Neurogenic bladder

Description:

Neurogenic dysfunction of a bladder cannot be considered as an independent disease in the standard sense of this word. It is the collective syndrome combining the states arising in connection with the inborn or acquired defeats at various levels of the nerve pathways and the centers innervating a bladder and providing function of any urination. All forms of neurogenic dysfunctions are combined by the fact of dissociation of a bladder as working system with the cortical centers providing any character of an urination at the person.

Classification of neurogenic dysfunctions of a bladder

  1. Not slowed down cortical bladder.
  2. Reflex spinal bladder.
  3. Not adapted bladder:
        1.spinalny;
        2.ganglionarny.
  4. Areflektorny bladder:
        1.spinalny;
        2.ganglionarny;
        3.intramuralny primary (megalotsist);
        4.intramuralny secondary (mioneyrogenny atony).
  5. Mixed (арефлекторно - not adapted)))))))))))) a bladder.
  6. The wrinkled bladder.

Symptoms of the Neurogenic bladder:

Typical manifestation of disturbances of an urination at localization of demyelinating defeats above the center of the urination located in the bridge of a brain is the detruzor hyperreflexia. The speeded-up urination through short periods, an imperative incontience of urine, a strangury are typical symptoms of a hyperreflexia of a detruzor. Arising in any span and often in the inconvenient place, the specified symptoms bring considerable concern to patients. The origins of these symptoms consist in decrease or loss of any control over the act of an urination and decrease in adaptation ability of a detruzor. At the same time the reflex arc including the center located in sacral area and the center of an urination in the field of the bridge of a brain remains untouched. In other words, at a detruzor hyperreflexia, despite saving the independent act of an urination, accumulation of enough urine in a bladder becomes impossible.

At defeat of suprasacral area patients can lack for supraspinal suppression of autonomous reductions of a bladder that is followed by a detruzor hyperreflexia up to an imperative incontience of urine, as well as in case of cerebral disturbances. At the same time spinal damages have also the characteristics in the form of defeat of the reticulospinal ways going from the bridge of a brain and participating in synergy integration of activity of an urethral sphincter and detruzor. In addition to involuntary reductions of a detruzor, reduction of a cross-striped sphincter of an urethra is at the same time noted that causes a delay of an urination and is followed by increase in intravesical pressure. The specified fortune was come into by the name of a detruzorno-sphincteric dyssynergia.

Clinical manifestations of suprasacral damage of a spinal cord develop from irritativny (the speeded-up, imperative urination, sometimes to an imperative incontience of urine, in a combination to a strangury) and obstructive (interruption of a stream of urine is frequent to a full delay of an urination that can be followed by pain in lower parts of a stomach and a crotch) symptoms. Incomplete bladder emptying with the advent of a residual urine is characteristic of a detruzorno-sphincteric dyssynergia that raises a possibility of development of inflammatory complications of a bladder and upper uric ways, and also an urolithiasis. To all other, at this level of defeat incomplete relaxation of a cross-striped sphincter and its paralysis can be noted that is shown by a severe form of an incontience of urine (a sphincteric incontience).

Defeat of sacral area causes loss of reflex reduction of a detruzor (a detruzorny areflexia) and loss of sokratitelny ability of a cross-striped sphincter of an urethra. In this situation patients show complaints to lack of desires to the act of an urination. In the absence of normal bladder emptying further at patients the urine incontience owing to overflow of a bladder develops. Other option of disturbance of an urination at sacral damages is decrease in sokratitelny ability of a detruzor that causes disturbance of bladder emptying and is shown by the complicated urination a sluggish stream with feeling of incomplete bladder emptying. All listed above symptoms from the lower uric ways can lead to various disturbances of upper uric ways - to a vesicoureteral reflux, expansion of ureters and a pelvis, pyelonephritis and a chronic renal failure.

In view of the fact that bladder denervation, at whatever level it occurred, leads to sharply expressed trophic disturbances, disease often is complicated by the intersticial cystitis causing a sklerozirovaniye and wrinkling of a bladder (microcysts). This heavy complication aggravates danger to kidneys and in some cases demands special surgical interventions for increase in capacity of a bladder.

Reasons of the Neurogenic bladder:

In an etiology of neurogenic dysfunctions of a bladder the level and prevalence of defeat of a nervous system have major importance. So, the injury, tumors, inflammatory and degenerative diseases causing cross dissociation of a spinal cord in the field of lumbosacral segments or above will bring to essentially identical, though having specific shades, to disturbances of an urination.

The reasons which are directly reproducing denervation can be combined in several groups:

    * Inflammatory and degenerative diseases and tumors of a head and spinal cord and their covers, the extra spinal and intramural centers of a bladder and conduction paths (private forms - the encephalitis, diabetic and postvaccinal neuritis, cholesteatomas, tuberkuloma demyelinating diseases etc.).
    * Traumatic damages of the same educations to the most extended sense (strokes, gaps, prelums, destructions, including an injury of paravesical nervous educations at difficult delivery or surgical interventions on bodies of a basin).
    * Inborn defects of terminal department of a backbone and spinal cord.
    * Defeat of an intramural nervous system of a bladder at obstructive uropathies and an inborn underdevelopment vesical ганглиев (megalotsist).

Treatment of the Neurogenic bladder:

Treatment of neurogenic dysfunctions of a bladder continues to remain difficult and in many respects still an unresolved task. The disease affects the most difficult mechanisms of relationship of detruzorno-sphincteric systems, breaks all three functions of a bubble - accumulation, deduction and exile of urine.

Until recently even the task to give the scheme of treatment based on the pathogenetic principles and approaches was not set. It has the expressed symptomatic focus also now.

It is possible to allocate three main directions of a symptomatic treatment: medicamentous, electrostimulation and palliative and symptomatic operations. However a main type of treatment of urological disturbances at patients with neurogenic dysfunctions of a bladder is use of pharmacological means. It depends on disturbances of urodynamic of the lower uric ways leading to difficulties in accumulation of urine in a bladder or bladder emptying.

For treatment of neurogenic dysfunctions of a bladder carry to medicamentous drugs:

    * anticholinergic drugs - block muskarinovy holinoretseptor in a bladder at the expense of what reduction of contractility of a detruzor in the conditions of its hyperreflexia is reached;
    * myotropic spasmolytic relaxants;
    * and - adrenoblockers - reduce a tone of an internal sphincter;
    * beta adrenoblockers - raise a tone of a detruzor and intravesical pressure, promoting thereby urine exile;
    * and-adrenostimulyatory - raise a tone of sphincters and urethral resistance, promoting thereby urine deduction;
    * antagonists of calcium ions;
    * E2 and F2a prostaglandins;
    * intravesical administration of the drugs possessing neurotoxic influence.

Recently note positive effect at use of low-intensive laser radiation (helium - the neon laser).

However, neither drug treatment and stimulation, nor symptomatic operations yield satisfactory resistant results. Therefore in the last 20 years persistent attempts of development of the methods of treatment based on the pathogenetic principles of recovery of an innervation of a bladder are made. A variety of forms of neurogenic dysfunctions does not allow to resolve successfully all issues of pathogenetic therapy by means of one method. All complex of pathogenetic therapy needs to be applied as soon as possible before there come secondary complications in other bodies and systems, and also a degeneration of local neuromuscular structures.