Detrusor no reflex

Introduction Detrusor-free reflex is one of the types of neurogenic bladder detrusor function. Normal urination activity is caused by the spinal reflex center and sympathetic, parasympathetic, and body nerves. The bladder urethral dysfunction caused by damage to the central nervous system or peripheral nerves that control urinary function is called neurogenic bladder. According to the detrusor function, it is divided into two categories: 1 detrusor hyperreflexia; 2 detrusor no reflection. 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 and urethral dysfunction produces complex urination symptoms, and poor urination or urinary retention is one of the most common symptoms. The resulting urinary tract complications are the leading cause of death in patients.

Cause

(1) Causes of the disease

Brain disease

(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 bleeding is the most common. Studies have shown that nerve conduction bundles that control the detrusor and extra-urethral sphincters are almost identical to the nerve-walking pathways that govern somatosensory and motor movements, and are therefore often compromised at the same time. There are many nucleus 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, the patient has special consciousness and sensorimotor dysfunction. In addition to the clinical manifestations of the primary disease, there is often urinary dysfunction. The type of urinary dysfunction varies depending on the location of the lesion.

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

(3) Brain tumors: When the tumor affects the frontal lobe, basal ganglia or midbrain damage, urinary dysfunction may occur. Therefore, this symptom may indicate the significance of localization diagnosis to some extent. The main symptoms are frequent urination, urgency, and urge incontinence. In a few cases, dysuria and urinary retention occur.

(4) Multiple sclerosis: a chronic progressive central nervous system characterized by the presence of 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 advanced stage. It 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 to control urination. The mechanism of its occurrence is mainly that the cerebral cortex loses control of the detrusor center of the spinal cord.

2. Spinal cord lesions

(1) Trauma: Spinal cord injury is divided into direct injury, indirect injury and high-speed projectile injury, among which indirect injury is most common such as spinal fracture, dislocation or subluxation. The early stage of spinal cord injury is the period of spinal cord shock, during which the spinal cord below the injury plane loses control of all tissues and organs that it dictates. Spinal cord shock generally lasts for 2 to 3 weeks, and some last for more than 2 years. In the later stage of the injury, fibrotic scar formation occurs at the injury site, and spinal adhesions can occur. The neurons at the injury site are replaced by stellate cells, and the spinal cord is gelatinized.

(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 in the lumbosacral region. Large defects can cause spinal meningocele and more often have spinal dysplasia.

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

3. Peripheral neuropathy

(1) Diabetes: Due to the disorder of glucose metabolism, long-term diabetic patients increase the vascular resistance of the endometrium, causing ischemia and hypoxia, causing neuronal cells, axonal mutation, and demyelination of nerve fibers. The density of neurons in the bladder wall becomes thinner, the axons have degenerative lesions and nerve fragments, and the afferent and efferent fiber conduction impulses of the bladder lead to dysfunction of the bladder and urethra. Bladder dysfunction is one of the common complications of diabetic patients, and the incidence rate in patients with type 1 diabetes 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., urinary abnormalities often occur after surgery, the incidence rate is as high as 7.7% ~ 68%. It has been confirmed that the operation is caused by parasympathetic nerves, sympathetic nerves, pelvic ganglia and pudendal nerve damage in the pelvis.

(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.

There are many methods for classification of neurogenic bladder. The commonly used classification method in the past is the Bors classification method, which classifies the following five categories:

Upper motor neuron lesion

The lesion is above the spinal cord center (S2 ~ S4), including the sensory branch and the motor branch.

2. Lower motor neuron lesions

The lesion is located in the peripheral nerve of the spinal cord (S2 ~ S4) or below the central, including the sensory branch and the motor branch.

3. Primary motor neuron disease

The lesion is limited to the motor branch, and the sensory branch has no lesions, such as polio.

4. Primary sensory neuronal disease

The lesion is limited to the sensory branch. Motor neuron lesions, such as the neurogenic bladder caused by diabetes and spinal cord spasm.

5. "Mixed" lesions

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 has no guiding significance for the choice of treatment methods. In recent years, according to the international filling of the bladder, there is no inhibition contraction of the detrusor into two categories:

Detrusor hyperreflexia

The reaction of the detrusor to the stimulus is hyperreflexive, and there is no inhibition of contraction when measuring intravesical pressure. Dysfunction with or without the urethral sphincter.

2. Detrusor no reflection

The detrusor of this type of neurogenic bladder has no reflection or loss of reflexes. No inhibition of contraction occurs when measuring intravesical pressure. Dysfunction with or without the urethral sphincter.

(two) pathogenesis

Neuropathic bladder pathophysiologically divided into detrusor hyperthyroidism and detrusor no reflection. Detrusor instability (DI), detrusor hyperreflexia (DHR) and decreased bladder compliance are the three main types of detrusor hyperactivity. The 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 (BOO) patients with urinary sphincter hyperfunction are also common with filling period detrusor hyperreflexia, male DVA patients Syndrome is difficult to identify with BOO patients. Because DVA can be accompanied by sphincter coordination, external sphincter spasm, external sphincter denervation, internal sphincter spasm and so on.

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

1. Hald-Bradley classification: the functional changes are reflected in the lesion:

(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. Detrusor dysfunction is the most common, and multiple decompensation after long-term bladder outlet obstruction.

2. Lapides classification: classification based on sensory and motor function changes after neurological damage:

(1) Sensory dysfunction The nerve 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. More common in diabetes, sports ataxia, pernicious anemia. The urodynamics are changed to a large bladder capacity, a high compliance, a low pressure filling curve, and a large amount of residual urine.

(2) Exercise bladder: due to damage to the parasympathetic motor nerve of the bladder. Common causes are pelvic surgery or injury. Early manifestations include dysuria, painful urinary retention, and the like. Bladder pressure measurement shows that bladder filling is normal, but it is difficult to initiate spontaneous bladder contraction when the maximum bladder capacity is reached. Later, the bladder sensory function changes and a large amount of residual urine, bladder pressure measurement showed increased bladder capacity, high compliance bladder, unable to initiate detrusor contraction.

(3) Non-inhibitory neural bladder: It is due to the destruction of the nerve center or nerve conduction fibers that can inhibit the sacral urinary center, and the inhibition of the sacral urinary center is lost. It is common in cerebrovascular diseases, brain or spinal cord. Tumor, Parkinson's disease, demyelinating disease, etc. Most of them manifested as frequent urination, urgency, and urge incontinence. The urodynamics showed involuntary contraction of the bladder during storage. They could initiate detrusor contracture and urinate spontaneously. Generally, there was no difficulty in urinating and residual urine.

(4) Reflex nerve bladder: due to complete sensory and motor pathway damage between the iliac pulp and the brainstem. Most common in traumatic spinal cord injury and transverse myelitis, it can also occur in demyelinating diseases, as well as any process that may cause significant spinal cord injury. Typical manifestations are that the bladder loses its sensation and loses its ability to initiate spontaneous contraction, but spontaneous bladder degeneration can occur during bladder filling, with detrusor and sphincter synergistic disorders.

(5) autonomous neural bladder: due to damage to the medullary medulla, sacral nerve root or pelvic nerve, the bladder's sensation and movement are completely separated. The patient is unable to initiate urination spontaneously and has no bladder reflex activity. Bladder manometry showed no autonomic or spontaneous detrusor contraction, low bladder pressure and increased capacity.

3. Krane-Siroky classification: classified according to the abnormalities shown in 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. The diagnostic criteria were detrusor involuntary contractions that occurred more than 1.47 kPa (15 cm H2O) during the storage period. Subtypes are as follows: 1 sphincter coordination is normal: refers to the coordination of the urethral sphincter during the detrusor contraction. 2 external sphincter dyssynergia: refers to the detrusor contraction 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 inability of the detrusor to contract or contract during urination. Can be further divided into the following subtypes: 1 sphincter coordination normal: refers to the urethral sphincter can coordinate relaxation 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 angulation caused dysuria.

an examination

Related inspection

Cystoscopy urine routine

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 history of trauma, surgery, diabetes, polio, or history of drug application. 3 pay attention to the presence or absence of urinary sensation, bladder swelling and other feelings of decline or loss, such as the bladder's sensation is significantly reduced or increased, 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 ( Upper motor neurons have no lesions). Therefore, this test can be diagnosed as a neurogenic bladder, and can distinguish between lower motor neuron lesions (detrusor non-reflection) and upper motor neuron lesions (detrusor hyperreflexia).

Differential diagnosis

Detrusor instability: a symptom of benign prostatic hyperplasia. The size of benign prostatic hyperplasia is not directly proportional to the symptoms, so it can often be seen in the clinic. The clinical symptoms of benign prostatic hyperplasia are very obvious, but the signs are not obvious. The rectal prostatic hyperplasia is not obvious, and there is also obvious prostate hyperplasia during physical examination. No obvious clinical symptoms, or symptoms are not typical. Symptoms usually appear after the age of 50. Symptoms depend on the degree of obstruction, the rate of development of the lesion, and whether the infection and stones are combined, the symptoms are light and heavy, and the hyperplasia does not cause obstruction or mild obstruction.

Detrusor hyperreflexia: Overactive bladder (OAB) is a common disease, pons and intermedullary lesions, often manifested as detrusor hyperreflexia plus detrusor external sphincter dyssynergia, characterized by urine Urgent, with or without urge incontinence, often accompanied by frequent urination and nocturia. The Chinese Medical Association Urology Branch Urinary Control Group "Clinical Guiding Principles of Overactive Bladder" is defined as: OAB is a syndrome consisting of frequent urination, urgency, and urge incontinence. These symptoms can occur alone or in any combination. The form appears. During urodynamic examination, some patients in the bladder storage period, the bladder detrusor involuntary contraction, causing an increase in intravesical pressure, called detrusor overactivity. The two are both connected and different. The focus of the physical examination is on the abdomen, pelvis, rectum, and nervous system. Urine routine examination is a must, if it is positive, further bacteriology, cytology and other tests are required. For residual urine measurement after urination, urodynamic examination, etc., it should be selectively applied according to the patient's condition. After the pathological conditions such as infection, stone, and bladder cancer in situ are excluded, the diagnosis of overactive bladder can be made.

Urinary distress: urination has an unpleasant and painful feeling, urgency and urinary urgency, or frequent urination, but not particularly urgent, there is still a feeling of urine after the end of urine, common in acute urinary retention. The lower abdomen is full of sorrow and pain, urinary distress, want to urinate, uneasiness and other painful symptoms.

1. The symptoms of detrusor hyperreflexia are caused by non-inhibitory contractions, mainly urinary frequency, urgency, and urge incontinence. Some patients present with 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 loss or loss, limb paralysis and other symptoms.

Physical examination: 1 Anal sphincter tension test: Anal sphincter relaxation, indicating a decrease in spinal cord inactivity or activity. The anal sphincter contraction is too strong, indicating a 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 sponge muscle reflex test: stimulate the penis head or clitoris, causing anal sphincter contraction, indicating the presence of spinal cord activity.

The diagnosis of neurogenic bladder urethral dysfunction mainly includes three aspects: the diagnosis of neurological diseases, such as the nature, location, extent and extent of the lesion; the diagnosis of bladder urethral dysfunction, such as the type, degree of dysfunction, upper urine Road conditions, urinary tract complications, etc.; other related systems, diagnosis of organ dysfunction.

Method for identifying two neurogenic bladders

1. When measuring the intravesical pressure, observe whether there is any inhibitory contraction; if necessary, use the standing pressure measurement, cough, pull the catheter and other excitation methods. If there is no inhibition of contraction, it is a type of detrusor hyperreflexia. Otherwise, it belongs to the 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-neuronal bladder patients can also appear non-inhibitory contraction. 2 detrusor hyperreflexia patients in the supine position pressure measurement, some patients need to stimulate the hair to appear unchecked

2. Ice water test

After evacuating the bladder with the F16 catheter, 60 ml of 14 ° C ice water was quickly injected. If the detrusor reflex enters the bladder, within a few seconds, ice water (such as with a catheter) is ejected from the urethra; the detrusor reflects the bladder, and the ice water is slowly emanating from 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 is 10.6 kPa (80 mmHg). The detrusor is non-reflective and the urethra is lower than normal.

In the above examinations, it is more accurate to observe whether there is any inhibition of contraction, and other almost inspections have more chances of error. The cause of the error may be a "mixed" lesion.

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