Disorder of urinary bladder filling or emptying due to lesions

affecting the bladder innervation

Irritative Symptoms:Dysurea,frequency,urgency
Obstructive:Retention,Hesitancy,Staccato voiding,straining to void
,feeling of incomplete emptying
Causes
Acquired:Trauma to brain,spinal cord,or peripheral nerve
Congenital:Vactrel,tethered spinal cord,degenerative
neuromuscular limb anomalies,sacral agenesis .

The most practical way to classify neurogenic blader is by simple

functional system
1.Failure to store (By detrusor itself of bladder outlet)
2.Failure to empty
Or both……………………
Detrusor hyperactivity or poor compliance of bladder causes
elevated bladder pressure during bladder filling and hence
incontinence.
Incompetent neck or urethral sphincter mechanism causes failure to
store urine even if the bladder pressure is reasonable.
R
Hypotonic neurogenic muscle cannot produce enough pressure with
detrusor contraction to empty.
Alternatively bladder outlet may exhibit increased resistance due to
bladder outlet striated or smooth muscle sphincter dyssynergia.
The advantage of This urodynamic data is that treatment can be
based upon the urodynamic data
Myelomeningocoele
Ranges from occult dysraphism to to mmc,occurrence is declining
,especially in the past few decades due to use of folic acid.90% of the
pts with MMC have normal upper tracts but if no bladdercare is
administered,they show signs and symptoms of upper tract
deterioration or reflux within 5 years.so early urologic evaluation of
pt with mmc should be performed.
Centres performing the fetal closure of mmc report that there is little
to suggest that it improves extremities,bladder or bowel outcome
but reduces the need of VP shunting in those pts 50%.
Level of bony defect doesnot highlight the functional cord level
becoz the lesions may be partial and patchy.Before discharge,an
ultrasound is performed to see renal parenchymal
quality,hydronephrosis,size and bladder emptying ability.
Urologic evaluation of of pt with spinal dysraphism include
Sonogram,VCUG and post void residual volume.
Capacity of neonate`s bladder is 20-30ml,
capacity of child is age in years + 2 = no. of ounces × 30 = no. of
millilitres
Age(Yr)+2=onces
2xage +2 Capacity in onces for age<2year
Age/2 +6 onces >2year
Normal intravesical pressure remain at or below 5-10cm H20 until
capacity is achieved.
A postvoid residual of more than 5 ml in the neonate and greater
than 10% of the expected capacity in the older child is considered
abnormal.
5% have abnormal ultra sound in that case,VCUG and evaluation of
upper urinary tract function and drainage by renal scan is
performed.If USG is normal,further investigations can be delayed for
a few months.
10% of these pts have reflux so put on amoxicillin prophylaxis
10mg/kg once daily and serum creatinine concentration followed
during hospitalization.some kids experience poor emptying after
surgery for few days or few weeks.post void vol should be measured
in these pts.if it is >15ml,intermittent catherterization is
started.Crede`s manoeuvre should be avoided because it is
ineffective in emptying the bladder and magnifies the detrimental
effect of high intravesical pressure if reflux is present.
children with bladder pressure >40cm H2O at point of urinary
leakage and those with detrusor sphincter dyssynergia are much
more likely to show upper tract determination or VUR so early
urodynamic evaluation by typically 12 weeks of age is useful for
determining frequency of follow up and timing of initiatin of bladder
therapy programme.
If no infection is present and radiology is normal ,pt can be managed
by spontaneous voiding in the diaper(especially when leak point
pressur is low) .Folloew up is advise with renal USG and urine culture
at 6 months of age.If Dyssunergia is present,VCUG at 6 month of age
is reasonable, (especially when leak point pressur is high).
USG and culture should be done yearly if urinary tract is stable.IF
REFLUX OR UPPER TRACT DETERIORATION OCCURS,CLEAN
INTERMITTENT CATHETERIZATION,ANTICHOLINERGIC THERAPY AND
TEMPORARY CUTANEOUS VESICOSTOMY MAY BE WARRATED.
Periodic reassessment is mandatory becoz clinical and urodynamic
picture may change with growth and spinal cord retethering Bladder
management programme is started when there is worsening
reflux,deterioration of urodynamics,dilatation of upper urinary tract
or infection.If urinary tract is stable,such management is delayed
until social continence is required.

Corner stone of management is CIC,the purpose of which is to

provide periodic low pressure emptying of the bladder which can
prevent or even improve deterioration of uppr urinary tract,including
that secondary to reflux.
CiC in small child is done by care taker,later when the child grows,he
may assume task himself.Motivation has a posoitive role so it is
better to wait until social pressure affects his desire for continence
before initiating the bladder programme.,unless required for
treatment of bladder deterioration.
Pts with CIC may have bacteriuria(60%) with most pts becoming
culture +ve within one year,often with one or two symptomatic
episodes per year.
In patients with normal vesical pressure or no reflux,there is little
clinical significance of bacteriuria but in pt with high storage pressure
or reflux,there is upper tract deterioration with bacteriuria.Infection
with urea splitting organism (proteus) is of special concern,owing to
struvite stone formation.
Pharmacologic therapy is coupled with CIC in neurogenic
bladder,aimed to decreae the pressure in hypertonic ,non compliant
bladder or increase bladder outlet resistance to improve continence.

Tolterodine,oxybutynine and propanthaline are used to treat by

blocking the detrusor overactivity.Imipramine is also helpful, both
alone or in combination with anticholinergics by relaxing bladder or
tighten the outlet.Alphamimetics eg pseudoephedrine can be used
to treat inadequate outlet resistance.Sometimes the three of them
are used.side effects of alphamimetics may limit their use.Instillation
of oxybutynine in water can still be useful and of less side effecs and
still maintains a therapeutic response.Recently introduced
oxybutynine patch may offer an improved therapeutic index to pts.
Cyctoscopic injection of botulinum toxin may also be aiding to
decrease presue and increase compliance.but effect is short term
and repeated INJECTIONS ARE REQUIRED.
Urodynamis studies help clinician choose the mode of therapy and
other modalities and monitor their effects.it is more often a simple
measurement of pressure volume relationship during filling.
Double lumen catheter +pernial electrode
Contrast +monitored fluoroscopically

Bladdr compliance,hyperreflexic contractions,leak point

pressure,stree leak point pressure and bladder neck dyssynergia may
be extremely helpful in choosing the treatment options
It is crucial to understand when bladder pressure remains above 35-
40 mmhg,ureteral peristalsis does not effectively empty the urinary
tracts .Hydonephrosis and eventually renal insufficiency
results.Cystometric data can be coupled with the estimated hourly
urine output to establish cic intervals which would keep bladder
pressure in safe limit.medications can be sensibly adjusted to
increase cic interval to achieve dryness and avoid development or
progression of hydronephrosis.Nerve and bladder stimulation has
limited role.
In pts with high bladder filling pressure and deteriorating upper
urinary tract in which cic and pharmacotherapy cant be
used,temporary diversion with cutaneous vesicostomy is
offered.Protection of upper tract is thus acieved until other
intervention is started.This therapy is reserved for pts with serious
upper tract deterioration and who have other anatomic,social or
medical reasons ,cannot be managed with oother aforementioned
methods of treatment.Some people advocate urethral dilatation in
girls to diminish leak point pressure.
sURGICAL:
Though many pts can be managed with out surgical
intervention,those with reflux,poor compliant bladder or refractory
incontinence may benefit from surgical treatment.Treatment of
reflux in neurogenis bladder is much the same as in normal bladder.It
is imperative that bladder be treated for poor compliance and
hyperreflexia (CIC & anticholinergics) before and after surgery to
diminish risk of recurrence
Bladder enlargement or enhancement may be
required.Augmenttation is designed to create a bladder with good
compliance and adequate storage until it can be emptied by cic at
adequate social interval.