Neurogenic bladder: symptoms and diagnosis

Symptoms of a neurogenic bladder

Symptoms of the neurogenic bladder are mainly characteristic of accumulation: urgent (imperative) and frequent urination during the day and night, as well as urge incontinence. These symptoms are characteristic of neurogenic detrusor hyperactivity.

Symptoms of emptying the bladder include urinating with a thin sluggish stream, the need for abdominal pressure during urination, intermittent urination, a feeling of incomplete emptying of the bladder. They occur when the detrusor contractile activity decreases and there is no adequate relaxation of the transverse striatal urethral sphincter.

Often there is a combination of symptoms of accumulation and emptying of the bladder. This clinical picture is typical for detrusor-sphincter dissynergy.

It is also necessary to pay attention to such symptoms of the neurogenic bladder as pain, hematuria, fever and chills. They occur in acute and chronic pyelonephritis, ureterohydronephrosis, inflammation of the prostate, organs of the scrotum and urethra, which often accompany the neurogenic dysfunction of the lower urinary tract.

Diagnosis of a neurogenic bladder

It is important to remember that the late diagnosis of a neurogenic bladder is dangerous because of irreversible changes in the anatomical and functional state of the bladder and upper urinary tract, therefore, diagnosis and subsequent treatment of neurogenic disorders of the function of the lower urinary tract should be started as early as possible.

The survey begins with a survey and anamnesis, find out the patient's complaints. Often, neurological patients due to speech or cognitive impairment can not sufficiently clearly tell about their complaints and the history of the disease. Therefore, it is absolutely necessary, in addition to studying medical records, to ask the relatives of the patient in detail.

The obtained results, along with the data of previous neurological examinations, are extremely important, since only a neurologist can qualitatively establish a neurological disease, carry out topical diagnostics. Determine the prevalence of damage to the nervous system and make a prediction. In addition, assess the patient's mental state and intelligence, memory, attention, attitude to one's own situation, the ability to navigate in space and time, and so on.

To determine the safety of sensitive innervation, the skin sensitivity in the perineal region, the perianal region, the posterior surface of the thighs in the zone of the dermatome S2 and in the gluteal region in the zones S3 and S4 is studied. The decrease or complete loss of skin sensitivity testifies to generalized peripheral neuropathy (due to diabetes mellitus, alcohol intoxication, toxic effects), damage to the spinal cord or nerve roots.

The study of tendon reflexes allows us to obtain useful information on segmental and supra-segmental functions of the spinal cord. Increased activity of the deep tendon reflex (Babinsky reflex) indicates damage to the nerve pathways from the brain to the anterior horns of the spinal cord above the level of S1-S2 (upper motoneuron) and is usually combined with neurogenic detrusor hyperactivity. Decreased activity of this reflex indicates damage to the nerve pathways from the anterior horns of the spinal cord at the level of S1-S2 to the peripheral organs (lower motoneuron).

The definition of anal and bulbocavernous (or clitoral) reflexes helps to assess the safety of the sacral region of the spinal cord. When these reflexes are reproduced, irritation along the afferent fibers of the pudendal and / or pelvic nerve enters the sacral region of the spinal cord and returns through the efferent fibers of the sexual nerve.

The anal reflex is determined by an easy touch to the skin-mucous transition of the anus, which normally causes the reflex, visible to the eye. Reduction of the anal sphincter. The absence of a contraction usually indicates a lesion of the sacral nerve (except for the elderly, whose absence does not always serve as a pathological sign).

A bulbokavernozny (or clitoral) reflex is determined by fixing the contraction of the anal sphincter and pelvic floor mouse in response to clenching the clitoris or glans penis. The absence of bulbocavernous reflex is regarded as a consequence of damage to the sacral nerves or S2-S4 segments of the spinal cord. However, it should be borne in mind that approximately 20% of people in a normal bulbocavernous reflex may be absent.

It is important to assess the tone of the anal sphincter and its ability to arbitrarily reduce. The presence of a tone in the absence of an arbitrary reduction in the anus indicates a suprasacral lesion of the neural pathways, in which neurogenic hypertensive hypertension can be suspected.

Often a neurological examination involves the determination of evoked potentials from the posterior tibial nerve to establish the patency of nerve fibers.

Urological examination begins with an assessment of the symptoms characteristic of lower urinary tract diseases. Analyze the time of their appearance and dynamics, which is important in determining the causes of violation of the act of urination.

Symptoms of the neurogenic bladder can occur immediately after the onset of a neurologic disease (stroke and others) or damage to the nervous system (spinal cord injury) and in the distant period. It is noteworthy that in about 12% of patients with multiple sclerosis the first symptom of the disease is a violation of the act of urination.

To assess the symptoms of lower urinary tract diseases, use the diary of urination and the international questionnaire on the IPSS scoring system. Keeping a diary of urination involves recording the number of urination and episodes of urgent urges, the volume of each urination and episodes of urge incontinence for at least 72 hours. The diary of urination is important in assessing the complaints of patients with impaired bladder accumulation.

Initially, the IPSS questionnaire was proposed for the evaluation of violations of the act of urination in prostate diseases, but now it is successfully used to assess the symptoms of lower urinary tract diseases caused by other diseases, including neurological ones. The IPSS questionnaire includes 7 questions regarding the symptoms of impairment of accumulation and emptying of the bladder.

Symptoms characteristic of lower urinary tract diseases can be a consequence not only of neurological diseases and disorders, but also of different urological nosologies, therefore it is important to perform a full urological examination, especially for men.

Laboratory diagnosis of a neurogenic bladder includes biochemical and clinical blood analysis, urine sediment analysis, bacteriological urine analysis. Results of a biochemical blood test can reveal an increase in the level of creatinine and urea due to a violation of the nitrogen excretory function of the kidneys. Often the cause of this is vesicoureteral reflux and ureterohydronephrosis in neurological patients with impaired bladder emptying function. When studying the urine sediment, the main attention is paid to the presence of bacteria and the number of leukocytes. Bacteriological analysis of urine allows to determine the type of microorganisms and their sensitivity to antibiotics.

Ultrasonic scanning of kidneys, bladder, prostate in men and determination of residual urine is a mandatory method of examination of all patients with neurogenic dysfunction of the lower urinary tract. Pay attention to the anatomical state of the upper urinary tract (a decrease in the size of the kidneys, thinning of the parenchyma, expansion of the bowl-and-pelvic system and ureters), determine the volume of the bladder and residual urine. When detecting neurological patients with prostate adenoma, it is important to determine the dominant cause of symptoms of impaired bladder emptying.

X-ray diagnosis of a neurogenic bladder in the form of excretory urography and retrograde urethrocystography is used according to indications. More often, retrograde urethrocystography is used to exclude urethral stricture.

The main modern method for diagnosing neurogenic dysfunction of the lower urinary tract is the UDI. Researchers believe that treatment of this category of patients is possible only after determining by the urodynamic examination the form of the violation of the function of the lower urinary tract. 48 hours before UDI, it is necessary to cancel (if possible.) Medications that can affect the function of the lower urinary tract. All patients with damage to the cervical and thoracic spine should monitor blood pressure during the study, because they have increased risk of autonomic dysreflexia (sympathetic reflex) in response to filling the bladder in the form of headaches, increased blood pressure, redness of the face and sweating .

UFM is a non-invasive urodynamic method for determining urine flow parameters. UFM, along with ultrasound determination of residual urine volume, serve as the basic instrumental methods for assessing the impairment of the function of the lower urinary tract. To correctly determine the parameters of the flow of urine and the volume of residual urine, it is recommended to repeat them repeatedly at different times of the day and always before performing invasive methods of investigation. To disrupt the function of emptying the bladder, a decrease in the maximum and average flow rate of urine, interruption of the flow of urine, an increase in the time of urination and the time of the flow of urine are characteristic.

Cystometry - registration of the relationship between the volume of the bladder and the pressure in it during filling and emptying. Usually cystometry is performed with a simultaneous EMG of the pelvic floor muscles. The detrusor's ability to stretch in response to the flow of fluid into the bladder and to maintain the pressure in it at a sufficiently low level (not more than 15 cm of water), which does not cause detrusor reduction, is called the detrusor adaptive capacity. Violation of this ability occurs with suprasacral lesions and leads to phase or terminal detrusor hyperactivity (increased pressure more than 5 cm of water).

With filling cystometry, the sensitivity of the bladder is determined in response to the introduction of fluid. Normally, the patient, in response to the filling of the bladder, notes the increased urge to act of urination until a pronounced and irresistible urge, but involuntary cuts of detrusor are absent. For the increased sensitivity of the bladder, the first sensation of filling appears, as well as the first and strong urge for the act of urination on the reduced volume of the fluid injected into the bladder. With a decreased sensitivity of the bladder, there is a weakening of the urge to act as an urination when the bladder becomes full until completely absent.

The most important parameter of filling cystometry is detrusor pressure at the point of leakage. This is the lowest value of detrusor pressure, at which there is a leakage of urine through the urethra in the absence of abdominal tension or detrusor contraction. When the value of detrusor pressure in the point of leakage is more than 40 cm of water. There is a high risk of vesicoureteral reflux and damage to the upper urinary tract.

The absence of an increase in the electromyographic activity of the pelvic floor muscles during filling cystometry, especially at high volumes of injected fluid, as well as with an increase in abdominal pressure, indicates the absence of contractile activity of the transverse striatal urethral sphincter.

The "pressure / flow" study consists of simultaneous recording of intravesical and abdominal pressures (with automatic calculation of their difference in detrusor pressure), as well as parameters of the urine flow. Neurological patients always simultaneously record the electromyographic activity of the transverse striatal sphincter of the urethra. The "pressure-flow" study allows estimating the coordination between detrusor contraction and relaxation of the urethral striated sphincter and the pelvic floor muscles during the act of urination. According to the results of the "pressure-flow" study, the function of the detrusor and the transverse striatal sphincter of the urethra is determined. Normally, with an arbitrary detrusor reduction, the striated sphincter of the urethra and the pelvic floor muscles relax, followed by emptying the bladder without residual urine. To reduce detrusor activity is characterized by a decrease in detrusor of reduced force or length during the emptying of the bladder. The lack of detrusor activity is manifested in the non-closure of detrusor when trying to empty the bladder. Violation of the function of the transverse striatal sphincter of the urethra consists in the absence of adequate relaxation of the latter during the act of urination (electromyographic activity is recorded). Only during the "pressure / flow" study can such an urodynamic state be recognized as an external detrusor-sphincter dissynergy, i.e. Involuntary contraction of the transverse striated sphincter of the urethra and pelvic floor muscles during detrusor reduction. External detrusor-sphincter dissynergy manifests itself by increased electromyographic activity during the emptying of the bladder.

Video-dynamic study allows you to record the above-mentioned parameters of filling phases (cystometry) and emptying ("pressure-flow" and EMG of the transverse striatal urethra and pelvic floor muscles) of the bladder with simultaneous radiologic imaging of the VMP and lower urinary tract. During the video-dynamic study, in contrast to the standard UDI, it is possible to detect a violation of relaxation of the smooth muscle structures of the neck of the bladder (internal detrusor-sphincter dissynergy) and vesicoureteral reflux.

According to the testimony of UDI, special tests are performed: a test with cold water. The test with cold water consists in measuring detrusor pressure when the cooled distilled water is rapidly introduced into the bladder. In patients with damage to the upper motoneuron in response to the rapid introduction of a cooled fluid, there is a sharp reduction in detrusor, often accompanied by urgent urinary incontinence.

A positive test result indicates a lesion of the lower segments of the spinal cord or bladder nerves.

Thus, urodynamic methods of investigation allow to reveal all existing forms of neurogenic dysfunction of the lower urinary tract. Cystometry filling allows you to assess the phase of accumulation of the bladder and determine the decrease or increase in the sensitivity of the bladder, a decrease in the adaptive ability of the detrusor, an increase in the volume of the bladder, detrusor hyperactivity and sphincter complicity.

"Pressure-flow" with simultaneous EMG of the pelvic floor muscles helps to evaluate the phase of bladder outflow and to detect a decrease or absence of detrusor contractile activity, external detrusor-sphincter dissynergy, violation of adequate relaxation of the transverse striatal sphincter of the urethra.

Video-dynamic study allows to diagnose internal detrusor-sphincter dissynergy and violation of adequate relaxation of the neck of the bladder.

[1], [2], [3], [4]