Neuro-urology deals with the diagnosis and treatment of urological conditions that result due to damage, disorders or diseases of a neurological nature, or when the normal functioning of the brain is affected.
Neurogenic Bladder is a dysfunctional lower urinary tract that occurs due to causes other than primary urinary tract pathology.
The act of passing urine is completely voluntary, except in infants and small children who have automatic and involuntary passing of urine. Urination is initiated when a person wants to pass urine, and can be controlled if the situation is not conducive.
This process of passing of urine should be free, without the need to strain, and should empty the bladder fully each time urination takes place. When the bladder keeps filling, the sphincters tighten and prevent the leakage of urine. When the bladder contracts to empty, the sphincters open to let urine out.
These work in an extremely coordinated manner. Any condition other than this – such as an involuntary leakage of urine or any difficulty experienced in urination – is abnormal, and needs evaluation.
The passing of urine, or the control of urination, is regulated by the central nervous system. Messages from the brain are sent through the spinal cord, and the lumbar and sacral nerves, to the bladder and the sphincters.
This control is lost if the spinal cord or its nerves are damaged, or the normal functioning of the brain itself is affected. The bladder may then lose sensation and fail to empty. Or it may overwork – the sphincter may or may not open appropriately.
Diseases such as Parkinson’s, Alzheimer’s, large cerebral haemorrhage, dementia, spinal cord injury / tumours / transverse myelitis, diabetes mellitus or injury to the nerves by surgery, etc., may all cause a neurogenic bladder.
Diagnosis & Tests
Patients with a neurogenic bladder present one or more of the following signs and symptoms:
- Retention of Urine
- Inability to Control Urination (Frequency and Urgency)
- Urinary Incontinence
- Loss of Bladder Sensation
- Disturbance of Bowel Control: is also very common
- oma, Paralysis: The above symptoms are in addition to the general symptoms of neurological injury such as coma / paralysis, etc.
While the physical disabilities may seem very frightening, they are usually not life-threatening. But bladder dysfunction, while not very overt, is usually the cause of severe morbidity, renal failure and even death. It is often neglected due to a lack of awareness of its ill-effects.
The clinical diagnosis of a neurogenic bladder is made on the basis of certain simple and preliminary tests such as:
- Urine Analysis
- Ultrasound Evaluation
- Tests that Document the Degree of Change in the Urinary Tract
- Urodynamic Study: This is similar to the ECG study of the heart function. This is performed by passing various small catheters of different sizes into the urinary passage and the rectum. This test also measures the activities of the sphincters. All of these are studies performed on a computer.
The focus in managing a neurogenic bladder is to prevent renal damage. Renal damage occurs due to intolerably increased pressures in the bladder, causing a back-pressure effect on the kidneys, resulting in their slow damage without symptoms in the early stages. The kidneys also develop urinary tract infection, stones, etc.
All treatment is therefore aimed at reducing these bladder pressures. A normal urination may or may not be achieved, but this is not important. If this happens in the process of treatment, it is a bonus. Treatments for neurogenic bladder are:
- Clean Intermittent Self-Catheterisation (CISC) for Men and Women: is the simplest of treatments that teaches patients to pass a catheter themselves, every 4-6 hours, depending upon the urine volumes, to keep the bladder empty and also to prevent incontinence.
- Pacemaker: A new form of treatment, which involves the placement of a pacemaker at the level of the spinal cord, is now being tried out in India. Selected patients do extremely well with this form of treatment.
- Medical Treatment: Medicines are also used to reduce the pressures in the bladder. Usually, the tablets will have to be taken for a lifetime, until alternative therapies can be instituted.
- Bowel Management: Management of neurogenic bladder must also include bowel management as an integral part of the treatment. This may include change in the dietary fibre, enemas, digital evacuation of stools, etc.
Surgery: is performed either to reduce the pressures in a bladder by adding other body tissues resulting in an increase in capacity, or by inserting an artificial sphincter to prevent a constant leak of urine. Surgery is resorted to only if all other measures have failed