NEUROGENIC BLADDER

Peter B. J. Wu, M.D., M.P.H. PM & R at Stanford

I. Neuroanatomy December 28, 1992

Central: Four neuroanatomic curcuits

1) Pathways to and from the frontal lobes to the pontine-mesencephalic reticular formation.

2) Pathways to and from the the pontine-mesencephalic reticular formation to sacral gray matter.

3) The detrusor nuclei and pudendal nuclei in the sacral gray matter with interneurons.

4) Motor cortex to pudendal nucleus.

Peripheral: Pudendal nerve (S2-4), Sympathetic- Hypogastric nerve (T11-L2), Parasympathetic- Pelvic nerve (S2-4).

II. Evaluation

a) Physical examination- genital sensation, bulbocavernous reflex.

b) Laboratory exam- serum creatinine and BUN, urinalysis and C/S, PVR, excretory urography, renal scan, cystoscopy, voiding cystourethrography.

c) Urodynamics- cystometry with/without EMG.

III. Neurogenic bladder

Uninhibited neurogenic bladder dysfunction

Upper motor neuron bladder dysfunction

Lower motor neuron bladder dysfunction

Mixed type A neurogenic bladder dysfunction

Mixed type B neurogenic bladder dysfunction

Myogenic detrusor insufficiency

IV. Treatment of storage dysfunction

1) Hyperreflexia of detrusor:

--- propantheline bromide (Pro-Banthine) 7.5 - 15 mg tid - qid., Oxybutynin chloride (Ditropan) 5 mg tid - qid.

--- b-adrenergic stimulation: Isopreoterenol, progesterone, less effective with marked side effects.

2) Ineffective closure of the internal urethral sphincter:

--- a-sympathetic:phenylephrine, phenylpropanolamine, ephedrine, pseudoephedrine, imipramine (Tofranyl) 25 mg tid.

3) Ineffective closure of the voluntary external sphincter:

--- neuromuscular re-education and strengthening, surgery.

V. Treatment of emptying dysfunction

1) Weak expulsive force of detrusor:

--- bethanechol (Urecholine) 25 - 50 mg tid or qid.30 minuets before voiding, Crede maneuver.

2) Hyperactive internal sphincter:

--- a-adrenergic blockers: phenoxybenzamine (Dibenzyline) 10 mg tid or qid, phentolamine (Regitine), prazosin HCl (Minipress), terazosin (Hytrin).

3) Hyperactive external sphincter:

--- baclofen, diazepam, dantrolene: not effective.

VI. Surgical treatment

1) To promote drainage: TUR-S, Pudendal nerve block and neurectomy, Electrical stimulation.

2) To promote storage: Subarachnoid blocks, Sacral rhizotomy, Perivesical denervation, enterocystoplasty, Cystourethropexy, Bladder neck tubularization, Artificial urinary sphincter, Urinary diversion, Continent pouches and Reservoirs.

to articles.