bladder dysfn

7/30/2019 BLADDER DYSFN

1/23

Bladder and Sexual rehabilitation

following Spinal cord injury


2/23

Anatomy of bladder

Parasympathetic S2-4 pelvic splanchnicnerves main motor innervation

Sympathetic from L1-2 via sup and infhypogastric plexus


3/23

parasympathetic[ cholinergic] S2-4

Detrusor Contraction

Sympathetic T12-L2[ adrenergic]

Inhibitory to detrusor Constrictor for

bladder sphincter


4/23

Sensory innervation

Stretch receptors in bladder Through parasympathetic to spinal cord

via posterior root of S2-4Ascend in lateral spinothalamic tract Micturition centre inpons and inferior

frontal gyrus in cerebral cortex.


5/23

Physiology of sexual function

Erection

[ Parasympathetic]

Impulses in pelvic splanchnicnerves Vasodilatation in corpora

cavernosa

Spongy tissue becomesengorged and veins

compressed causing erection

Ejaculation

[Sympathetic and somatic]

Sympathetic from T11 to L2

Contraction of epididymis,ductus deferens, seminalvesicles, ejaculatory duct andbladder neck thus causingEMISSION.

Rhythmic contraction of

bulbospongiosus by perinealnerve compresses penileurethra and causesEJACULATION.


6/23

Anterior division ofS2,3,4

Pudendal nerve A] Dorsal nerve of

penis

B] perineal nerve

Pelvic splanchnicnerves [nervi

erigentes] From S2-4 Mix with sympathetic

nerves in inf

hypogastric plexusand distribute topelvic viscera


7/23

Bladder Dysfunction in SCI

Supra sacral bladder

Lesion above conusmedullaris

Hypereflexic detrusor

with or without DESD Hypereflexic sphincter

Sacral bladder

Lesion at or below theconus i.e caudaequina

Areflexic detrusor Sphincter paralysed

Bladder dysfunction

Spinal shock phase Recovery phase Established phase


8/23

Treatment

Spinal shock phase CIC

Recovery phase- Less frequent CIC

Established phase comprises ofDiagnosing the type of bladder

Treatment accordingly


9/23

Management in Established phase[Rehabilitation]

Investigation: RFT, Imaging of UUT,Urodynamic Studies

Urodynamic studies provides objectivemeasurement of bladder and sphincterfunction

Done after spinal shock/ acute urinaryretention resolves


10/23

Classification of neurogenic Bladder

Failure to empty[retention]

Bladder: acontractile

Sphincter: DESD,DISD

Failure to store[incontinence]

Bladder: overactivity

Sphincter:incompetent


11/23

Goals of bladder rehabilitation

Preserve and protect upper urinary tract [keep bladder pressure


12/23

Factors influencing rehab options

co-morbid conditions

Cognitive functions

Motivation/pt complaince

Hand functions


13/23

Rehabilitation methods

A] detrusor underactivity

B] detrusor overactivity

C] yearly surveillence to screen for bladdercancer


14/23

A] If detrusor underactivity

1] Clean intermittent catheterisation:

best, safe,

but patients hand fn, cognitive fn and complianceneeded.

2] Indwelling Catheter:

Foleys or suprapubic tube

Inferior option compared to cic complication: pyelonephritis, calculi[50%], loss of

detrusor compliance, later stage bladder cancer.


15/23

3] crede / valsalva manuever: in patientswith low resistence

4]Cholinergic agonists: bethanecholaugments bladder contraction.C/I: in those pts with DESD

5] Incontinent Iliovesicostomy 6] Neuro modulation: anterior sacral rootstimulation- now obsolute procedure.


16/23

B] Detrusor Overactivity

1] Anticholinergic: First line of Rxoral oxybutynin, trospium

2]Botulinum Toxin A: into the bladder

3]Augmentation enterocystoplasty


17/23

Sexual dysfunction

Sacral parasympatheticneurons are imp inpreservation ofreflexogenic erection

Orgasmic sensationsrun in spinothalamictract

Gets abolished incord transection

Sexual dysfunction

Erectile Dysfunction Ejaculatory dysfunction Impaired Orgasm


18/23

Sexual rehabilitation

Sexual rehabilitation

Sexual functionFertility function

[Functional infertility]

Family completed family not completed


19/23

Sexual Function rehabilitation

1] oral medication: phosphodiesteraseinhibitors

2] Vacuum erection devices 3] intra cavernous injections : eg

papaverine

4] Penile prosthesis


20/23

Rehabilitation for functionalinfertility

1] Penile Vibratory Stimulation:

2] Electro ejaculation


21/23

Penile Vibratory stimulation

If injury below T10- L2 this method isuseful

Electrodes over frenulum of glans- collectejaculate- artificial insemination


22/23

Electro Ejaculation

Electrodes in rectum to stimulate hypogastric plexuscauses ejaculation.

Indication: if PVS fails

If lesion above T6 Retrograde ejaculation occurs later ejaculate is

collected by catheterisation artificial insemination.

Adv effects: causes severe rise in BP, Arrythmia,

flushing. To prevent this: ca channel blockers 2 days prior to theprocedure, or oral nifedipine 30min before theprocedure.


23/23

Sai Ram

bladder dysfn

Documents