The neurogenic bladder represents (flaccid or spastic) a bladder dysfunction caused by neurological damage. Symptoms overflow incontinence, frequent urination, urgency, urge incontinence and retention can count on. The risk of serious complications is high (eg. As recurrent infections, vesicoureteral reflux, automatic reflex bladder, kidney damage). The diagnosis comprises imaging and cystoscopy or urodynamic examination. Treatment consists u. a. in catheterization or measures to trigger a micturition.
(See also overview of micturition.)
The neurogenic bladder represents (flaccid or spastic) a bladder dysfunction caused by neurological damage. Symptoms overflow incontinence, frequent urination, urgency, urge incontinence and retention can count on. The risk of serious complications is high (eg. As recurrent infections, vesicoureteral reflux, automatic reflex bladder, kidney damage). The diagnosis comprises imaging and cystoscopy or urodynamic examination. Treatment consists u. a. in catheterization or measures to trigger a micturition. (See also overview of micturition.) Any change which damages the bladder or the afferent and efferent signals to the bladder outlet, can cause neurogenic bladder. The cause disturbances occur at the level of the central nervous system (eg., Stroke, spinal cord injury, meningomyelocele, amyotrophic lateral sclerosis), of the peripheral nerves (z. B. diabetes, alcohol intoxication or vitamin B12 deficiency, neuropathies, herniated disk, damage caused by pelvic surgery) or at both levels in question (eg. as Parkinson’s disease, multiple sclerosis, syphilis). Bladder outlet obstruction (eg. As a result of benign prostatic hyperplasia, prostate cancer, fecal impaction, or urethral stricture) often co-exists and may worsen the symptoms. In the flaccid (hypotonic) neurogenic bladder, the volumetric capacity is large, the bubble pressure low and bladder contractions missing. They can be caused by damage to peripheral nerves or by damage to the spinal cord at the level of S2-S4. In acute spinal cord injury, a long-term flaccidity or spasticity may be represented at the initial laxity connect, or bladder function improves after days, weeks or months. Spastic bladder capacity is normal or low, and there is involuntary contractions. They usually caused by brain injury or spinal cord lesions above T12. The exact symptoms vary depending on the location and severity of the injury. Bladder contraction and relaxation of the external sphincter are typically not coordinated (detrusor-sphincter dyssynergia). Mixed forms (flaccid and spastic bladder) can have many causes, including syphilis, diabetes mellitus, brain and spinal cord tumors, stroke, lumbar disc herniation and demyelinating or degenerative disorders (multiple sclerosis, amyotrophic lateral sclerosis). Symptoms and complaints Overflow incontinence is the primary symptom in patients with a flaccid bladder. Patients keep urine back and feel a constant “overflow dribbling”. Men typically have an erectile dysfunction. Patients with spastic bladder suffer from frequent urination, nocturia and spastic paralysis with sensory deficits. Most have intermittent contractions of the bladder, urine leakage and, if they have no sense of loss, causing urination. In patients with bladder sphincter dyssynergia, a sphincter spasm can prevent the complete emptying during urination. The usual complications are frequent UTIs and urinary calculi is. Hydronephrosis with vesicoureteral reflux can occur because the large amount of urine pushes the Vesicoureteral connection, resulting in dysfunction with reflux and in severe cases of kidney damage. Patients with high thoracic or cervical spinal cord injury are at risk due to automatic dysreflexia (a life-threatening syndrome with malignant hypertension, bradycardia or tachycardia, headache, piloerection or sweating caused by unregulated sympathetic hyperactivity). This disorder can be caused by an acute (caused by urinary retention) bladder over-elongation or (caused by constipation or fecal impaction) Flatulence of the abdomen. Diagnostic ultrasound residual urine volume of serum creatinine renal Usually cystography, cystoscopy and Cystomanometry with urodynamic investigations. The diagnosis is made clinically. Usually, the residual urine is determined conducted a kidney ultrasound to detect any hydronephrosis, and serum creatinine measured to assess renal function. Other findings are collected often in patients who are not able to autocatheterism or can not report to urinate (z. B. greatly weakened the elderly or patients after stroke). In patients with hydronephrosis or nephropathy, not weakened, cystography, cystoscopy and Cystomanometry are recommended with urodynamic studies usually, and can guide further therapy. Occasionally, however, the cystography is used to determine bladder capacity and prove reflux. By means of cystoscopy be examined duration and severity of retention (by detection of bladder trabeculae). It is also used to estimate the bladder outlet. Cystomanometry can check whether bladder capacity and pressure are high or low. If this investigation carried out during the recovery phase of a flaccid paralysis of the bladder after spinal cord injury, they can be used to assess the Detrusorfunktion and the chance of success of a rehabilitation useful (tests). show Uroflow measurement with Sphinkterelektromyographie whether the bladder contraction and the Sphinkterrelaxation run coordinated. Therapy catheterization Increased hydration drug operation when conservative measures fail, the prognosis is good if the disorder is diagnosed and treated early, before the kidneys are damaged. Specific treatments provide catheterization and measures to trigger urination is. General measures include monitoring of renal function, check for UTI, increased fluid intake to reduce the risk of UTIs and urinary calculi (although this measure may enhance the incontinence), early mobilization, frequent changes of position and reduction of calcium intake to prevent stone formation. In flaccid paralysis of the bladder catheterization, especially after acute spinal cord injury, an immediate indwelling catheter or an intermittent catheter treatment is necessary. Intermittent catheterization is preferable to the indwelling catheter because of the high risk of UTI and (in men) urethritis, Periurethritis, prostatic and Harnröhrenfisteln. If the patient can not catheterize themselves, the construction of a suprapubic catheter sinnvoll.Medikamenten and other therapies In spastic paralysis of the bladder, the treatment depends on whether the patient can hold water. Anticholinergics may be helpful. Patients who can maintain normal amounts of water, the technique of the triggered urination can be taught (eg., By suprapubic pressure stroke the legs). For patients who do not have normal bladder capacity, the treatment is the same as for patients with urge incontinence (urinary incontinence in adults: Treatment), including drugs (see table: drugs used to treat incontinence) and Sakralnervenstimulation.Operative procedures The last resort is surgery , The indication for surgery is when patients are threatened by severe acute or chronic complications or if social circumstances, spasticity, tetraplegia make permanent or intermittent bladder drainage impossible. Sphincterotomy transforms the bladder in an open passage organ in men. Sacral (S3 and S4) rhizotomy transformed spastic bladder in a flaccid bladder. For urinary diversion an ileal conduit and a ureterostomy are suitable. Are patients to not be able to life-threatening situations (eg. As kidney failure, Urosepsis) can result. A surgically implanted artificial and mechanically controlled sphincter is another option for patients who have an adequate bladder capacity and mobility of their upper extremities, and may follow the instructions regarding the handling of this tool. Conclusion damage to the nerves that control urination can make the bladder flaccid or spastic. A flaccid bladder tends to cause overflow incontinence. Spastic bladder tends frequent urination, urgency incontinence and-especially with bladder sphincter dyssynergia – to cause retention. Measurement of residual urine volume, renal sonography and measurement of serum creatinine should be performed and in many patients also cystography, cystoscopy and Cystomanometry with urodynamic investigations. For the treatment of flaccid bladder includes an increased fluid intake and intermittent self. The treatment of spastic bladder is done with actions that trigger the urination and / or measures to urge incontinence (including drugs).