Bladder physiology

1. BLADDER PHYSIOLOGY
AND DISORDERS.
DR SUHAIL RAFIK

2. ANATOMY

8. NERVE SUPPLY OF BLADDER

9. T11,
T12

10. NERVE SUPPLY

11. BRADLEY’S LOOPS : 1ST LOOP
 Also called the cerebral loop
 Connects the cortical areas with the pontine micturition centers “BARRINGTON
NUCLEUS”
 Cortex influences the pons and decides when to void and when to not.

12. BRADLEY’S LOOP

13. BRADLEY’S LOOP

14. LOOP 2
 Functions between the pons and the bladder
 Gets affected in any lesion involving the spinal cord above the sacral center

15. BRADLEY’S LOOP

16. LOOP 3
 Detrusor contraction sends
Afferent to Pudendal Nerve nucleus i.e.Onuff’s nucleus(somatic)
Inhibits external urethral sphincter
Hence the sphincter relaxes and allows voiding

17. LOOP 4
 “Urethral reflex”
 Flow of urine into the urethra stimulates the local plexuses and further helps in
relaxation of the external sphincter
 Helps in voiding

18. 5th LOOP
 Cortex influences the Onuff’s nucleus
 Which sends signals via somatic pudendal nerve
 Relaxes the external sphincter and helps voiding
 “Meaning everyone can voluntarily void even without a full bladder” because your
cortex decided so.

19. BLADDER CONTROL CENTERS

20. BARRINGTONS NUCLEUS
FIRST SIGNAL
AT 150 ML
STIMULATES A
FIBRES
SECOND SIGNAL
AT 400ML
STIMULATES BOTH
A FIBRES AND PAIN
FIBRES

23. BLADDER DISORDERS

24. EAU GUIDELINES ON NEURO-UROLOGY
PRE VOID :
frequency
Urgency
Urge incontinence
NORMAL VOIDING
NO POST VOID
RESIDUE
PREVOID:
UMN features
VOID:
Hesitancy
Cannot hold in between
Detrussor-sphincter
dysynergia
Double void
POST VOID:
Residual urine present
PRE VOID:
Normal
VOID:
Hesitancy
Poor or absent flow
Overflow
incontinence
POST VOID:
Increased residual
urine
1
2
3

25. LAPIDES CLASSIFICATION OF BLADDER DISORDERS

26. UNINHIBITED CORTICAL BLADDER
 Suprapontine lesion
 Bradley’s loop 1 affected
 Cortical pons pathway affected
 No social inhibiton
 Voids at wrong time, wrong place
 Small, spastic bladder
 Increased frequency

28.  Seen in :
 Cerebrovascular accidents
 Frontal tumors
 Parasaggital meningiomas
 Normal Pressure Hydrocephalus : gait disturbance, cognitive impairment, impaired bladder control.
 ACA aneurysm
 Parkinsons disease
 Demyelinating conditions

29. AUTOMATIC / REFLEX BLADDER
 Infrapontine lesions
 Sacral Reflex arc intact
 The Pons decision over switching between bladder filling and voiding- lost
 Frequent small voids
 Small bladder
 Seen in Multiple sclerosis / spinal cord tumours / spinal cord trauma.

30. AUTONOMOUS BLADDER
 Sacral or infrasacral lesion
 No nervous control over bladder
 Acts independently
 LMN bladder
 Large volume residual urine present
 Seen in conus medularis / cauda equine syndrome / peripheral neuropathy

31. SENSORY PARALYTIC BLADDER
 Isolated afferent denervation lesions
 No sensation of bladder filling
 Bladder overdistended
 Overflow incontinence
 Voluntary voiding needed
 Motor innervation intact
 Saddle anaesthesia present (s2,s3,s4 afferent lost)
 Seen In : multiple sclerosis / diabetes mellitus / tabes dorsalis

32. MOTOR PARALYTIC BLADDER
 LMN bladder
 Isolated motor denervation lesions
 Bladder sensation present
 Painful urine retention
 Bulbocavernous and anal reflex absent
 Has to void by Credes’ maneuver - pressure over distended bladder /lower abdomen
 Seen in lumbosacral meningomyelocoele / lumbar canal stenosis / extensive pelvic surgery / poliomyelitis /
polyradiculopathy

34. STRESS INCONTNENCE

35.  Normally during coughing/ sneezing intra abdominal pressure increases
 However urinary continence is maintained as the Nucleus retroambiguous sends signals to
ventrolateral medulla
 Stimulates the Onuff’s nucleus
 Contracts the external sphincter and pelvic floor muscles
 Multiple pregnancy and childbirth with instrumentation damages the pelvic integrity – stress
incontinence

36. TREATMENT
 The primary aims in treating neurourological disorders are:
 1. protection of the upper urinary tract;
 2. improvement of urinary continence;
 3. restoration of (parts of) the LUT function;
 4. improvement of the patient’s QoL.
 Further considerations are the patient’s disability, cost-effectiveness, technical
complexity, and possible complications

37.  Conservative treatment
 Assisted bladder emptying Triggered reflex voiding is not recommended as there
is a risk of pathologically elevated bladder pressures. Only in the case of absence,
or surgically reduced outlet obstruction it may be an option.
 Caution: bladder compression techniques to expel urine (Credé) and voiding by
abdominal straining (Valsalva manoeuvre) create high pressures and are
potentially hazardous, and their use should be discouraged

38.  Rehabilitation
 In selected patients, pelvic floor muscle exercises, pelvic floor electro-stimulation,
and biofeedback might be beneficial

39.  External appliances
 Social continence for the incontinent patient can be achieved using an appropriate
appropriate method of urine collection.
 Medical therapy
 A single, optimal, medical therapy for patients with neurourological symptoms is
not yet available. Muscarinic receptor antagonists are the first-line choice for
treating neurourological disorders.

40. REFERENCES
 EAU guidelines on neurourology
 DeJong’s The Neurologic Examination
 Localization in Clinical neurology

41. THANK YOU
 THANK YOU