Neurogenic bladder is a dysfunction of the bladder caused by congenital or acquired pathology of the nervous system. Depending on the state of the detrusor, hyper- and hyporeflective types of pathology are differentiated. The disease can manifest itself as pollakiuria, urinary incontinence or its pathological delay. Diagnosis of the syndrome consists in a complete neurological and urological examination (tests, urography, ultrasound of the kidneys and bladder, uroflourometry, cystography and cystoscopy, sphincterometry, radiography and MRI of the spine, MRI of the brain, etc.). Treatment may include non-drug and drug therapy, catheterization of the bladder, surgical intervention.
Meaning
Neurogenic bladder is a fairly common condition in clinical urology associated with the inability to carry out voluntary reflex accumulation and excretion of urine due to organic and functional damage to nerve centers and pathways regulating this process. Urination disorders have a social aspect, since they can limit a person’s physical and mental activity, create a problem of his social adaptation in society.
Pathology is often accompanied by myofascial syndrome, pelvic venous congestion syndrome (venous congestion). In more than 30% of cases, the development of secondary inflammatory and dystrophic changes from the urinary system is observed: vesicoureteral reflux, chronic cystitis, pyelonephritis and ureterohydronephrosis, leading to arterial hypertension, nephrosclerosis and chronic renal failure, which can threaten early disability.
Causes
A failure occurring at any stage of the complex multilevel regulation of the urination process can lead to the development of one of the numerous clinical variants of neurogenic bladder. In adults, the syndrome is associated with damage to the brain and spinal cord (with stroke, compression, surgery, spinal fracture), as well as inflammatory degenerative and tumor diseases of the nervous system – encephalitis, multiple encephalomyelitis, polyneuropathy, polyradiculoneuritis, tuberculosis, cholesteatoma, etc.
Neurogenic bladder in children may occur with congenital defects in the development of the central nervous system, spine and urinary organs, after a birth trauma. Urinary incontinence can be caused by a decrease in the extensibility and capacity of the bladder due to cystitis or neurological diseases.
Classification
Hyperreflective neurogenic bladder is isolated, manifested in the accumulation phase by detrusor hyperactivity (with suprasegmental lesions of the nervous system) and hyporeflective – with reduced detrusor activity in the excretion phase (with damage to the segmental-peripheral apparatus of urination regulation). The syndrome may be based on the desynchronization of the activity of the detrusor and sphincter of the bladder (internal and external detrusor-sphincter dissinergia).
Symptoms
Neurogenic bladder syndrome can have permanent, periodic or episodic manifestations, and the variety of its clinical variants is determined by the difference in the level, nature, severity and stage of damage to the nervous system. Typical for the hyperactive variant of pathology are pollakiuria, including nocturia, imperative urges and urinary incontinence. The predominance of detrusor tone leads to a significant increase in intravesical pressure with a small amount of urine, which, with weakness of the sphincters, causes imperative urges and frequent urination.
The hyperactive type of the syndrome is characterized by a spastic state and emptying with the accumulation of less than 250 ml of urine; the absence or small volume of residual urine, difficulty in arbitrary initiation and the act of urination itself; the appearance of vegetative symptoms (sweating, rising blood pressure, increased spasticity) before infection in the absence of urges; the possibility of provoking urination by irritation of the thigh area and above the pubis. In the presence of a number of neurological disorders, uncontrolled rapid discharge of a large volume of urine may occur – “cerebral non-inhibited bladder”.
The relative predominance of sphincter tone in detrusor-sphincter dissinergia is expressed by complete urinary retention, urination during straining, and the presence of residual urine. A hypoactive neurogenic bladder is manifested by a decrease or absence of contractile activity and emptying with a full and even overflowing bladder during the discharge phase.
Due to hypotension of the detrusor, there is no increase in intravesical pressure necessary to overcome the resistance of the sphincter, which leads to complete delay or sluggish urination, straining during miction, the presence of a large (up to 400 ml) volume of residual urine and the preservation of the feeling of fullness of the bladder. With a hypotonic stretched bladder, urinary incontinence (paradoxical ischuria) is possible, when the overflow of the organ causes mechanical stretching of the internal sphincter and uncontrolled discharge of urine in drops or small portions outwards.
Complications
Denervation causes the development of pronounced trophic disorders and complications in the form of interstitial cystitis, leading to sclerosis and wrinkling of the bladder. Stones may form in the urinary tract that disrupt the outflow of urine, provoking the development of infection. In the case of spasm of the sphincter, vesicoureteral reflux may occur (reverse urine flow into the ureters and kidneys, leading to inflammation). The syndrome is often accompanied by functional neurotic disorders, which may later become decisive.
Diagnostics
For diagnosis, it is necessary to conduct a thorough history collection, laboratory and instrumental examination. In a survey of parents of a child with a neurogenic bladder, they find out how the birth took place, whether there is a hereditary predisposition to the disease. To exclude inflammatory diseases of the urinary system, a blood and urine test is performed – general, according to Nechiporenko, a functional test of Zimnitsky, a biochemical examination of urine and blood.
The main methods of instrumental diagnosis of the syndrome are ultrasound of the kidneys and bladder, cystoscopy, MRI, X-ray examination of the urinary tract (conventional and mictional urethrocystography, excretory urography, ascending pyelography, radioisotope renography), urodynamic studies (cystometry, sphincterometry, profilometry, uroflowmetry).
In the absence of diseases from the urinary system, a neurological examination is performed to detect pathology of the brain and spinal cord using electroencephalography, CT, MRI, x-ray of the skull and spine. Differential diagnosis is carried out with prostate hypertrophy, stress urinary incontinence in the elderly. If it is impossible to determine the cause of the disease, they talk about a neurogenic bladder with an unclear etiology (idiopathic).
Treatment
Therapy is carried out jointly by a urologist and a neurologist; its plan depends on the established cause, type, degree of severity of bladder dysfunction, concomitant pathology (complications), the effectiveness of previous treatment. Non-drug, medical and surgical treatment is used, starting with less traumatic and safer therapeutic measures.
The hyperactive variant responds better to treatment. Medicines are used that reduce the tone of the muscles of the bladder, activate organ circulation and eliminate hypoxia: anticholinergic drugs (hyoscine, propantelin, oxybutynin), tricyclic antidepressants (imipramine), calcium antagonists (nifedipine), alpha-blockers (phentolamine, phenoxybenzamine).
Recently, the use of botulinum toxin injections into the wall of the bladder or urethra, intravesical administration of capsaicin and resinferatoxin is considered quite promising in the treatment of hyperreflexia, detrusor-sphincter dysenergy and infravesical obstruction. In addition, drugs based on succinic acid, L-carnitine, hopanthenic acid, N-nicotinoyl-gamma-aminobutyric acid, coenzyme forms of vitamins with antihypoxic and antioxidant effects are prescribed.
In parallel, non-drug methods of treating neurogenic bladder are used: physical therapy (special exercises for pelvic muscles), physiotherapy (electrical stimulation, laser therapy, hyperbaric oxygenation, diadin therapy, thermal applications, ultrasound), bladder training, normalization of drinking and sleeping, psychotherapy.
The hypoactive variant of the disease is more difficult to treat. The existing stagnant phenomena in the bladder create a risk of infection, the development of secondary lesions of the urinary system. In the treatment of neurogenic syndrome with signs of hypotension, it is important to ensure regular and complete emptying of the bladder (with the help of forced urination, external compression (taking Cred), physiotherapy, training of the muscles of the bladder and pelvic floor, periodic or permanent catheterization).
Indirect and M-cholinomimetics (betanechol chloride, distigmine bromide, aceclidine, galantamine) are used as drug therapy to enhance the motility of the bladder, reduce its effective volume and the amount of residual urine. Alpha-blockers are individually prescribed (phenoxybenzamine – for internal detrusor-sphincter dissinergia, diazepam and baclofen – for external detrusor-sphincter dissinergia), alpha-sympathomimetics (midodrine and imipramine – in case of urinary incontinence under stress).
In drug therapy of neurogenic bladder for the prevention of urinary infections, it is necessary to control the amount of residual urine and take antibacterial drugs (nitrofurans, sulfonamides), especially in patients with vesicoureteral reflux.
Surgical endoscopic intervention in hypotension of the organ consists in transurethral funnel-shaped resection of the neck of the bladder, which further provides the possibility of emptying by weak pressure from the outside. In the hyperreflective variant (with pelvic floor spasticity and detrusor-sphincter dissinergia), an incision of the external sphincter is made, which reduces the pressure of urination, and subsequently – the hyperreactivity of the detrusor, increasing the capacity of the bladder.
Surgical enlargement of the bladder (using tissue plasty), elimination of vesicoureteral reflux, cystostomy drainage for emptying the bladder is also possible. Pathogenetic treatment of neurogenic bladder syndrome reduces the risk of damage to the urinary organs and the need for surgical intervention in the future.
