the catheter is pulled.
• If the rectal sphincter contracts, there is no possible reflex activity and
LMN lesions
Residual Urine:
• This examination shows the perfection of bladder emptying.
• After emptying the bladder, the patient is immediately catheterized.
• Residual urine is normally negligible.
• Large values ​of 10-20%, often seen in Neurogenic Bladder, are usually
not acceptable.
• This shows incomplete emptying of the bladder, remaining urine allows
a place for infection to occur
Radiographic Inspection:
• The most common way is a static cystogram to examine the anatomy
of the urinary tract.
• Voiding cystourethrogram to test the function of the urethra and
bladder during emptying.
• Retrograde urethrogram for detecting strictures, reflexes or diverticuli.
• Sphincterometry to measure the resistance given by the sphincter.

Urodynamic Test:
• Cystometrograph is a useful guide for treating neurogenic bladder and
also for classification.
• It provides a volume-pressure curve pattern that shows sensation,
filling pressure, detrusor capacity and contraction.
Treatment
The main goal, without considering the etiology and level of
diagnosis, is to maintain kidney function This can be done by improving
the function of the bladder cycle and emptying completely.
• Prevention of urinary tract infections and bladder overdistention is an
integral part of the rehabilitation program, by finding a urine
expenditure method that is tailored to the needs of each patient.
• Internal catheters (intermittent or indwelling) are used only if the
urine is still stuck in the bladder.
• Inkontinesia can often be treated in men using catheter condoms and
in women wearing diapers.
• If the catheter is indispensable, intermaitten catheters are more
important than indwelling catheters because they reduce infection and
complications, and accelerate bladder retraining

complication
• bladder cancer
• ISK
• Hidronefrosis
• etc

Prognosis
• Prognosis is good if the disorder is diagnosed and treated before kidney
damage.