Neurogenic bladder

Introduction to neurogenic bladder Neurogenic bladder urethral dysfunction is a type of dysfunction of the bladder and/or urethra caused by neuropathy or damage, often accompanied by a coordinated disorder of bladder and urethral function. Neurogenic bladder urethral dysfunction produces complex urinary symptoms, poor urination or urinary retention is one of the most common symptoms, and the resulting urinary tract complications are the leading cause of death. basic knowledge Sickness ratio: 0.05% Susceptible people: no special people Mode of infection: non-infectious Complications: urinary tract infection, vesicoureteral reflux, pyelonephritis, renal failure, hydronephrosis

Neurogenic bladder etiology

Brain disease (20%):

(1) cerebrovascular disease: common with hypertensive intracranial hemorrhage, atherosclerotic cerebral infarction, cerebral embolism, intracranial arteritis, subarachnoid hemorrhage, cerebral vascular malformation and rupture of basilar aneurysm, etc. Internal hemorrhage is the most common. Studies have shown that the nerve conduction bundles that control the detrusor and external urinary sphincters are almost identical to the nerve walking pathways that govern the somatosensory and motor movements. Therefore, they are often damaged at the same time. There are many nerve nuclei involved in urinary control in the brain, such as Basal ganglia, cerebellum, globus pallidus, striatum, thalamus, etc. When the above nerve pathway or nuclei are damaged, patients often have urinary dysfunction in addition to special consciousness, sensorimotor dysfunction and clinical manifestations of the primary disease. The type of abnormal urination function varies depending on the location of the lesion.

(2) Parkinson's disease: is a chronic progressive central nervous system dysfunction, manifested as limb tremor, slow physical activity, gait instability, body-like gear-like rigidity during examination, 25% to 75% of patients have bladder function Abnormalities, mainly manifested as difficulty in urinating, urgency or urgent urinary incontinence.

(3) Brain tumors: Tumors involving the frontal lobe, basal ganglia or midbrain damage may have abnormal urination function, so this symptom has a certain degree of significance for the diagnosis of location. The main symptoms are frequent urination, urgency and urge incontinence. In a few cases, dysuria and urinary retention occur.

(4) Multiple Sclerosis: Chronic progressive central nervous system disease characterized by scattered demyelinated plaques in the brain and spinal cord resulting in a variety of different neurological symptoms or signs. About 5% of patients in the early stage may have Bladder dysfunction, up to 90% in the late stage, can be expressed as frequent urination, urgency, urge incontinence, and occasional urinary retention.

(5) Alzheimer's disease: Urinary incontinence is the most common symptom of the urinary system, mostly urge incontinence and loss of consciousness controlled urination. The mechanism is mainly due to the loss of control of the cerebral cortex to the detrusor center of the spinal cord.

Spinal cord lesions (20%):

(1) Trauma: Spinal cord injury is divided into direct injury, indirect injury and high-speed projectile damage. Among them, indirect injury is most common, such as spinal fracture, dislocation or subluxation. The early stage of spinal cord injury is the spinal cord shock period. All the organs and organs that it controls are out of control. The spinal cord shock usually lasts for 2 to 3 weeks, and some of them are more than 2 years old. In the later stage of the injury, the fibrotic scar is formed at the injury site, and the meningeal adhesion can occur. The neurons in the injured part are star-shaped. Cell replacement, spinal cord gelatinization.

(2) Spinal cord diseases: such as spinal tuberculosis, disc herniation, metastatic tumors, cervical spondylosis, etc.

(3) vascular disease: spinal artery embolization can cause damage to the spinal cord at the corresponding site.

(4) neural tube insufficiency: the most common lumbosacral, large defects can cause spinal meningocele, more combined with spinal dysplasia.

(5) Others: syringomyelia, poliomyelitis, transverse myelitis and multiple sclerosis can cause bladder urethral dysfunction.

Peripheral neuropathy (20%):

(1) Diabetes: In patients with long-term diabetes, due to disorder of glucose metabolism, the vascular resistance of the endometrium increases, causing ischemia and hypoxia, causing nerve cells, axonal degeneration, demyelination of nerve fibers, and density of neurons in the bladder wall. Thinning, axon has degenerative lesions and nerve fragments, bladder afferent and efferent fiber conduction impulse disorder, leading to bladder urethral dysfunction, bladder dysfunction is one of the common complications of diabetic patients, in patients with type I diabetes The incidence rate is as high as 43% to 87%.

(2) After pelvic organ resection: such as radical resection of rectal cancer, radical resection of uterine cancer, etc., frequent urinary abnormalities occur after surgery, the incidence rate is as high as 7.7% ~ 68%, has been confirmed due to surgery on the parasympathetic pelvic nerve, Sympathetic nerve, pelvic ganglia and pudendal nerve injury.

(3) Herpes zoster: Herpes zoster virus is lurking in the cells of the posterior horn of the spinal cord and spreads along the nerve sheath, destroying the nerves. When the lumbar nerve or the sacral nerve is involved, urinary frequency and urinary retention may occur.

"Mixed" lesions (20%):

Autonomic motor neuron lesions (parasympathetic nerves) associated with urination are not at the same level as body motor neuron lesions, one in the upper motor neuron, the other in the lower motor neuron, or one in the lesion and the other in the lesion.

Although this classification method is more detailed, it is too complicated, and it has no guiding significance for the choice of treatment methods. In recent years, there is no inhibition contraction of the detrusor in the international filling according to the bladder filling into two categories:

1. Detrusor hyperreflexia: The reaction of the detrusor to the stimulus is hyperreflexive, with no inhibitory contraction when measuring intravesical pressure, with or without dysfunction of the urethral sphincter.

2. Detrusor-free reflex: The detrusor of this type of neurogenic bladder has no reflection or reflex to stimulation, and does not show non-inhibitory contraction when measuring intravesical pressure, with or without dysfunction of the urethral sphincter. .

Pathogenesis

Neuropathic bladder pathophysiologically divided into detrusor hyperthyroidism and detrusor no reflex, detrusor instability (DI), detrusor hyperreflexia (DHR) and decreased bladder compliance are detrusor hyperactivity The main types of sphincters can be characterized as normal coordination, external sphincter dyssynergia or internal sphincter dyssynergia, detrusor weakness (DVA) is common in patients with neurological diseases, and bladder outlet obstruction stems from urinary sphincter hyperfunction (BOO Patients, accompanied by filling period detrusor hyperreflexia is also very common, male DVA patients with syndromes and BOO patients with difficulty in identification, because DVA can be accompanied by sphincter coordination, external sphincter spasm, external sphincter denervation, internal sphincter spasm Wait.

There are several ways to classify neurogenic bladder and urethral dysfunction:

1. The Hald-Bradley classification reflects changes in function with lesions:

(1) Detrusor contraction and urethral sphincter diastolic coordination in the lesions on the spinal cord, and more detrusor hyperreflexia, normal sensory function.

(2) Most patients with sacral pulp lesions have detrusor hyperreflexia, detrusor and urethral sphincter activity are not coordinated, and sensory function is related to the degree of nerve damage, which may be partial loss or complete loss.

(3) Intramedullary lesions include afferent and efferent neuropathy of the iliac pulp. Due to detrusor motor nerve damage, detrusor can be produced without reflex, and sensory nerve damage can cause loss of sensory function.

(4) The vast majority of peripheral autonomic neuropathy is seen in diabetic patients, characterized by bladder sensory insufficiency, increased residual urine volume, and finally decompensation, detrusor contraction weakness.

(5) Muscle lesions may include the detrusor muscle itself, the smooth muscle sphincter, all or part of the striated muscle sphincter, the most common detrusor dysfunction, and multiple decompensation after long-term bladder outlet obstruction.

2. The Lapides classification is classified according to the changes in sensory and motor function after nerve damage:

(1) Sensory disorder: The bladder is caused by the blocked conduction of sensory fibers between the bladder and the spinal cord or between the spinal cord and the brain. It is more common in diabetes, sports ataxia, pernicious anemia, etc. The urodynamic changes are large in bladder capacity. High compliance, low pressure filling curve, can have a large amount of residual urine.

(2) exercise bladder: due to bladder parasympathetic motor nerve damage, common causes are pelvic surgery or injury, early manifestations of dysuria, painful urinary retention, etc., bladder pressure measurement shows that bladder filling can be normal, but the maximum Bladder volume is difficult to initiate spontaneous bladder contraction, late manifestation of bladder sensory function changes and a large number of residual urine, bladder pressure measurement shows increased bladder capacity, high compliance bladder, can not initiate detrusor contraction.

(3) Non-inhibitory nerve bladder: It is the nerve center or nerve conduction fiber that can inhibit the sacral urinary center, and it has lost the inhibition of the sacral urinary center. It is common in cerebrovascular diseases, brain or spinal cord. Tumors, Parkinson's disease, demyelinating diseases, etc., mostly manifested as frequent urination, urgency, urge incontinence, urodynamics showed involuntary contraction of the bladder during storage, and can spontaneously initiate detrusor contraction and urination, generally no Difficulties in urination and residual urine.

(4) Reflex nerve bladder: from the complete sensory and motor pathway damage between the iliac pulp and the brain stem, most commonly in traumatic spinal cord injury and transverse myelitis, can also occur in demyelinating diseases, and any possibility The process of causing obvious spinal cord injury is typically characterized by loss of sensation of the bladder and loss of the ability to initiate spontaneous contraction, but spontaneous detrusor contraction may occur during bladder filling, with detrusor and sphincter synergistic disorders.

(5) autonomous neural bladder: due to damage to the iliac pulp, sacral nerve root or pelvic nerve, resulting in complete separation of bladder sensation and movement, patients can not initiate urination spontaneously, no bladder reflex activity, bladder pressure measurement shows no autonomy or spontaneous Detrusor contraction, low bladder pressure, increased capacity.

3. The Krane-Siroky classification classifies the abnormalities shown by the urodynamic examination:

(1) Detrusor hyperreflexia: The spontaneous or induced contraction of the detrusor during storage is called detrusor instability. If there is an abnormality of the central nervous system, it is called detrusor hyperreflexia. Diagnosis The standard is the involuntary contraction of the detrusor in the storage period of more than 1.47 kPa (15cmH2O), divided into the following subtypes: 1 sphincter coordination normal: the urethral sphincter can coordinate relaxation when the detrusor contracture urination, 2 external sphincter Synchronous disorder: When the detrusor contracture urination, the external urinary sphincter is still in a contracted state, leading to urethral insufficiency, 3 internal sphincter dyssynergia: refers to the urethral sphincter does not relax when the detrusor contracture urination.

(2) Detrusor no reflex: refers to the weakness of the detrusor during urination, which can be further divided into the following subtypes:

1 sphincter coordination is normal: refers to the coordinated relaxation of the urethral sphincter during urination.

2 external sphincter spasm or achalasia: manifested as urinary sphincter sphincter in a continuous contraction state.

3 internal sphincter spasm or achalasia: manifested as urinary tract mouth is not open when urinating.

4 external sphincter denervation: refers to the external urethral sphincter and pelvic floor muscles after the innervation of muscles atrophy, relaxation, resulting in bladder urethral sag, urethral horns to produce dysuria.

Neurogenic bladder prevention

In fact, almost all diseases of the nervous system can affect the function of the bladder, and the nervous system that controls the function of the bladder is composed of various nerve tissues including the central and peripheral tissues. Therefore, as long as a part of the nerve tissue is damaged, it may affect the function of the bladder. Such as stroke, Parkinson's disease, multiple sclerosis, diabetes, spinal cord bulging, spinal cord trauma or surgery, pelvic trauma or surgery, etc., may affect bladder function.

In addition, poor urinary habits, organ aging, inflammation or anxiety and other factors caused by neurological deterioration, will affect the bladder function, resulting in a neurogenic bladder.

Therefore, prevention of nerve damage and prevention of neurological deterioration are possible ways to prevent neurogenic bladder.

Neurogenic bladder complications Complications, urinary tract infection, vesicoureteral reflux, pyelonephritis, renal failure, hydronephrosis

Urinary tract infection is the most common complication of neuropathic bladder. 10% to 15% of patients may have urinary calculi. The incidence of vesicoureteral reflux in neurogenic bladder is 10% to 40%, usually reversible. When the urination situation is improved, the remaining urine is reduced, the bladder pressure may be reduced when there is a possibility of self-improvement, and may also be complicated by pyelonephritis, renal failure, hydronephrosis, and renal dysfunction.

Neurogenic bladder symptoms Common symptoms Poor urination Detrusor no reflection No urinary incontinence Upper urinary tract structure and function damage Urethral detrusor reflex urinary frequency enuresis

1. The symptoms of detrusor hyperreflexia are caused by non-inhibitory contractions, mainly urinary frequency, urgency and urge incontinence, and some patients show stress urinary incontinence or enuresis.

2. Patients with detrusor non-reflection can not open or open the bladder neck during urination, often manifested as dysuria, urinary retention, and urinary incontinence.

3. In addition to urinary symptoms, may be accompanied by constipation, fecal incontinence, perineal sensation diminished or lost, limb paralysis and other symptoms.

Physical examination: 1 Anal sphincter tension test: Anal sphincter relaxation, indicating that the spinal cord is inactive or less active, and the anal sphincter contraction is too strong, indicating hyperreflexia of the spinal cord. 2 anal reflex test: stimulate the skin around the anus, such as anal contraction indicates the presence of spinal cord activity, 3-ball cavernosal muscle reflex test: stimulate the penis head or clitoris, causing anal sphincter contraction, indicating the presence of spinal cord activity.

Neurogenic bladder examination

A series of imaging examinations, such as intravenous urography (excretory urography), ultrasound, cystography, and urethrography, are useful for evaluating neurogenic bladder secondary damage and disease progression, and can show urinary tract stones. Urinary urethroscopic examination can determine the extent of bladder outflow obstruction. A series of intravesical angiography in the recovery period of hypotonic bladder can provide a detrusor function index, which indicates the recovery prospect, urine flow rate of urine flow. Mechanical measurements, the electromyogram of the sphincter to check the urethral pressure map, are helpful for diagnosis.

Urinary examination of patients with urinary tract infection may have red blood cells, positive white blood cells and urine culture.

1. Ice water test: If the spinal cord is damaged above the center, the ice water is injected into the bladder, and the ice water is vigorously ejected within a few seconds; there is no such reaction under the spinal cord.

2. Urodynamic examination: can reflect detrusor hyperreflexia or detrusor no reflection and urethral sphincter function.

3. Excretory bladder urethrography : visible urethral wall formation, diverticulum and typical "Christmas tree"-like bladder, dynamic observation of abnormal detrusor contraction, abnormal relationship between detrusor contraction and urethral internal and external sphincter, residual urine Increase and so on.

Neurogenic bladder diagnosis

Diagnose based on

History

1 urinary dysfunction with defecation dysfunction (such as constipation, fecal incontinence, etc.), the possibility of neuropathy through the original bladder.

2 pay attention to whether there is trauma, surgery, diabetes, polio and other medical history or history of drug application.

3 pay attention to the presence or absence of urinary sensation, bladder swelling or other feelings of decline or loss, such as the bladder's sensation of significant decline or increase, you can diagnose the neurogenic bladder.

2. Check

1 When there is a perineal sensation diminished, the anal sphincter tension is reduced or enhanced, the neurogenic bladder can be diagnosed, but the lack of these signs can not rule out the possibility of neurogenic bladder.

2 pay attention to the presence or absence of spina bifida, meningocele, tibia dysplasia and other deformities.

3 There is residual urine, but there is no mechanical obstruction of the lower urinary tract.

4 Electrical stimulation of spinal cord reflex test, this method mainly tests whether the spinal reflex nerves of the bladder and urethra are intact (ie, whether there are lesions in the lower motor neurons) and whether the neurons from the cerebral cortex to the pudendal nucleus (the spinal cord center) have lesions ( The upper motor neurons have no lesions. Therefore, this test can diagnose the stagnation of the neurogenic bladder, and distinguish the lower motor neuron lesions (detrusor non-reflection) and the upper motor neuron lesions (detrusor reflex). Break into).

Method for identifying two neurogenic bladders

1. When measuring intravesical pressure, observe whether there is any inhibitory contraction; if necessary, use standing pressure measurement, cough, pull the catheter and other excitation methods, such as the appearance of non-inhibitory contraction, it is a detrusor reflex Class, otherwise, belongs to the class of detrusor without reflection.

This test is one of the main criteria for classification, but:

1 Inflammation, stones, tumors and lower urinary tract obstruction (such as benign prostatic hyperplasia) in the bladder, non-inhibitory bladder patients may also have no inhibitory contraction.

2 Detrusor reflex hyperthyroidism When the patient is in the supine position, some patients need to stimulate the hair to appear uninhibited contraction.

2. Ice water test: After emptying the bladder with F16 catheter, quickly inject 60ml of 14°C ice water. If the detrusor reflex reflects into the bladder, within a few seconds, ice water (such as with a catheter) is taken from the urethra. It is ejected; the detrusor reflects the bladder, and the ice water is slowly coming out of the catheter.

3. Anal sphincter tension: Anal sphincter relaxation is a type of detrusor without reflection.

4. Urethral closure pressure map: the maximum urethral closure pressure is normal or higher than normal, the detrusor hyperreflexia, the maximum urethral closure pressure is lower than normal, the detrusor no reflection.

5. Determination of urethral resistance: normal urethral resistance was 10.6 kPa (80 mmHg), and the urethral reflex without detrusor was lower than normal.

In the above examinations, it is more accurate to observe whether there is no inhibitory contraction. Others are almost inspected and have more chances of error. The cause of the error may be mixed lesions (Bors classification) neurogenic bladder, ie detrusor Neuropathy is not at the same level as neuropathy of the external urinary sphincter.

Diagnosis of neurological diseases In addition to medical history, physical examination and related auxiliary examinations, neurophysiological examination has become an important content.

Diagnosis of bladder and urethral dysfunction In addition to medical history, physical signs and other routine examinations, urodynamic examination plays an extremely important role in the diagnosis. It not only shows various manifestations of bladder urethral dysfunction, but also reveals the onset of the disorder. Mechanisms provide an important basis for etiological analysis and treatment.

Differential diagnosis

1. Benign prostatic hyperplasia: occurs in men over 50 years old, has dysuria, urinary retention, severe cases of kidney, ureteral dilatation, rectal examination, cystoscopy, cystography can be clearly diagnosed.

2. Bladder neck obstruction: Women have dysuria and urinary retention, normal skin around the anus and perineal sensation, cystoscopy or urodynamic examination can be identified.

3. Congenital urethral valve: more common in children, dysuria, urinary retention, urethroscopic or urethrography can be identified.

4. Female stress urinary incontinence: normal detrusor function, decreased urethral resistance, positive bladder neck elevation test, bladder urethra angiography disappeared posterior urethral urethra, bladder neck position decreased.

5. Urethral stenosis: It can be congenital or acquired, with dysuria as the main manifestation. The urethral probe has obvious stenosis, and urethrography can confirm the diagnosis.

6. Bladder neck obstruction: dysuria is often accompanied by urination pain, sudden interruption of urinary flow during urination, strong echoes can be seen by ultrasound, opaque shadows are seen in the plain area of the bladder, and cystoscopy can be confirmed by cystoscopy. ,number.

7. Bladder cancer: located in the neck of the bladder, the pedicled tumor near the triangle area can cause dysuria, urinary retention and other symptoms due to blockage of the urethral opening, but the patient usually has intermittent painless hematuria. Cells, IVU can be seen in the filling area of the bladder area, cystoscopy can directly identify the location, size, number of tumors, and can also take biopsy.

The material in this site is intended to be of general informational use and is not intended to constitute medical advice, probable diagnosis, or recommended treatments.