Generality
The neurological bladder is a dysfunction of the urinary bladder, which occurs due to a pathology of the central nervous system or peripheral nerves involved in the control of urination.
Existing in two forms - the flaccid form and the spastic form - the neurological bladder can cause problems such as urinary retention or urinary incontinence; moreover, if due to very serious causes or if not subjected to the right treatments, it can be harmful to the kidneys and give rise to complications, such as: kidney stones and hydronephrosis with vesico-ureteral reflux.
To diagnose the neurological bladder and identify its precise triggering cause, the following are fundamental: physical examination, medical history, neurological evaluation, urological studies, urodynamic studies and radiographic examinations.
The neurological bladder requires causal therapy, where possible, and symptomatic therapy.
Brief anatomical reference of the Bladder
Also known as urinary bladder, the bladder is a hollow, muscle-membranous and unequal organ, which serves to collect urine produced in the kidneys and ready for expulsion via the mechanism of urination .
The bladder is located in the anterior region of the pelvis, resting on the pelvic floor, behind the abdominal wall and the pubic symphysis, in front of the rectum and above the prostate in man, in front of the uterus and vagina in the woman.
What is the Neurological Bladder?
The neurological bladder, or neurogenic bladder, is a dysfunction of the urinary bladder resulting from a disease of the central nervous system or peripheral nerves involved in the control of urination.
The main consequences
Depending on what triggers it, the neurological bladder can affect the ability to empty the bladder (giving rise to urinary retention ) or alter the mechanisms that serve to keep urine inside the bladder (triggering urinary incontinence ).
Causes
The urinary bladder is connected to the central nervous system by means of sensory peripheral nerves (afferent peripheral nerves) and motor peripheral nerves (efferent peripheral nerves). The sensory peripheral nerves have the task of informing the central nervous system about the filling level of the bladder; the peripheral motor nerves, on the other hand, have the function of transmitting the impulses needed to empty the latter from the central nervous system to the bladder.
Among the causes of the neurological bladder, there are all those conditions that alter, in some way, the afferent control (ie the control of the filling level) or efferent (ie the control of the emptying) of the bladder.
These conditions include:
- Spinal cord diseases ;
- Spinal injuries ;
- Neural tube defects ;
- Some brain tumors ;
- The state of pregnancy ;
- Peripheral neuropathy .
Other causes of neurological bladder:
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Spinal Cord Diseases
The spinal cord is, together with the brain, one of the two main nervous structures, which constitute the so-called central nervous system (CNS).
Located within the spinal canal (the empty space of the vertebral column resulting from the vertical arrangement of the vertebrae), the spinal cord extends from the occipital hole to the second lumbar vertebra, has two distinct areas of neurons called white matter and gray matter, and gives rise to 31 pairs of peripheral nerves called spinal nerves .
Among the various diseases of the spinal cord that can cause neurological bladder, syringomyelia deserves special mention.
Syringomyelia is a pathological condition characterized by the formation, inside the spinal canal, of cysts filled with liquid, which - especially when they are large in size - are responsible for more or less deep damage to the spinal cord.
Syringomyelia recognizes various causes, including: a congenital malformation of the cerebellum known as Arnold-Chiari syndrome, spinal cord trauma, spinal cord tumors, some forms of meningitis, the so-called rigid spine syndrome and episodes of hematomyelia .
Syringomyelia is so called, because the liquid-filled cysts that characterize it are called syringes .
Spine Injuries
Supporting axis of the human body, the vertebral column (or rachis ) is the skeletal structure resulting from the stacking of the vertebrae .
In number 33-34, the vertebrae are irregular bones separated from each other by a discoidal element, called intervertebral disc .
The intervertebral discs are essentially circular containers composed of fibrocartilage, within which there is a gelatinous substance, called the pulpy nucleus, and the cartilaginous tissue that surrounds the aforementioned nucleus pulposus, ie the so-called fibrous ring .
The most common spine injury related to the neurological bladder is the herniated disc .
In medicine, the expression "herniated disc" indicates the exit from its natural seat of the nucleus pulposus, contained within the intervertebral disc.
The herniated disc is the result of an injury to an intervertebral disc, which may depend on:
- Aging;
- Spinal trauma;
- Violent torso rotations;
- Repeated lifting of excessive weights;
- The habit of maintaining a wrong posture;
- The presence of a back muscle too weak.
Curiosity: what are intervertebral discs used for?
In addition to providing for the conjunction of the adjacent vertebrae, the intervertebral discs have the task of absorbing, by means of the pulpy nucleus, the shocks and loads that weigh on the spine. In other words, with their particular content, the intervertebral discs act as shock-absorbing bearings.
Neural Tube Defects
The neural tube is the structure of the human embryo, from which originates the central nervous system present at birth.
The neural tube defect most associated with the presence of the neurological bladder is the so-called spina bifida .
Spina bifida is a congenital malformation of the spine, due to which the meninges and, sometimes, also the spinal cord come out of their natural seat (corresponds to the spinal canal).
Brain tumors
A brain tumor is the result of the abnormal proliferation of one of the cells constituting the brain proper (or telencephalon ).
Brain tumors affect the function of the brain area where the neoplasm is located; this explains why their symptoms vary from patient to patient, depending on the region of the brain affected.
A brain tumor is associated with the neurological bladder, when it occurs in a cerebral area delegated to afferent or efferent control of the bladder.
Today, it is known that control of the urinary bladder by the brain is due to: thalamus, prefrontal cortex, cerebral cortex (or insula ), anterior cingulate cortex and periaqueductal gray matter .
Pregnancy
Pregnancy can cause neurological bladder, when the uterus, increasing due to the growth of the fetus, pushes on those neighboring peripheral nerves responsible for afferent or efferent control of the urinary bladder.
Peripheral Neuropathy
Peripheral neuropathy is the morbid condition resulting from damage or malfunction of peripheral nerves.
Peripheral neuropathy recognizes numerous causes, including first and foremost: diabetes mellitus, alcoholism, vitamin B deficiency, chronic kidney disease and chronic liver disease .
The neurological bladder is one of the possible consequences of a peripheral neuropathy, when the latter affects the peripheral nerves responsible for afferent or efferent control of the urinary bladder.
Types
Experts in the field of urinary tract dysfunctions (bladder in particular) recognize the existence of two types of neurological bladder:
- The neurological bladder of the flaccid type.
In subjects with this form of neurological bladder, the volume of urine is high, the urinary flow pressure is very low and there is no bladder contraction.
- Spastic neurological bladder.
In patients with this form of neurological bladder, the volume of urine is normal or lower than normal and there are continuous bladder contractions.
The characteristics of the neurological bladder (ie the fact of being flaccid or spastic) vary in relation to which nervous structures responsible for bladder control have undergone functional alteration.
Symptoms and Complications
The symptoms of the neurological bladder vary from patient to patient, depending on whether the aforementioned urinary bladder dysfunction is flaccid, spastic or mixed.
Flaccid Neurological Bladder: Symptoms
The flaccid-type neurological bladder causes regurgitation incontinence, a condition characterized by:
- Filling beyond bladder size;
- Inability to completely empty the bladder (urinary retention);
- Post-voiding drip.
In male patients, the flaccid neurological bladder is often associated with erectile dysfunction.
Spastic Neurological Bladder: Symptoms
The neurological bladder is typically responsible for:
- Frequent urination;
- Nocturia (that is the repeated need to urinate during the night);
- Urgent need to urinate ( overactive bladder ), even when the bladder is not full;
- Urine leakage.
Complications
In severe cases or in the absence of adequate treatment, a condition such as neurological bladder can give rise to some complications; among the latter, we note in particular:
- The predisposition to the development of urinary tract infections ;
- Kidney stones ;
- Hydronephrosis with vesico-ureteral reflux.
As can be seen, therefore, the severe or untreated neurological bladder is responsible for damage to the kidneys .
In the specific case in which the neurological bladder depends on a spinal cord injury, patients may also experience a potentially lethal complication, known as autonomic dysreflexia (or autonomous dysreflexia ) and characterized by: malignant hypertension, bradycardia or tachycardia, headache, piloerection and excessive sweating.
Diagnosis
The complete diagnosis of a condition such as the neurological bladder is generally the result of: a thorough physical examination, a detailed medical history, a neurological evaluation, urological studies, urodynamic studies and radiological studies related to the urinary tract and not only.
By complete diagnosis we mean medical researches are not limited to the identification of the condition, but also to discover the triggers and characteristics of the present disorder.
Urological studies
Among the urological studies that a doctor can prescribe to an individual with a neurological bladder (or suspected), include cystoscopy, an ultrasound of the urinary tract and urine culture.
Urodynamic studies
The list of urodynamic studies useful for deciphering the characteristics of the neurological bladder includes:
- Cystometry;
- Post-voiding residual measurement;
- The uroflowmetry;
- The profilometry of urethral pressure.
Radiological studies
Among the radiological studies that a doctor could prescribe in the presence of a neurological bladder (or suspected), include: excretory urography, cystometrography and CT or magnetic resonance of the central nervous system (brain and spinal cord).
Radiological investigations relating to the central nervous system are fundamental when there is the suspicion that the neurological bladder depends on a disease of the spinal cord (eg: syringomyelia) or brain (eg, brain tumor).
In general, the aforementioned suspicion is the result of an objective examination, in which symptoms were found that could be associated with the conditions described above
Therapy
The neurological bladder requires causal therapy, where possible, and symptomatic therapy .
Causal therapy consists in eliminating the factor responsible for the aforementioned condition; symptomatic therapy, on the other hand, consists of relieving symptoms and preventing complications (or, at least, delaying their appearance).
Causal therapy: the details
The causal therapy varies according to what the doctor has identified as a trigger for the neurological bladder; causal therapy therefore varies from patient to patient.
Examples:
- If the neurological bladder depends on a peripheral neuropathy due to diabetes mellitus, the causal therapy will consist in all those treatments that allow to maintain normal blood sugar (therefore, physical activity, adequate diet and eventually drugs);
- If the neurological bladder is the result of a herniated disc, the causal therapy will include all those remedies useful to cancel the compression of the spinal nerves (peripheral nerves) operated by a pulpy nucleus coming out of its intervertebral disc;
- If the neurological bladder derives from a severe syringomyelia, the causal therapy will consist in a surgical intervention aimed at eliminating the anomalous cyst present in the spinal cord.
Unfortunately, some causes of neurological bladder - including, for example, spina bifida or amyotrophic lateral sclerosis - are incurable.
When the neurological bladder is due to the state of pregnancy, the causal therapy is essentially the delivery; in fact, with the escape of the newborn from the uterus, there is less compression of the peripheral nerves that compromise the afferent or efferent control of the urinary bladder.
Symptomatic Therapy: the details
To counteract the symptoms of neurological bladder and prevent complications, the therapist could resort to:
- Bladder catheterization .
It basically consists of inserting a catheter into the bladder, in order to empty the latter from the urine.
The catheter can be inserted into the bladder either through the urethra (urethral bladder catheter) or through a hole made in the abdomen (suprapubic bladder catheter).
Depending on the causes of the neurological bladder, the bladder catheter may be abiding (ie permanent) or intermittent (ie removed after each bladder emptying).
- A specific drug therapy .
Depending on the type of neurological bladder present, it may be necessary to use drugs for emptying the bladder or drugs for urinary incontinence.
- Surgery .
It represents the solution to more serious clinical cases, which do not benefit tangibly from any of the previous symptomatic treatments.
Surgery for neurological bladder includes various treatments, including: bladder sphincterotomy, urinary derivation, application of an artificial sphincter and enlargement cystoplasty.
OTHER USEFUL REMEDIES
Remaining in the field of symptomatic therapy, patients with a spastic neurological bladder could benefit from the so-called Kegel exercises (they are exercises to strengthen the pelvic floor muscles), while patients with a flabby neurological bladder could benefit greater consumption of liquids during the day.
Prognosis
The prognosis in the case of neurological bladder depends on at least two factors, which are:
- The severity of the trigger. If at the origin of the neurological bladder there is a difficult or impossible to cure cause, the prognosis could probably not be benevolent and the patient may need to undergo continuous symptomatic therapies or very invasive symptomatic treatments.
- Timeliness of diagnosis and therapy. The more the diagnosis and treatment are timely, the less risk there is that the neurological bladder will cause complications.
