Neurogenic bladder Ri 曾志龍

Preface Neurogenic voiding dysfunction (neurogenic bladder), neuropathic bladder/neuropathic urethra

Innervation Autonomic: Somatic: Para.(S2~4)-pelvic n.-bladder(detrusor contracture) Sym.(T11~L2)-paravertebral chain-hypogastric n.-bladder/urethra(detrusor relaxation) Somatic: cortex-(S2~4)-pudendal n.-external sphincter

Physiology 排尿：pelvic floor musculacture, external sphincter relax urethralDetrusor contractureTrigone(防止VUR)bladder pressure neck open 解畢：Detrusor relax, bladder neck close, external sphincter tone 排尿途中：external sphincter contracturedetrusor relax

Cause intracranial lesion：腦血管病變、巴金森氏症、老年痴呆症以及大腦退化等 spinal cord lesions：外傷性脊髓損傷(spinal cord injury)，多發性硬化症(multiple sclerosis)以及脊髓束緊症(tethered cord)等等 peripheral neuropathy：cauda equina syndrome以及骨盆手術術後造成之骨盆神經叢受傷 metabolic disease：最常見的是糖尿病所引發之周邊神經病變

Suprasacral cord lesion：detrusor hyperreflexia, detrusor-external sphincter dyssynergia (DESD) Supra-T6：autonomic dysreflexia (膀胱漲尿時，病人交感神經張力會有異常增加的現象，導致血壓上升、心跳加快、患部以上潮紅及冒汗頭痛 )

各種上神經元病變及下神經元病變之逼尿肌反射情形 逼尿肌反射亢進或正常 反射低下或無反射 上神經元病變 腦血管病變 44 20(45%) 24(55%) 巴金森氏症 40 28(70%) 12(30%) 顱內病變 20 14(70%) 6(30%) 多發性硬化症 12 8(67%) 4(33%) 頸椎或胸椎傷害 32 21(66%) 11(34%) 148 91(61%) 57(39%) 下神經元病變 薦椎傷害 8(18%) 36(82%) 腦膜脊髓膨出症及脊椎裂 34 6(18%) 28(82%) 骨盆腔內手術 132 4(3%) 128(97%) 糖尿病神經病變 24 0(－) 24(100%) 234 18(7.6%) 216(92.4%)

Krane & Siroky classification 逼尿肌反射亢進 Coordinated sphincter (括約肌協調) Non-relaxed striated sphincter (橫紋括約肌無放鬆性) Denervated striated sphincter (橫紋括約肌去神經化) Non-relaxing smooth muscle sphincter (BN) (平滑括約 肌無放鬆性) 逼尿肌無反射 Striated sphincter dyssynergia (橫紋括約肌共濟失調) Smooth muscle sphincter (BN) dyssynergia (平滑括約 肌共濟失調)

Stroke Initially urinary retentiondetrusor hyperreflexia and inadequate contractility (DHIC)incontinence, dysuria Frontal, parietal lobe, internal capsuleexternal sphincter dysfunctiondysuria

Stroke Cerebral hemorrhage-85% detrusor areflexia / Cerebral infarction-10%detrusor hyperreflexia, may combine with obstruction (pseudo-dyssynergia, BPH)

Other intracranial diseases 巴金森氏症：detrusor hyperreflexia, pseudo-synnergia, DHIC 小腦病變（cerebellar ataxia)： hyperreflexia, DESD Cerebral palsy：normal or hyperreflexia Senile dementia：hyperreflexia, DHIC, areflexia d/d with BPH

Others Multiple sclerosis DM 好發30~50 y/o female (80~96%) 60~70% detrusor hyperreflexia 20~40% DESD 15~40% hypocontractility DM 55~60% detrusor hyperreflexia 35% detrusor hyporeflexia, areflexia Sym. tone ?bladder neck tone d/d with hypocontractility

Diagnosis Hx, PE, NE X-rays of skull and spine KUB EEG CMG

Management Step by step 初期foley 3~7 days (膀胱攣縮,感染) 穩定後CIC or CISC (<500ml, adequate I/O) Clean intermittent (self) catheterization 尿路動力學檢查評估(when?,cons. clear, LE motor function recover, or clamp foley to test) Trocar cystostomy

Medication Increase contractibility：cholinergic，例如bethanechol chloride，可選擇性地使膀胱及腸道肌肉收縮。α adrenergic antagonist。 Decrease outlet resistence：phenoxybenzamine、prazosin、terazosin、alfuzosin等對平滑括約肌有效。Valium、baclofen、dantrolene sodium等對橫紋括約肌之放鬆有幫助。Botulinum A toxin直接注射也可麻痺括約肌。 Decrease contractibility：anticholinergic，例如Propantheline bromide、oxybutynin chloride、dicyclomine等。其他如 imipramine、verapamil等也有臨床上的價值。 Increase outlet resistence：促進交感神經的藥物，例如ephedrine等，但效果並不很確定。 retention > incontinence

症 狀 用 藥 增強逼尿肌活性 bethanechol 降低逼尿肌反射亢進(膀胱內 灌注) oxybutynin tolterodine imipramine flavoxate dicyclomine 降低出口阻力 alpha-adrenergic blocker skeletal muscle relaxant nitric oxide donors 增強出口阻力 methylephedrine

Surgery 抗逆流手術 膀胱擴大手術 (Bladder augmentation) 加強膀胱頸或括約肌手術 Increase submucosa ureter length 膀胱擴大手術 (Bladder augmentation) 膀胱容積小、壓力高、compliance 差、leak point pressure高、括約肌不協調，目前最常用 加強膀胱頸或括約肌手術 Reconstruction, sling Urethral stent

Conclusion d/d the mechanism Most are reversible! Regular follow up bladder function (cystometrography) Treat underlying disease (MM, PD, infection)

Reference Burney TL, Senapati M, Desai S, Choudhary ST, Badlani GH: Acute cerebrovascular accident and lower urinary tract dysfunction: A prospective correlation of the site of brain injury with urodynamic finding. J Urol 1996; 156: 1748-1750. Kuo HC: Effect of botulinum a toxin in the treatment of voiding dysfunction due to detrusor underactivity. Urology 2003; 61:550-554 Blaivas JG: The neurophysiology of micturition: A clinical study of 550 patients. J Urol 1982; 127:958-963. Hald T, Bradley WE: Neuropathology. In: The Urinary Bladder: Neurology and Dynamics. Baltimore: Williams & Wilkins, 1982, pp 48-57 C J Fowler, KJ malley: Investigation and management of neurogenic bladder dysfunction. Journal of Neurology Neurosurgery and Psychiatry 2003;74

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