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Neurogenic bladder in children
Last reviewed: 18.10.2021
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Neurogenic bladder (NDMP, neurogenic dysfunction of the bladder, detrusor-sphincter dissynergy) - a variety of violations of reservoir and evacuation functions of the bladder, as a result of a violation of the regulation of urination at various levels (cortical, spinal peripheral).
The mechanism of accumulation and emptying of the bladder
The activity of the bladder and sphincters of the urethra is strictly cyclic, which can be divided into two phases: accumulation and evacuation, which together constitute a single "mixing cycle".
Accumulation phase
The reservoir function of the bladder is provided by a clear mechanism of interaction between the detrusor and the sphincter of the urethra. Low intravesical pressure, with a constant increase in the volume of urine, is due to the elasticity and the detrusor's ability to stretch. During the accumulation of urine detrusor is in a passive state. The sphincter apparatus reliably blocks the exit from the bladder, creating a urethral resistance many times higher than the intravesical pressure. Urine can continue to accumulate even when the elastic reserves of the detrusor are exhausted and intravesical pressure rises. However, high urethral resistance allows you to keep urine in the bladder. Urethral resistance by 55% is provided by tension of the transverse striated muscles of the pelvic diaphragm and by 45% by the work of the internal sphincter of smooth muscle fibers controlled by the autonomic nervous system (sympathetic - 31% and parasympathetic - 14%). In the interaction of a-adrenergic receptors, mainly located in the neck of the bladder and the initial section of the urethra, the smooth muscle of the internal sphincter of the urethra is contracted with the noradrenaline mediator. Under the influence of beta-adrenergic receptors located along the entire surface of the detrusor, the muscles that expel the urine (i.e., detrusor) relax, thereby ensuring the maintenance of low intravesical pressure in the urine accumulation phase.
Thus, the mediator of the sympathetic nervous system, norepinephrine, when interacting with a-receptors reduces the smooth musculature of the sphincter, and detrusor relaxes with beta receptors.
[6], [7], [8], [9], [10], [11], [12], [13], [14], [15]
Emptying phase
Strong reduction of the detrusor is accompanied by relaxation of the external sphincter with emptying the bladder under relatively low pressure. In the neonatal period and in children of the first months of life, urination is involuntary, with the closure of arches of reflexes at the level of the spinal and midbrain. In this period, detrusor and sphincter functions are usually well balanced. As the child grows during the formation of the regime of urination, three factors are important: an increase in the capacity of the bladder by the frequency of urination; acquisition of control over the sphincter; the appearance of inhibition of the urinary reflex, which is carried out by inhibitory cortical and subcortical centers. Since 1.5 years, most children have the ability to feel the filling of the bladder. Cortical control of subcortical centers is established by the 3rd year.
Neurogenic bladder dysfunction may be the cause of the occurrence, progression and chronicization of diseases of the urinary system such as vesicoureteral reflux (PMR), pyelonephritis, cystitis.
[16], [17], [18], [19], [20], [21], [22], [23]
Pathogenesis of the neurogenic bladder
The pathogenesis of the neurogenic bladder is complex and not fully understood. Leading role belongs to hypothalamic-pituitary insufficiency, delay in the maturation of the centers of the system of regulation of the act of urination, dysfunction of the autonomic nervous system (segmental and supra-segmental levels), receptor sensitivity and detergent bioenergetics. In addition, there is a certain adverse effect of estrogen on urodynamics of the urinary tract. In particular, hyperreflexia in girls with an unstable bladder is accompanied by an increase in estrogen saturation, which causes an increase in the sensitivity of M-holinoretseptorov to acetylcholine. This explains the predominance of girls among patients with micturition disorders of a functional nature.
Symptoms of a neurogenic bladder
All the symptoms of a neurogenic bladder are conventionally divided into three groups:
- manifestations of bladder diseases of exclusively neurogenic etiology;
- symptoms of complication of the neurogenic bladder (cystitis, pyelonephritis, vesicoureteral reflux, megaureter, hydronephrosis);
- clinical manifestations of neurogenic involvement of pelvic organs (colon, anal sphincter).
Diagnosis of a neurogenic bladder
The state of the bladder is estimated by the number of spontaneous urination per day for normal drinking and temperature regimens. Deviations from the physiological rhythm of spontaneous urination are the most common symptoms of a neurogenic bladder.
To determine the type of neurogenic bladder, it is necessary to study the rhythm and volume of urination and conduct a functional study of the bladder.
Diagnosis of a neurogenic bladder
What do need to examine?
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Treatment of a neurogenic bladder
Treatment of a neurogenic bladder is a complex task that requires joint efforts of nephrologists, urologists and neuropathologists with a complex of differentiated corrective measures. For patients with a neurogenic bladder, a protective regime is recommended with the elimination of psychotraumatic situations, with a full sleep, the abandonment of emotional games before a night's sleep, and walking in the fresh air.