Dysfunction of the bladder and urethra caused by damage to the central and peripheral nervous system that regulates and controls the physiological activity of urination is called neurogenic bladder and urethral dysfunction. Renal failure is the main cause of death in these patients.
I. Etiology.
1, trauma Trauma is the most common cause of neurogenic bladder in adults. The main ones are spinal cord injury and craniocerebral trauma. Most acute spinal cord injuries are caused by traumatic vertebral compression or fracture or dislocation.
2, congenital anomalies congenital anomalies can be seen in spina bifida, spondylolisthesis and cystic spina bifida.
3, surgical injury.
4, diseases affecting the nervous system hypertension, diabetes, syphilis, tremor palsy, multiple sclerosis, stroke, etc.
5, drug influence long-term or overdose of some drugs and affect the central nerve of urination, such as hypotensive drugs.
6, the cause is unknown in patients with neurogenic incontinence, the cause is unknown accounted for 20%.
Second, classification
Neurogenic bladder classification is cumbersome, Krane and Siroky (1984) were the first to broadly divide into two categories based on urodynamic findings: hyperreflexic type (referred to as hyperactive), in which the detrusor muscle has a contraction greater than 15 cmH20 during the bladder filling period, and non-reflexic type of detrusor (referred to as choked).
Clinical manifestations
The symptoms are complex and varied, including abnormal urination, extra-urethral symptoms and their complications. Abnormal urination: including abnormal sensation (no urge to urinate and reflex bladder distension), abnormal urinary control (mainly various types of urinary incontinence), abnormal time between urination, etc. Extra-urinary symptoms: including defecation dysfunction, sexual dysfunction, lower limb and foot deformities, skin abnormalities and abnormal skin sensory functions. Urinary tract complications: mainly recurrent urinary tract infections, hydronephrosis secondary to ureteral reflux and obstruction, and urinary tract stones.
IV. Clinical treatment and rehabilitation
The basic treatment principles of neurogenic bladder are.
1, for those with curable and recoverable primary neuropathy, treatment should first be directed at the primary disease, while measures to protect the function of the vesicourethra should be taken, and the function of the vesicourethra should be restored with the cure of the primary disease.
2. For those who cannot recover from neuropathy, treatment should be given for the type of vesicourethral dysfunction in order to achieve “balanced bladder”.
3.Other treatments include: protection of the function of the forced urinary muscle, prevention and treatment of upper urinary tract complications (e.g., hydronephrosis, ureteral reflux, etc.), improvement of quality of life, and treatment of other urinary tract complications (e.g., urinary tract infections and urinary tract stones). Thus, the function of the upper urinary tract is effectively protected and the quality of life is improved.
(I) Non-surgical treatment
1.General treatment
(1) Catheterization Catheterization is one of the most basic and simple early treatment methods. It is suitable for patients with urinary retention, where the upper urinary tract is often damaged, such as hydronephrosis and impaired renal function, which require indwelling urinary drainage; neurogenic bladder with vesicoureteral reflux is also suitable for catheterization treatment. The main purpose of catheterization is to protect and restore renal function. On the other hand, catheterization helps to control urinary tract infections. Depending on the duration of the disease and the urodynamic performance of the bladder wall ureter, catheterization is classified as continuous catheterization, intermittent catheterization, and intermittent open catheterization.
Continuous catheterization: Patients with loss of urinary capacity due to delirium, bladder paralysis due to spinal shock after spinal cord injury and patients with hyperreflexia of the forceps urethra, low urethral pressure, and dilation muscle insufficiency are usually firstly used in continuous catheterization.
Intermittent catheterization: for patients with hyperreflexic neurogenic bladder in which the detrusor external sphincter is synergistically dysfunctional, but the hyperreflexic detrusor can be suppressed by medication. Within the scope of use, intermittent catheterization is superior to indwelling catheterization, mainly because it reduces the rate of infection, promotes early recovery of the detrusor reflex, avoids bladder contracture, reduces penile and scrotal complications, and reduces autonomic dysreflexia. The process of intermittent self-catheterization should be gentle and clean to avoid contusion of the urethra and the occurrence of infection. In general, patients without incontinence and spontaneous urination can be catheterized once every 4 – 6 hours, and after the appearance of spontaneous urination, it can be extended to once every 6 – 8 hours, and when the residual urine is less than 100 ml, catheterization can be stopped for observation. according to Bors and Comarr, the bladder can reach equilibrium when the residual urine volume is 10% – 20% of bladder capacity. The absence of infection and a residual urine of less than 100 ml is a good indicator of a balanced bladder function.
Intermittent open catheterization: A catheter is left in place and the catheter is opened once every 3 – 4 hours to empty the bladder. It is generally indicated for the recovery period of spinal shock after spinal cord injury. The advantage is that it prevents bladder contracture and smaller bladder capacity. For patients with hyperactive bladder forceps reflexes and significantly elevated intravesical pressure, the possibility of “occult hydronephrosis” caused by vesicoureteral urinary reflux can be avoided.
(2) Bladder irrigation is not used as a routine treatment. It is mainly used in the following cases: when the urine is cloudy and consists of residue and sediment; bladder bleeding; fungal bladder infection.
(3) Induced detrusor reflex voiding method Some patients with hyperreflexic neurogenic bladder promote voiding by finding trigger points to stimulate the detrusor reflex, such as snapping the suprapubic area, squeezing the penis, pulling the pubic hair, stimulating the anus or dilating the anus, etc., with a view to developing a spontaneous detrusor reflex and stimulating the detrusor reflex contraction and external sphincter relaxation. As the suprasacral nerve injury is mostly accompanied by the synergistic disorder of the urethral sphincter, the resistance of the bladder outflow tract is often very high, and reflex urination often cannot be achieved as desired. Therefore, attention should be paid to the urinary reflex and the amount of bladder residual, and catheterization should be chosen for excessive residual urine, and surgical methods can also be used to reduce bladder outflow tract resistance in patients with high bladder neck pressure.
2.Neuropharmacological treatment
(1) Cholinomimetic drugs These drugs are mainly used to enhance bladder contraction and improve the ability to urinate. Their therapeutic effect is mainly derived from the excitation of M receptors, causing an increase in urethral resistance but not conducive to achieving therapeutic goals. The latter effect is due to the simultaneous excitation of N1 receptors, which causes urethral sympathetic excitation and contraction of urethral smooth muscle; anticholinesterase drugs cause excitation of N2 receptors and increased urethral transverse muscle tone; and excitation of urethral smooth muscle M receptors, which causes contraction of the urethra. The main drugs are: tranylcypromine, vinpocetine, neostigmine, bis-neostigmine, etc.
(2) Anticholinergic drugs mainly inhibit bladder contraction by antagonizing peripheral M receptors, Nl receptors in pelvic ganglia and central cholinergic receptors. Commonly used drugs include: probenecid, bromhexine, hydroxybutynin chloride, atropine, etc.
(3) Adrenomimetic drugs adrenomimetic drugs are substances with chemical structure similar to norepinephrine, and are commonly used in the treatment of lower urinary tract dysfunction according to their selective action on sympathetic receptors. Commonly used drugs include: neoforin, ephedrine, pseudoephedrine, salbutamol, etc.
(4) Anti-adrenergic drugs are a group of drugs that can bind to adrenergic receptors, while producing essentially no or less adrenomimetic effects, and impede endogenous or exogenous adrenomimetic transmitters or drugs from binding to receptors, thus producing anti-adrenergic effects. Other drugs, which have no receptor antagonism per se, produce anti-adrenergic effects by inhibiting sympathetic nerve centers, or by blocking the release of neurotransmitters from sympathetic nerve terminals. The latter effect is represented by drugs such as colistin, methyldopa and guanethidine.
(5) Smooth muscle relaxants have a direct relaxing effect on the detrusor muscle; have varying degrees of anticholinergic effects; and local anesthetic effects. The common indications for these drugs are unstable bladder, hyperreflexia of the detrusor muscle, and urge incontinence. The main drugs are: flavone permethrin, dicyclomine, etc.
(6) Other drugs: tricyclic antidepressants, calcium antagonists, prostaglandins and prostaglandin synthesis inhibitors, skeletal agents relaxants, etc.
3.Electrical nerve stimulation therapy
Electrical stimulation therapy refers to the use of specific parameters of electric current to stimulate the pelvic tissues and organs or the nerve fibers and nerve centers innervating them, through the direct effect on the effector, or the influence on the activity of the nerve pathway, to change the functional state of the bladder/urinary guide, in order to improve the urinary storage or voiding function. Electrical stimulation was first proposed by Caidwell in 1958, and its clinical application began in the mid-1970s. Since then, as the understanding of the lower urinary tract nerve and nerve reflex pathway improved, as well as the continuous improvement of electrical stimulation equipment and treatment methods, electrical stimulation treatment has developed rapidly. At present, electrical stimulation has become one of the treatment methods for lower urinary tract dysfunctional diseases, and has increasingly become an important treatment method for some of the urinary dysfunctional diseases. Commonly used electrical stimulation methods are.
(1) pelvic floor muscle electrical stimulation. Electrical stimulation of the pelvic floor muscle has a more positive effect on incontinence caused by bladder contraction, and causes both inhibition of bladder contraction and strengthening the role of urethral closure, and also has value in the treatment of mixed incontinence. The main side effects are: vaginal irritation and infection that may occur in a few patients due to repeated manipulation.
(2) Electrical stimulation of the bladder forced urinary muscle is mainly used to treat forced urinary contraction weakness, especially when the sacral medullary detrusor center and its efferent nerves are damaged, and is the only feasible electrical stimulation option when the reflex arc is incomplete.
(3) Sacral nerve root electrical stimulation anatomical and neurophysiological studies have revealed that S2–4 are the low control centers of the forceps and external urethral sphincter, with S3 predominating. Using appropriate electrical parameters and stimulation methods, stimulation of the above-mentioned nerve roots can alter the contraction and diastolic states of the bladder and external urethral sphincter, thereby improving bladder storage or improving bladder voiding function. It is one of the most researched and promising methods in the field of electrical stimulation therapy. It is indicated for: neurogenic hyperreflexia of the detrusor muscle with severe urinary incontinence or dilatation of the upper urinary tract, where pharmacological and conservative treatments have failed and the pathway from the efferent nerve to the effector is intact. It is less effective in those who already have severe forceps fibrosis; in those who have unstable non-neurogenic forceps with very severe clinical symptoms that are difficult to control by other methods; in those who have the above mentioned problems along with external urethral sphincter closure insufficiency, and in those who have bladder outlet obstruction, the bladder outlet obstruction problem should be solved first or simultaneously.
(4) Pelvic nerve electrical stimulation is mainly used to treat bladder contraction weakness. This treatment is satisfactory in inducing contraction of the detrusor muscle, but it often prevents the patient from obtaining normal voiding because of the concomitant contraction of the external urethral sphincter. The practical use is limited.
Stimulation of the spinal cord anatomy suggests that the parasympathetic preganglionic fibers innervating the bladder forceps are located in the lateral tract of the spinal cord, whereas the nuclei of the external urethral sphincter are located in the ventral corner of S2–4. Therefore, if the electrodes are placed in the proper position, the contraction of the detrusor muscle can be induced to produce voiding by selective stimulation of the detrusor center of the spinal cord.
(ii) Surgical treatment
The treatment of neurogenic bladder should be based on the principle of “low-pressure urinary storage, urinary control, and low-pressure voiding” to effectively protect the function of the upper urinary tract and improve the quality of life. The aim of surgical treatment is to protect and improve the function of the kidneys and restore urinary function as much as possible, i.e. to achieve a balance between urinary storage and urinary output. Surgery should establish a high compliance bladder with sufficient capacity to provide a constant storage of urine for abdominal pressure voiding or intermittent clean catheterization (CIC); for true stress urinary incontinence increase urethral pressure at the same time, thus improving symptoms, quality of life and protecting upper urinary tract function. The postoperative residual urine should be less than 1/3 of the bladder capacity and without vesicoureteral reflux. Currently, the following types of surgical procedures are commonly used.
1.Neurosurgical treatment
Administer spinal canal decompression to release the embolus and the compression of the nerve. The cone should be loosened while checking for other local lesions, including tumors, adhesions, etc. should be removed together. The literature reports that the earlier the onset and longer the duration of clinical symptoms, the worse the recovery effect of surgery, so all cases should be operated early. In adult patients, postoperative functional recovery is not as good as in children, or even no improvement at all, but if there is local tumor compression, surgical removal of the tumor to release the compression still has some efficacy.
2.Surgery to reduce bladder outlet resistance
This surgery is suitable for patients with no tone in the forceps, large bladder capacity, significantly higher urethral resistance, urinary retention or more residual urine.
(1) Transurethral internal sphincterotomy is performed at 9 points (for unilateral cut) and 3 points (for bilateral cut) of the bladder neck by applying electrodesiccoscopy to the internal urethral sphincterotomy. Extent of excision: 1.0 – 1.5 cm long (bladder neck to the head of the seminiferous tuberosity for men), 0.5 cm wide and deep fatty layer.
(2) Transurethral external sphincterotomy aims to cause complete urinary incontinence, eliminate residual urine, reduce urinary tract infection, and protect renal function. It is indicated for those with bladder neck obstruction or external sphincter spasm, those with excessive residual urine and dyspareunia due to reduced tone of the detrusor muscle and relatively high urethral resistance, those with increased residual urine or dyspareunia due to external sphincter spasm and bladder neck hypertrophy resulting in elevated urethral resistance or weak detrusor contraction, and those with bladder neck obstruction where transurethral dilation is ineffective. It is often necessary to use urinary control measures, such as the application of external urinary collectors, placement of artificial urethral sphincters, etc.
(3) Bladder neck and posterior urethroplasty There are many methods of bladder neck and posterior urethroplasty, commonly used are Young–Dees surgery and Leadbetter surgery. It is suitable for patients with neurogenic bladder incontinence with some bladder capacity. The surgery can reconstruct a thin and longer urethra than the original bladder neck and posterior urethra.
3.Surgery to increase bladder outlet resistance
(1) Artificial urethral sphincter implantation is indicated for patients with severe neurogenic bladder incontinence with some bladder capacity; bladder forceps weakness, excessive residual urine, and urinary incontinence after performing internal and external urethral sphincterotomy. Contraindications are: incontinence with severe detrusor hyperreflexia; combined primary bladder contracture incontinence; severe vesicoureteral reflux incontinence; and intraurethral obstruction.
(2) The mechanism of action of periurethral injection therapy is that in some patients with urinary incontinence, the bladder neck and proximal urethra are open during the bladder storage period, and the intraurethral pressure is reduced, and the pressure at the point of leakage is lowered. Injection of sclerosing agents into the posterior urethra or submucosa around the bladder outlet narrows the urethral lumen, thereby increasing the intraurethral pressure and acting to close the internal urethral opening and posterior urethra, effectively controlling urinary flow without causing significant changes in voiding pressure or resistance to urinary flow. Patients best suited to receive periurethral injection therapy are those with internal urethral sphincter dysfunction, such as some women with stress urinary incontinence.
(3) Bladder neck suspension The main cause of neurogenic incontinence is low bladder outlet resistance. The use of bladder neck suspension can significantly increase bladder outlet resistance. On the one hand, it strengthens the function of the pelvic floor muscles and prevents them from falling so that the bladder can be supported; on the other hand, it corrects the funnel-shaped fall of the bladder neck.