How does the bladder work normally?
Urination is a complex reflex coordinated by the brain and spinal cord. In the accumulation phase, the bladder muscle is relaxed and the sphincter is closed. At the moment of urination, the opposite happens: the muscle contracts, and the sphincter simultaneously relaxes.
If the neural pathways are damaged, this coherence is disrupted. Depending on the level of damage, fundamentally different pictures emerge.
- Hyperactive (spastic) variant - the bladder contracts involuntarily when its volume is small; typical in spinal cord lesions above a certain level and in multiple sclerosis
- Hypoactive (sluggish) variant - the bladder contracts poorly, stretches and does not empty; characteristic of damage to the lower parts of the spinal cord and peripheral nerves, including diabetes
- Detrusor-sphincter dyssynergia - the bladder muscle contracts, and the sphincter at this moment does not relax, but contracts; the most dangerous option for the kidneys
Reasons
- Spinal cord and spine injuries
- Multiple sclerosis
- Stroke and other brain damage
- Parkinson's disease
- Diabetic neuropathy is one of the most common causes of flaccid bladder
- Herniated intervertebral discs with compression of the cauda equina
- Tumors of the brain and spinal cord
- Congenital anomalies: spina bifida
- Consequences of extensive surgery on the pelvic organs with nerve damage
- Chronic alcoholism and toxic polyneuropathies
Symptoms
- Frequent urination and sudden urge with spastic variant
- Urinary incontinence
- Difficulty urinating, sluggish stream, need to strain
- Feeling of incomplete emptying and large volume of residual urine
- Complete urinary retention
- Lack of urge or, conversely, a perverted feeling of fullness
- Recurrent urinary tract infections
- Constant dripping when the bladder is full
- Constipation and sensitivity in the perineal area
Why is a neurogenic bladder dangerous?
- Vesicoureteral reflux - urine backing up into the kidneys
- Hydronephrosis with gradual loss of kidney tissue
- Recurrent pyelonephritis
- Chronic kidney disease and kidney failure
- Bladder and kidney stones
- Urosepsis
- Pressure ulcers and secondary infections in immobile patients
- Autonomic dysreflexia in patients with high levels of spinal cord injury - life-threatening rise in pressure
The key parameter that determines the prognosis is the pressure inside the bladder during the accumulation phase. It is high blood pressure, and not the fact of incontinence or retention, that damages the kidneys. Therefore, the goal of treatment is formulated as transferring the bladder to low pressure mode.
Diagnostics
- Diary of urinations and catheterizations
- Ultrasound of the kidneys and bladder with mandatory determination of residual urine
- Comprehensive urodynamic study - the main method: measures pressure in the bladder, its capacity and coordination with the sphincter
- Creatinine and estimated glomerular filtration rate
- General analysis and urine culture
- Cystoscopy for long-term catheterization, stones, blood in urine
- Void cystourethrography to detect reflux
- Consultation with a neurologist and examination of the underlying disease
Treatment
- Intermittent self-catheterization is the main method for incomplete emptying; performed by the patient independently according to a schedule and is preferable to an indwelling catheter
- Drugs that reduce the activity of the bladder muscle - in case of spasticity
- Alpha blockers to facilitate bowel movements
- Botulinum therapy of the bladder - for severe hyperactivity, resistant to drugs; often combined with self-catheterization
- Neuromodulation
- Cystostomy - if catheterization through the urethra is impossible
- Surgical increase in bladder capacity - in some severe cases
- Treatment and prevention of urinary tract infections
- Treatment of the underlying neurological disease
- Regime of fluid intake and emptying by the hour
Observation: why is it lifelong?
- Regular monitoring of creatinine and ultrasound of the kidneys, even if you feel well
- Periodic assessment of residual urine volume
- Repeat urodynamic studies if symptoms change
- Blood pressure control
- Timely treatment of infections, but without uncontrolled use of antibiotics for asymptomatic bacteriuria
- Education of the patient and relatives about catheterization techniques and signs of complications
Where they are observed and treated in Tashkent
Management of neurogenic bladder requires collaboration between a urologist and a neurologist, as well as access to urodynamic testing and endoscopic treatments.
In Tashkent, observation and treatment of such patients, including botulinum therapy of the bladder and surgical urinary diversion, are carried out at the UROLOGIC COMPLEX medical center and at the Tashkent Medical Park clinic.
At your appointment, take notes from a neurologist and data on the course of the underlying disease - tactics directly depend on the level and nature of damage to the nervous system. Clinic contacts are below.
