This document provides information on neurogenic bladder. It begins with the anatomy and physiology of normal bladder function controlled by the brain and spinal cord. It then defines neurogenic bladder as any bladder dysfunction caused by disruption of normal bladder innervation, which can be congenital or acquired. The main types of neurogenic bladder are described as spastic or flaccid, depending on whether the lesion is above or below the lumbosacral spinal cord. Causes include spinal cord injury, multiple sclerosis, and congenital conditions. Symptoms vary between types but include issues with storage and emptying of urine. Treatment aims to preserve kidney function and typically involves medications, injections, or surgery to manage symptoms. Ayurved

1. 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.

2. Index-
 Anatomy & physiology
 Introduction
 Defination
 Types
 Causes
 Symptoms
 Investigation
 Examination
 Treatment
 Ayurvedic corelation & treatment

4. 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.

5. 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.

6. 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.

10. 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!

11.  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.

12. 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.

13. 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.

14. Spastic type NB showing: ‘Christmas tree’ or ‘pine
tree’ effect.heavy trabeculation,cellules and small
diverticula in cystography

15. Type 2- Flaccid (atonic/nonreflex or autonomous)
neurogenic bladder
 It will caused by lower motor neuron lesion.
 Most common 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.
 Loss of perception of fullness permits overstretching of the
detrusor and atony of the muscle and these contributes to weak
and inefficient detrusor contraction.

16. The flaccid NB seen seen on cystography showing oval
shaped bladder

17. Difference
Type 1 spastic
 Vertebral level- lesion above L1
 Symptoms-urgency,frequency,urgency
incontinence,hesistancy,retension
 Bladder scan- -/+rasied postvoid residual
urine
 Uroflowmetry-interrupted flow
 Detrusor- overactivity,detrusor muscle
dyssynergia
 Bladder capacity-low
 Risk-back pressure changes
Type 2 flaccid
Lesion at/below L1
Hesistancy,retension
Postvoid residual urine >100ml
Low
Underactivity,sphincter insufficiency
High
stasis

19. 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. ..

20. Causes
Diseases
 Spinal cord trauma
 Tabes dorsalis
 DM
 MS
 Cord tumors
 Herniated intervertebral
disk
 Stroke
 Alzheimer’s disease
 Neuronal
 Herpes zoster
Congenital anomaly
 Myelomeningocele
 Absence of the sacrum

21. 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.

22. 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

23. Complications:
 Sepsis
Hydronephrosis
Renal failure

24.  Laboratory studies:
Urinalysis
Urine cytology
MRI of spine & brain
Radiological evaluation

25.  Investigations
 Noninvasive bladder investigation
post void residual volume –in out catheterization
ultrasound
uroflowmetry
 Cystometry
 Sphincter EMG
 Neuroimaging
 Cystoscopy

26.  Treatment
Anticholinergic drugs
Cholinergic drug and alpha blockers
Electric stimulation
botulinum toxin injection
Sphinctreotomy
Catheterization

27.  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.

28. 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

29. 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

30. Ayurvedic aspect of neurogenic bladder
 Kosthagata vata
 Pakvashayagata vata
 Gudagata vata
 Mutraghat
 Mutrakruccha
 Mutravrutta vata
 Bastimarmaabhighat w.s.r. to bastikundala
 Vatavyadhi

31.  Ayurvedic aspect of neurogenic bladder
1. Mutraveghavrodhjanya roga acc. to
charaka
(physiological aspect)
Symptoms=बस्तिमेहनय ोः शूलं मूत्रकृ च्छ्रं शशरो ुजा |
विन म िङ्क्षण न होः तय स्ललङ्क्गं मूत्रननग्रहे ||
ch.su.7/7
Treatment=तिेद िग हन भ्यङ्क्ग न ् सवपिषश्च िपीडकम ्|
मूत्रे प्रनिहिे कु य िस्रत्रविधं बस्तिकमि च ||

32. 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 विनामो
Sacral region मूत्रकृ च्छ्रं, मूत्रननग्रहे

33. 2. Kosthagata vata
 Symptoms=ित्र क ष्ठ श्रििे दुष्टे ननग्रह मूत्रिचिस ोः||२४||
ब्रध्नहृद्र गगुलम शिोःप श्ििशूलं च म ुजिे| ch.chi.28
 Treatment=विशेषितिु क ष्ठतथे ि िे ष रों [१] वपबेन्नरोोः||८९||
प चनैदीपनैयुिक्िैरोम्लैि ि [२] प चयेन्मल न ्| ch.chi.28
[१] ‘षीरों’ इनि प .|
[२] ‘प चनीयै रोसैयुिक्िैरोन्यैि ि’ इनि प .|

34. 3. Pakvashayagata vata
Symptoms= पक्ि शयतथ ऽन्त्रकू ां शूल ट पौ करो नि च||२८||
कृ च्छ्रमूत्रपुरोीषरिम न हं त्रत्रकिेदन म्|
ch.chi.28

35. 4. Gudagata vata
 Symptoms= ग्रह विण्मूत्रि ि न ं शूल ध्म न श्मशकि रो ोः||२६||
ाङ्क्घ ुजत्रत्रकप रपृष्ठरो गश षौ [१] गुदस्तथिे|
ch.chi.28
[१] ‘...रो गश थौ’ इनि प .|
 Treatment=गुदपक्ि शयतथे िु कमोद िििनुद्श्रधिम ्||९०||
ch.chi.28

36. 1Kosthagata
2 Pakvashayagata
3 Gudagata

37. 5. Mutraghat w.s.r. to vatkundalika
 रोौक्ष्य द्िेगविघ ि द्ि ि युरोन्िरोम श्रििोः |
मूत्रं चरोनि सङ्क्गृह्य विगुणोः कु ण्डलीकृ िोः ||५||
 सृाेदलप लपमथि सुजातकं शनैोः शनैोः |
ि िकु ण्डशलक ं िं िु व्य श्रधं विद्य ि् सुद ुजणम ् ||६||su.ut.58
 गनिसङ्क्ग दुद िृत्तोः स मूत्रतथ नम गिय ोः|
मूत्रतय विगुण ि युर्िग्नव्य विद्धकु ण्डली||३९||
 मूत्रं विहस्न्ि संतिम्र्र्ङ्क्गगौरोििेष्टनैोः|
िीव्रुजङ्क्मूत्रविट्सङ्क्गैि ििकु ण्डशलके नि स ||४०||ch.si.9

38. 6. Mutrakruchha
 मूत्रत्रितय व्यि य त्तु रोेि ि ि द्धिं च्छ्युिम ्|
पूिं मूत्रतय पश्च द्ि स्रिेि् कृ च्छ्रं िदुच्छ्यिे||३२||
ch.si.9
 ि िेन वपत्तेन कफे न सिैतिथ ऽशर्घ िैोः शकृ दश्मरोीभ्य म ् |
िथ ऽपरोोः शकि रोय सुकष्ट मूत्र पघ िोः कश्रथि ऽष्टमतिु ||३||
 अश्मरोीं च सम श्रिरय यदुक्िं प्रसमीक्ष्य िि् |
यथ द षं प्रयुञ्ाीि तनेह ददमवप च क्रमम् ||१६||
su.ut.59

39. Difference
मूत्र घ ि मूत्र िरो धोः……………………(absence of urination)
मूत्रकृ च्छ्रं दुोःखेन मूत्रप्रिृवत्तोः…………(difficulty in urination)

40. 7.Mutravrutta vata
 Nidana= िेगसन्ध रोण द म दशर्घ ि दर् ान ि्||१७||
मम िघ ि द्गा ष्र श्िशीघ्रय न पिंसन ि्| ch.chi.28
 Lakshana= मूत्र प्रिृवत्तरो ध्म नं बतिौ मूत्र िृिेऽननले||६९||ch.chi.28
 Treatment= यूषैग्र िम्य म्बुा नूपरोसैि ि तनेहसंयुिैोः|
प यसैोः कृ शरोैोः स म्ललिणैरोनुि सनैोः||७७||ch.chi.28

41. 8. Bastimarmabhighat
बतिौ िु
ि िमूत्रिचोननग्रहिङ्क्षणमेहनबस्तिशूलकु ण्डल द िििगु
लम ननल ष्ठील पतिम्र्न शर्कु क्षषगुदि णिग्णग्रह दयोः
……….. Ch.si.9/6
Treatment :
Kumbhisweda
Niruha basti/anuvasan basti
Virechan

42. Bastikundala
द्रुि ध्िलङ्क्घन य स दशर्घ ि ि् प्रपीडन ि्|
तितथ न द्िस्तिुजद्िृत्तोः तथूलस्तिष्ठनि गर्ििि्||४४||
Treatment
द ष श्रधक्यमिेक्ष्यैि न ्
मूत्रकृ च्छ्रहरोैाियेि ्||४९||
बस्तिमुत्तरोबस्तिं च सिेष मेि द पयेि ् |

43. अलपम ंसश णिग्णि ऽभ्यन्िरोिोः कट्य ं मूत्र शय बस्तिोः,
ित्र वप सद्य मरोणमश्मरोीव्रण दृिे, ित्र प्युर्यि शर्न्ने न
ाीिनि, एकि शर्न्ने मूत्रस्र िी व्रण र्िनि, स िु
यरनेन पक्र न्ि रो हनि;
ि णीक ण्डय ुजपय िशय च्छ्छ दनौ प श्ि िन्िरोप्रनिबद्धौ
ननिम्बौ, ित्र धोःक यश ष दौबिलय च्छ्च मरोणं;
 Basti marma
प श्ििय ािघनबदहर् िगे पृष्ठिंशमुर्यि
कु कु न्दरोे, ित्र तपश िज्ञ नमधोःक ये
चेष्ट पघ िश्च
 Kukundar marma
Nitamb marma
Ref. su.sa.6

44. Roga Swedan
a
Snehan
a
Basti Kshara Dipana/
pachana
Treatment
like
udavarta
1.Mutra-
vegavrodha
+ + +
(Trividha)
- - -
2.Kostha-
Gata vata
- - - + + -
3.Pakwasha
ya &
gudagata vata
- - - - - +
4.Basti
avrutta vata
- - +
(Uttara)
- - -
5.Mutravrutta
vata
- + +
(Anuvasana)
- - -
Summery of Classical line of Management

45. 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