Neurogenic Bladder

*Presented by: Dr. Prachi P. Kakkad

P.G. 1ST Year Kayachikitsa

**Guided by: Dr. M. N. Shaikh

M.D.(Ayu.)
Principal
Govt. akhandanand ayurved college,
Ahmedabad, Gujarat.
Index-
 Anatomy & physiology
 Introduction
 Defination
 Types
 Causes
 Symptoms
 Investigation
 Examination
 Treatment
 Ayurvedic corelation & treatment
Anatomy and physiology
 Anatomically, the bladder which consists of smooth
muscle, and the base, which includes the trigone and
bladder neck that are intimately connected to the pelvic
floor.
 The bladder outlet has two urethral sphincters, the
internal (smooth muscle) sphincter and the external
(striated muscle) sphincter.
 Females have a less complex urethral sphincter
mechanism that surrounds a shorter urethra.
Cont…
 Regulation of micturition involves cortical, subcortical,
spinal cord, and bladder mechanisms ,
 Cortical control areas in the frontal and cingulate gyri as
well as subcortical areas provide inhibitory influence on
micturition at the level of the pons and excitatory
influence on the external urinary sphincter.
 This allows voluntary control of micturition so that
normally bladder evacuation can be delayed until an
appropriate time and place to void are chosen.
 The pontine micturition center (PMC, also known as
Barrington’s nucleus or M-region) is essential for the
coordination of micturition.
Cont…
 Normal voluntary micturition includes bladder filling,
storage, and emptying .
 The kidneys filtering 180L per day though only
approximately 800 to 2000 ml per day is excreted as
urine.
 This filtrate is transported through the ureters to the
bladder. The ureters, which are approximately 25–
30cm in length, pass obliquely through bladder wall at
the ureterovesicular junction to form a one-way valve
that serves to prevent retrograde reflux of urine to the
kidneys during bladder filling and emptying stages.
Introduction
 Neurogenic bladder refers to all types of bladder dysfunction caused
by an interruption of normal bladder innervation. Condition may
be congenital or acquired
 No cure but can be managed
 Subsequent complications include:
urinary incontinence, residual urine retention, urinary tract
infection, calculi formation, and renal failure.
 A neurogenic bladder can be –
1. spastic (hypertonic, reflex, or automatic),
2. flaccid (hypotonic, atonic, nonreflex, or autonomous)
 Most cases managed with medication and surgical treatment.
 The primary goal of the physician is to maintain and preserve renal
function!
 Definition
 Neurogenic bladder is the name given to a number of urinary conditions in
people who lack bladder control due to a brain, spinal cord or nerve
problem.
 This nerve damage can be the result of diseases such as multiple sclerosis
(MS), Parkinson's disease or diabetes. It can also be caused by infection of
the brain or spinal cord, heavy metal poisoning, stroke, spinal cord injury,
or major pelvic surgery. People who are born with problems of the spinal
cord, such as spina bifida, may also have this type of bladder problem.
Type 1- spastic(reflex or automatic)
neurogenic bladder caused by UMNL
 Any lesion of the cord above the voiding reflex arc.
 Most common cause are trauma,tumor & MS.
 Voiding is interrupted,involuntary,& incomplete.
 Hypertrophy of the detrusor develops,often leading to
vesicourethral reflux.
 Dilatation of the internal sphinter occur.
 The external sphincter and perineal muscles becomes spastic &
obstructive,causes incearsed resistance to the flow urine and
results in an impaired stream and residual urine.
Uninhibited neurogenic bladder
(mild spastic NB)
 These type of NB may develop following a cerebral vascular
accident or arteriosclerotic degeneration in spinal cord.
 It may occur as the first sign of MS.
 The lesion is centered either in the inhibitory centers of cortex
or in pyramidal tract (UMN).
 Therefore,facilitative impulse passing continually down the
cord keep sacral centers so excitable that even a small
quantity of urine elicits an uncontrollable micturation
reflex,thereby promoting frequent urination.
Spastic type NB showing: ‘Christmas tree’ or
‘pine tree’ effect.heavy trabeculation,cellules
and small diverticula in cystography
Type 2- Flaccid (atonic/nonreflex or
autonomous) neurogenic bladder
 It will caused by lower motor neuron lesion.
 Mostcommon cause of flaccid neurogenic bladder is
trauma,tumors,herniated intervertebral disks,tabes
dorsalis,poliomyelitis & congenital defect.
 Vesical
dysfunction arises when there is injury to center of
micturition in cord (S2-4), cauda equina, sacral roots or nerve
there by interrupting the sacral reflex arc.
 Lossof perception of fullness permits overstretching of the
detrusor and atony of the muscle and these contributes to weak
and inefficient detrusor contraction.
The flaccid NB seen seen on cystography
showing oval shaped bladder
 Difference
Type 1 spastic Type 2 flaccid

 Vertebral level- lesion above L1 Lesion at/below L1

 Symptoms-urgency,frequency,urgency
incontinence,hesistancy,retension Hesistancy,retension
 Bladder scan- -/+rasied postvoid residual Postvoid residual urine >100ml
urine
 Uroflowmetry-interrupted flow Low
 Detrusor- overactivity,detrusor muscle Underactivity,sphincter insufficiency
dyssynergia
 Bladder capacity-low High
 Risk-back pressure changes stasis
 icourethral reflux:-

Vesicoureteral reflux
(VUR) is a condition in
which urine flows
backward from the
bladder to one or both
ureters and sometimes to
the kidneys. ..
Causes
Diseases Congenital anomaly
 Spinal cord trauma
 Myelomeningocele
 Tabes dorsalis
 Absence of the sacrum
 DM
 MS
 Cord tumors
 Herniated intervertebral
disk
 Stroke
 Alzheimer’s disease
 Neuronal
 Herpes zoster
Nerve damage may be result of:

 Child birth
 Pelvic injury
 Brain and spinal cord injury
 Herniated disc
 Heavy metal poisoning or tumors of the brain, spinal
cord or pelvis.
 Symptoms of NB
 Overactive bladder
 Frequent urination,in the daytime and night Stress
incontinence
 Urge incontinence
 Inability to urinate(urinary retention)
 Underactive bladder-bladder is unable to signal when
full
Complications:

 Sepsis

 Hydronephrosis

 Renal failure
  Laboratory studies:

 Urinalysis
 Urinecytology
 MRI of spine & brain
 Radiological evaluation
  Investigations

 Noninvasive bladder investigation

post void residual volume –in out catheterization
ultrasound
uroflowmetry
 Cystometry
 Sphincter EMG
 Neuroimaging
 Cystoscopy
  Treatment
 Anticholinergic drugs
 Cholinergic drug and alpha blockers
 Electric stimulation
 botulinum toxin injection
 Sphinctreotomy
 Catheterization
  Pharmacologic Interventions
 Tricyclic Antidepressant Drugs :

 Imipramine not only reduces bladder tone through its strong

anticholinergic effects and antispasmodic properties but it
also increases bladder internal sphincter tone through α-
adrenergic agonist effect to further facilitate urine storage.

 Additionally, imipramine has a local anesthetic effect on

bladder mucosa, which may further reduce bladder
contractility through spinal reflex mechanisms.
Cont…
 Anticholinergic (Antimuscarinic) Medications:
 This class of medication reduces reflex (involuntary) detrusor activity by
blocking cholinergic transmission at muscarinic receptors and is the first-line
option for treating neurogenic detrusor overactivity (NDO)

 Cholinergic Agonists:
 Urecholine is a synthetic muscarinic agonist with no significant nicotinic
effects. It can be used to promote detrusor contraction in lower motor neuron
lesions.

 Alpha-2 Adrenergic Agonists:

 This class of medications can be used in neurogenic bladder dysfunction when
the internal urinary sphincter is spastic, which occurs with detrusor sphincter
dyssynergia in upper motor neuron bladder dysfunction
Surgical Interventions
 Procedures to Enhance Detrusor Storage :
Neuromodulation for Neurogenic Detrusor Overactivity.
Enterocystoplasty.

 Bladder Sphincter Procedures to Enhance Emptying :

Sphincterotomy
Urethral Stents and Balloon Dilatation

 Sling surgery
 Ayurvedic aspect of neurogenic bladder

 Kosthagata vata
 Pakvashayagata vata
 Gudagata vata
 Mutraghat
 Mutrakruccha
 Mutravrutta vata
 Bastimarmaabhighat w.s.r. to bastikundala
 Vatavyadhi
 Ayurvedic aspect of neurogenic bladder
1. Mutraveghavrodhjanya roga acc. to
charaka
(physiological aspect)
Symptoms=बस्तिमेहनय ोः शूलं मूत्रकृच्छ्रं शशर रुजा |
शिन म िङ्क्षण न होः स्य स्तिङ्गं मूत्रशनरहे ||
ch.su.7/7
Treatment=स्वेद िग हन भ्यङ्ग न् सशपिषश्च िपीडकम् |
मूत्रे प्रशिहिे कुय ि स्तरिशिधं बस्तिकमि च ||
 Cont…
In the ancient time our acharya Charak has mentioned the pathology of
mutravega vidharan(Suppression of Natural urinal urge).
The sign and symptoms illustrated equally represent the pons & lumbar,
thoracicand sacral segment of spinal cord’s pathology.
Voiding Reflex Centre Sign & Symptoms
Pons शिरोरुजा
Lumbar segment बस्तिमेहनयोोः िूलं
Thoracic segment शिनामो
Sacral region मूत्रकृच्छ्रं, मूत्रशनग्रहे
 2. Kosthagata vata
 Symptoms=ित्र क ष्ठ शििे दु ष्टे शनरह मूत्रिचि स ोः||२४||
ब्रध्नहृद्र गगुल्म शिोःप र्श्िशूलं च म रुजिे | ch.chi.28
 Treatment=शिशेषििु क ष्ठस्थे ि िे क्ष रं [१] शपबेन्नरोः||८९||
प चनैदीपनैयुिक्तैरम्लैि ि [२] प चयेन्मल न् | ch.chi.28

[१] ‘क्षीरं ’ इशि प .|

[२] ‘प चनीयै रसैयुिक्तैरन्यैि ि ’ इशि प .|
 3. Pakvashayagata vata

 Symptoms= पक्व शयस्थ ऽन्त्रकूां शूल ट पौ कर शि च||२८||

कृच्छ्रमूत्रपुरीषत्वम न हं शत्रकिेदन म्|
ch.chi.28
4. Gudagata vata
 Symptoms= रह शिण्मूत्रि ि न ं शूल ध्म न श्मशकिर ोः||२६||
ाङ्घ रुजशत्रकप त्पृष्ठर गश षौ [१] गुदस्तस्थिे|
ch.chi.28
[१] ‘...र गश थौ’ इशि प .|

 Treatment=गु दपक्व शयस्थे िु कमोद िििनुस्तििम् ||९०||

ch.chi.28
 1Kosthagata
2 Pakvashayagata
3 Gudagata
5. Mutraghat w.s.r. to vatkundalika
 रौक्ष्य द्वे गशिघ ि द्व ि युरन्तरम शििोः |
मूत्रं चरशि सङ्गृह्य शिगुणोः कुण्डलीकृिोः ||५||
 सृ ाेदल्प ल्पमथि सरुजास्कं शनैोः शनैोः |
ि िकुण्डशलक ं िं िु व्य शधं शिद्य ि् सुद रुजणम् ||६||su.ut.58

 गशिसङ्ग दु द िृत्तोः स मूत्रस्थ नम गिय ोः|

मूत्रस्य शिगुण ि युर्िग्नव्य शििकुण्डली||३९||
 मू त्रं शिहस्तन्त संिम्भर्ङ्गगौरििेष्टनैोः|
िीव्ररुजङ् मूत्रशिट् सङ्गैि ि िकुण्डशलकेशि स ||४०||ch.si.9
6. Mutrakruchha
 मू शत्रिस्य व्यि य त्तु रे ि ि ि ििं च्युिम् |
पूिं मूत्रस्य पश्च द्व स्रिेि् कृच्छ्रं िदु च्यिे||३२||
ch.si.9
ि िेन शपत्तेन कफेन सिैिथ ऽशर्घ िैोः शकृदश्मरीभ्य म् |
िथ ऽपरोः शकिरय सुकष्ट मूत्र पघ िोः कशथि ऽष्टमिु ||३||
 अश्मरीं च सम शित्य यदु क्तं प्रसमीक्ष्य िि् |
यथ द षं प्रयुञ्जीि स्नेह शदमशप च क्रमम् ||१६||
su.ut.59
 Difference

मूत्र घ ि मूत्र िर धोः……………………(absence of urination)

मूत्रकृच्छ्रं दु ोःखेन मूत्रप्रिृशत्तोः…………(difficulty in urination)
 7.Mutravrutta vata
 Nidana= िेगसन्ध रण द म दशर्घ ि दर् ान ि्||१७||
मम ि घ ि द्गा ष्टर र्श्शीघ्रय न पिंसन ि्| ch.chi.28

 Lakshana= मूत्र प्रिृशत्तर ध्म नं बिौ मूत्र िृिेऽशनले ||६९||ch.chi.28

 Treatment= यूषैर ि म्य म्बुा नूपरसैि ि स्नेहसंयुिैोः|

प यसैोः कृशरै ोः स म्ललिणैरनुि सनैोः||७७||ch.chi.28
8. Bastimarmabhighat
 बिौ िु
ि िमूत्रिचोशनरहिङ्क्षणमेहनबस्तिशूलकुण्डल द िििगुल्म शन
ल ष्ठील पिम्भन शर्कुशक्षगुदि शणरह दयोः ………..
Ch.si.9/6
 Treatment :
 Kumbhisweda
 Niruha basti/anuvasan basti
 Virechan
Bastikundala
द्रुि ध्वलङ्घन य स दशर्घ ि ि् प्रपीडन ि्|
स्वस्थ न द्वस्तिरुजद् िृत्तोः स्थूलस्तिष्ठशि गर्ििि्||४४||

Treatment
द ष शधक्यमिेक्ष्यैि न् मूत्रकृच्छ्रहरै ाियेि्||४९||
बस्तिमुत्तरबस्तिं च सिेष मेि द पयेि् |
 Basti marma
अल्पम ं सश शणि ऽभ्यन्तरिोः कट् ं मूत्र शय बस्तिोः, ित्र शप
सद्य मरणमश्मरीव्रण दृिे, ित्र प्युर्यि शर्न्ने न ाीिशि, एकि
शर्न्ने मूत्रस्र िी व्रण र्िशि, स िु यत्नेन पक्र न्त र हशि;
 Kukundar marma
प र्श्िय ािघनबशहर् ि गे पृष्ठिं शमुर्यि
कुकुन्दरे , ित्र स्पश ि ज्ञ नमधोःक ये चेष्ट पघ िश्च

 Nitamb marma
ि णीक ण्डय रुजपय ि शय च्छ् दनौ प र्श् ि न्तरप्रशिबिौ
शनिम्बौ, ित्र धोःक यश ष दौबिल्य च्च मरणं;
Ref. su.sa.6
 Summery of Classical line of Management
Swedan Snehan Basti Kshara Dipana/ Treatment
Roga like
a a pachana
udavarta
1.Mutra-
vegavrodha
+ + + - - -
(Trividha)
2.Kostha-
Gata vata
- - - + + -
3.Pakwasha
ya &
- - - - - +
gudagata vata
4.Basti
avrutta vata
- - + - - -
(Uttara)
5.Mutravrutta
vata
- + + - - -
(Anuvasana)
 Samprapti ghataka
 Dosa= Vata
 Dushya= Rasa to Majja & Mutra, Purisha
 Srotas= Majja-mutra-anna-purish pradhantah
 Srotodushti= Sanga
 Adhisthan= Vasti/mutrashaya
 Samutthan= Pakwashayotha
 Agni= Visham
 Sama/nirma= both
 Vyadhi= Ashukari/chirkari
 Sadhyaasadhyata= Kruchhasadhya/asadhya