Treatment of neurogenic bladder in women
Neurogenic bladder dysfunction unites a group of pathological conditions, which are based on lesions of various parts of the nervous system responsible for the innervation of the bladder and providing the function of voluntary urination. Moreover, the main importance in their occurrence is not the nature of the disease, but the level and extent of damage to the nerve fibers.
The pathology of urination due to dysfunction of the lower urinary tract is often encountered by doctors of various specialties (urologists, neurologists, therapists). It is known that such disorders are detected in 50-90% of patients with multiple sclerosis, in 40-70% of patients with Parkinson's disease and in 100% of cases with severe spinal injuries.
Any damage to the nervous system between the cortical region of the brain and the bladder can cause dysfunction of the latter. The causes of this condition are diverse, the main ones are:
- Inflammatory degenerative diseases of the brain, spinal cord with a lesion of the pathways (encephalitis, transverse myelitis, diabetic neuropathies, post-vaccination neuritis, demyelinating diseases, etc.).
- Tumor process that affects the nervous tissue.
- Traumatic effects (breaks, compression, destruction of various parts of the spinal cord, pathways, trauma to the vesicular plexuses during operations or difficult labor).
- Hemorrhage in the brain.
- Congenital defects of the spinal column.
- Obstructive uropathy.
The mechanism of development of neurogenic dysfunctions of the lower urinary tract is quite complicated. In this case, the pathological process involves not only the bladder, but also the surrounding tissues. Violations of the normal functioning of the bladder are rarely isolated. In most cases, this pathology is combined with disorders of the innervation of the rectum, genital organs, lower body.
The primary link in the violation of the innervation of the bladder is the pathology of a complex reflex urination act, which consists of two phases - the accumulation of urine and emptying of the bladder.
Medical science knows several variants of neurogenic dysfunctions (depending on the level of the lesion).
- The first of them develops with functional weakness of the cortical urination centers, at which their influence on the urination reflex is weakened. In such patients, there is a picture of an inhibited cortical bladder, the main symptoms of which are irrepressible urges and frequent urination. It is characterized by complete emptying of the bubble.
- When the pathological process is localized at the level of the spinal cord above the lumbosacral centers, the act of urination occurs in the form of a spinal reflex, which is triggered by a smaller filling of the bladder and may be caused by unusual stimuli (for example, pressure on the lower abdomen). Since the cortical effects are turned off, the urge to urinate is not felt.
- Damage to the conductive paths below the sacral section leads to a complete dysfunction of the detrusor (muscle fibers of the bladder wall), which is accompanied by a spastic condition of the urethral sphincter. This disrupts the emptying of the bladder. Such a pathological condition can manifest itself by straining during urination, its discontinuity. As a result, a residual volume of urine is constantly found in the bladder, which contributes to hydronephrosis and creates problems in the kidneys.
Often, in inflammatory and degenerative diseases, isolated injuries of sympathetic or parasympathetic parts of the reflex chain occur at the spinal and extraspinal levels.
- With the defeat of the sympathetic fibers, the reserve function of the bladder is disturbed and there is a constant expulsion of urine - incontinence.
- A different picture arises with the defeat of parasympathetic fibers. It is characterized by areflectoriness and urinary retention with all the ensuing consequences - refluxes, expansion of the ureters, inflammatory processes of the pectoral-pelvis-plating system, and the development of renal failure.
- Incomplete simultaneous defeat of these parts causes partial disadaptation and areflexure of the bladder.
In the initial stages of the disease, the clinical picture is represented by various disorders of the act of urination. These include:
- the weakening of the urge or lack thereof,
- frequent or intermittent urination,
- urinary incontinence,
- straining during urination and urinary retention,
- feeling of incomplete emptying of the bladder.
Disorders of the impulses as the first link of the reflex chain are noted by all patients, but their nature may be different depending on the form of dysfunction.
- In the case of the cortical unbraked version of the disease, the urge is preserved, but it is imperative.
- Reflex dysfunction is characterized by the absence of urge with the formation of its equivalent in the form of pressure in the lower abdomen.
- In case of non-adapted forms of the disease, the urge is weakened, it can be caused by forced stretching of the bladder.
Another important symptom of this pathology is urinary incontinence. Primary incontinence develops when the sympathetic lumbar centers are affected. Often the cause of this are spinal hernias. Secondary incontinence is the outcome of chronic urinary retention. It is often combined with symptoms of kidney damage:
- lower back pain
- inability of the kidneys to perform its function in full.
All forms of reflex and mixed dysfunctions are accompanied by urinary retention. Such patients complain:
- on extra effort when urinating,
- the presence of a "tumor" in the lower abdomen,
- feeling of pressure in this area.
Among related complaints can be detected:
- impaired bowel function (constipation or fecal incontinence),
- gait change
- lower sensitivity of the lower limbs,
- trophic changes of the lower limbs.
Examination of patients with suspected neurogenic dysfunction of the bladder begins with an active questioning and history taking. If the patient is unable to provide this information (speech or cognitive defects), then a conversation with relatives is conducted and medical records are examined. At the same time analyze the time of occurrence of pathological symptoms and their dynamics.
Useful information allows you to get an objective study with the definition of sensitivity and reflexes. At this stage, it is important to identify the cause of dysfunction and give a complete assessment of the condition of the urinary tract. Therefore, the examination is necessarily conducted by a neurologist and a urologist.
To confirm the diagnosis, the results of additional research methods are needed. These include:
- clinical blood test,
- urinalysis (change in urinary sediment, decrease in relative density of urine),
- biochemical blood tests (increased creatinine and urea, electrolyte disorders),
- ultrasound of the kidneys and pelvic organs,
- urethrocystography (reveals a narrowing of the urethra, vesicoureteral reflux),
- excretory urography (detects expansion of the renal pelvis system, impaired renal function),
- urodynamic studies (determination of parameters of urine flow and its residual volume),
- cystometry (registration of the relationship between the volume of the bladder and pressure in it during filling and emptying).
The main treatment areas for patients with neurogenic dysfunction of the lower urinary tract are:
- creation of favorable conditions for sufficient emptying of the bladder and retention of urine,
- improving the quality of life
- maintaining normal kidney function.
The tactics of management of such patients is determined individually, taking into account the problems identified.
In case of violation of the emptying of the bladder apply:
- drug therapy (α-blockers, centrally acting muscle relaxants, benzodiazepines),
- operative treatment (resection or dissection of the bladder neck - during urinary retention, sacral and pudendal neurotomy, implantation of artificial sphincters - during urinary incontinence, as a last resort - permanent discharge of urine through the suprapubic fistula).
If the patient has urinary incontinence, then he is shown rectal or urethral electrostimulation of the bladder neck.
Due to the complexity of the innervation and the multiplicity of levels of closure of the urination reflex, it is rather difficult to choose the appropriate treatment methods appropriate to the nature of the lesion.
Persons suffering from neurogenic bladder dysfunction constitute a severe category of patients in need of social and medical rehabilitation. Timely diagnosis and early treatment (before the onset of complications and degeneration of local neuromuscular structures) helps alleviate the condition of such patients and improve their quality of life. However, many of them fail to fully restore the function of the lower urinary tract.
Origin and development of NDMP
In the structural kidney elements, cups and pelvis, filtering urine from the accumulated waste products: salts, pathogenic microorganisms, compounds formed after the breakdown of proteins. Through the ureters of urine, saturated with solutes, enters the bladder, from which it must be excreted. But dysregulation of urination does not allow urine to stand out at the request of a person, even if he feels that his bladder is full.
The bladder performs in the human body the function of the accumulation of urine and its excretion with a volume of more than 600-650 ml. A person is able to urinate, even if the volume of biological fluid does not exceed 250 ml.
The bubble is a hollow organ consisting of three layers:
- The inner shell contains many epithelial mucous cells that are in direct contact with urine.
- The middle layer contains smooth muscle fibers. Their main cluster is at the bottom of the bladder, near the opening of the urethra - the sphincter. This is the detrusor, the muscular membrane of the bladder, which is responsible for the release of urine from the human body.
- Fibrous tissue protects and forms bladder fibers.
Before the process of urination in the parasympathetic ganglia of the bladder, an impulse arises that enters the brain, transforms and returns. There is a urge to urinate, reducing the detrusor and the release of the bladder.
When neurogenic bladder dysfunction of any etiology appears, the impulse sent to the brain is not processed and is not returned. The bladder is overfilled, but there is no urge - spontaneous emptying occurs. In most cases, the person does not have time to run to the toilet.
The main classification NDMP
The concept of neurogenic bladder dysfunction includes such an extensive content of the causes of the occurrence of the disease that there are many classifications of disorders of urination regulation.
The following is considered to be the most convenient for diagnosis and treatment choice:
- Reflex bladder. The urge to urinate appears in the presence of 300 ml of urine. The person feels the urge, but the process should occur immediately or the bladder will empty involuntarily.
- Hyper-reflex bubble. It is characterized by a complete loss of sensitivity and control over the process.
- Hyporeflex blister. Even with the accumulation of a large amount of urine does not occur the process of urination. The pressure inside the hollow organ is completely absent, and the detrusor is in a relaxed state. In this condition, the patient should be under the supervision of medical personnel who help him empty his bladder.
- Areflector bladder. There is a deformation of the walls of the bladder, they lose the ability to stretch and conduct impulses. The body constantly accumulates a large amount of urine, causing the occurrence of bacterial infections.
- Wrinkled bubble. It requires the patient to be in the hospital, since urination is possible only after installing a catheter. In the bladder there is practically no urine, which leads to a loss of elasticity of all layers of the body with a gradual collapse of the walls.
This classification is convenient with a set of assessments of several processes at once - the state of the detrusor and the adaptability of the bladder to it.
Causes of NDMP
More than 10% of children under twelve years of age are diagnosed with neurogenic bladder dysfunction. In the absence of treatment or its impossibility for a number of physiological reasons, urination disorders also occur in adults. Here are the main reasons for the lack of neurogenic regulation:
- Diseases accompanied by severe brain lesions: Parkinsonism, Alzheimer's disease, multiple sclerosis.
- Inflammatory pathology of the membranes of the bladder, leading to disruption of its functioning.
- Inflammatory processes in the intervertebral discs with destruction of bone tissue: osteochondrosis, spondyloarthrosis, hernia.
- Degenerative diseases of the central nervous system, benign and malignant neoplasms: meningitis, encephalitis, neuropathy, encephalomyelitis.
- Violation of the functional activity of the bladder after surgery.
- Severe injuries resulting in damage to the brain or spinal cord.
- Injuries to the bladder resulting from squeezing or breaking the integrity of the walls.
- It is extremely rare to diagnose the impossibility or violation of urination against the background of a deep emotional disorder.
Neurogenic bladder dysfunction in children can result from a congenital disease or pathology that occurs during childbirth.
Features NDPA in children
Violations of the nervous regulation of the urge to urinate in children develop immediately after birth or at the stage of the formation of the fetus. Parents can not notice the presence of pathology due to the age of the child, because the ability to control the bladder appears by 2-3 years. It is necessary to consult a doctor if after 4 years one of the following urination disorders occurs in a baby:
- Urinary incontinence.
- Inability to empty the bubble.
- Rare urination.
- Urgent urges.
- Delay urination.
The inability of the detrusor or sphincter to control the timely emptying of the bladder develops as a result of frustration of the central nervous system. Children are less likely to be diagnosed with a regulation disorder that occurs when the spinal cord is damaged. As a rule, such babies are sick with cerebral palsy. With proper treatment, they can gain control over urination at the same age as their healthy peers.
Neurogenic bladder dysfunction in children can develop against the background of such diseases:
- Congenital pathologies of the central nervous system.
- Malignant neoplasms of different parts of the spine.
- Intervertebral hernia.
- Degenerative pathologies of the spinal column, in which it is impossible to conduct impulses from the bladder to the centers of regulation.
- Birth injuries.
Neurogenic disorders during urination are more common in girls than in boys. Detrusor receptors are hypersensitive to female sex hormones, especially estrogen. Therefore, incontinence and leakage of urine is more common for girls.
As a rule, in babies, specialists distinguish two types of bladder dysfunctions:
- Hyperactive form. Develops when it is impossible to control the central nervous system of the posterior bridge of the brain. The bladder is not able to trap fluid as the detrusor becomes extremely active. From the cavity of the bladder is a constant flow of urine. Hollow organ dysfunction leads to wrinkling and hardening.
- Hypoactive form. Develops with the defeat of the regulation centers in the sacral spinal column. The smooth muscles of the middle layer of the bladder lose their ability to contract in whole or in part. The bubble overflows with urine, but the child does not feel the urge. Urination occurs involuntarily. The sphincter may soon completely lose its functional activity.
When prescribing treatment, the pediatric urologist takes into account the degree of CNS damage, the characteristic features of the development of neurogenic dysfunction and the functional activity of the bladder.
The clinical picture of neurogenic dysfunction
The clinical picture of NDMP varies depending on the type and form of regulation disorder. Diagnosis of disorders in children is difficult because it is impossible to describe the sensations before and after the process of urination. The severity of symptoms depends on the degree of damage to the central nervous system or the sacral spine.
The following symptoms are characteristic of the hyperactive form of pathology:
- Urging occurs very often, but the volume of urine secreted does not exceed 50-100 ml.
- The appearance of pain in the abdomen and (or) the lumbar region. Occur when re-throwing urine into the ureters due to increased activity of the bladder.
- Children feel the urge, but urine is completely absent in the bladder. In adults, this symptom is less common.
- The probability of night urination is much higher than day. In a dream, bladder control is significantly reduced.
- The urge to urinate occurs a few minutes after emptying the bladder.
- All urges are impulsive and strong, often accompanied by painful sensations.
Children and adults may experience sweating, alternating with chills. Rare symptoms include hypertension and certain types of arrhythmias.
When hypoactive dysfunction most often appear such signs:
- Involuntary discharge of urine and leakage after emptying the bladder.
- Lack of desire to urinate when the bladder is full.
- To completely empty the bubble, a person must be very hard to push.
- Urine is excreted in a trickle or drop by drop.
- It always seems to a person that a lot of urine is left in the bubble. Often these concerns are justified. When conducting testing to determine the amount of residual urine, in such patients its volume reached 450-500 ml.
The hypoactive form of the bladder is almost always accompanied by bacterial infections. This is due to the constant presence and stagnation of urine. Warm acidic environment provokes active reproduction of pathogenic bacteria. After a few months, hemorrhagic cystitis, pyelonephritis, glomerulonephritis join the main disease.
This method of treatment can be successfully combined with other methods of therapy to accelerate and consolidate the result. The absence of contraindications and side effects allows the use of non-drug therapy, even in very young children. The main areas of urinary incontinence include:
- Pulse therapy treatment with an electric current with a frequency of about 80 Hz.
- The use of sinusoidal simulated currents.
- Therapy with warm air flow.
- Regular physiotherapy exercises with Kegel exercises. Based on the training of the muscle responsible for urination by the method of tension and relaxation.
- The use of molecular oxygen under high pressure in special hyperbaric chambers.
- Conducting physiotherapy using electrophoresis using solutions of chemical compounds.
- Using ultrasound and laser.
When treating neurogenic bladder dysfunction in children, it is important to adjust their daily routine - it will be easier to control urination and evaluate their quality:
- Regularly walk in the fresh air.
- Exclude active games before bedtime.
- Provide your baby a full sleep.
If the cause of urination disorders is a stressful situation, then it is necessary to protect the child from it.
Drug treatment NDMP
Neurogenic bladder dysfunctions are almost always accompanied by inflammatory infections, therefore, antibiotics and antimicrobial agents cannot be managed. In the absence of allergy, various generations of cephalosporins, combination drugs with clavulanic acid (Amoxiclav, Augumentin), Metronidazole are used. Amoxiccycline and Clarithromycin have proven themselves in the treatment of incontinence.
The antimicrobial preparations Nolitsin, Normobact, Norfloxacin are used to consolidate the results and prevent relapses.
Herbal remedies are also used:
With the development of dysbacteriosis, the intestinal microflora is restored by course taking Linex, Bifidumbacterin, Lactobacterin, Atsipol. Immunostimulants, vitamin complexes with microelements are necessary to strengthen the body. Especially important in disorders of urination are B vitamins, vitamin K and ascorbic acid. Vitamins A and E contribute to the restoration of vascular walls, prevents the reduction of their elasticity. The course of treatment is 1-2 months.
Is the appointment of light tranquilizers, antidepressants or sedatives. Babies are usually recommended:
- Tenoten children.
- Soothing children's fees.
- Syrup Novopassit.
Depending on the type of disorder, treatment is carried out:
- Anticholinergic drugs.
- Nonsteroidal anti-inflammatory drugs.
Additionally, prostaglandins, drugs with amino acids (Glycine), nootropic drugs (Pantogam) are prescribed.
Surgical operations are performed only in the absence of effectiveness of pharmacological therapy. If the cause of neurogenic dysfunction is pathology, which can be eliminated only with the help of surgeons, then such therapy will be of paramount importance. And then medical treatment of incontinence as a symptom of the underlying disease is carried out.
With the help of endoscopic methods, the following types of operations are carried out:
- Collagen is implanted in the ureters.
- A bladder neck resection is performed.
- Increases the volume of the bubble if necessary.
After treatment, children and adults are required to register. Once a trimester, they are required to pass biochemical blood and urine tests to monitor the progress of recovery. It is also necessary for the prevention of relapse.
If a small child can not control urination after 4-5 years, you should visit the pediatrician, who will write out a referral to narrower specialists. As a rule, neurogenic dysfunctions are not cured on their own, but only progressing. When a disease is detected, a hospital stay is required for diagnosis and treatment.
The condition in question is a specific disorder in which all patients complain that they have problems with the process of excretion of biological fluid (urine) from the body. However, it should be understood that all the signs that will be described later can occur singly or in complex, and also have different degrees of severity.
Pathological state is accompanied by various unpleasant symptoms. Source: 1lustiness.ru
Among the main symptoms, experts distinguish the following:
- Sudden urge to defecate,
- Feeling of pressure in the lower abdomen,
- No urge to urinate, or is it too weak,
- Inability to keep urine
- Delay of biological fluids in the body,
- Difficult urination.
Almost all patients, when talking with a urologist, pay attention to the fact that the previously confident jet has become sluggish or weakened. Also, people are often tormented by the feeling that the organ is not completely defecated, which causes a feeling of increased pressure in the abdomen. Less often, people are faced with the fact that to begin the process of urinating they should put some effort.
Together with this, there appears another unpleasant concomitant symptomatology:
- The inability to commit an act of defecation,
- Fecal incontinence,
- Violation of the menstrual cycle,
- Decreased sexual desire
- The development of erectile dysfunction,
- Paralysis or paresis of the lower limbs,
- The formation of trophic ulcers and bedsores,
- Change in the gait of a person
- Fluctuations in temperature and pain sensitivity of the legs.
In situations where the neuromuscular dysfunction of the bladder is not diagnosed in a timely manner, and the pathology progresses, the upper sections of the system may be involved. This causes the following symptoms associated with kidney damage to join the described symptoms: fever, lumbar back pain, loss of appetite, dry mouth, nausea and vomiting (CRF).
Especially popular among doctors and patients is such a procedure as paraffin applications. Thanks to them, you can get rid of high muscle tone. As for the representatives of the weaker sex, they are also encouraged to use physical factors in their complex effects on the body.
Depending on what type of pathology was diagnosed, the method will be determined. For example, in the case of the hyperreflex form, it is necessary to perform physiotherapeutic procedures that have sympathomimetic as well as antispasmodic action, which allows the muscles of the detrusor to relax and reduce the sphincter.
But in a situation with hyporeflex disorder, preference should be given to manipulations that have a stimulating effect on the detrusor. It is good if there are procedures in the complex capable of eliminating spasm, relieve inflammation, dilate vessels and improve blood circulation.
Among physiotherapy, particular preference is given to electrophoresis. Source: cistitus.ru
Therefore, to eliminate spasm in the detrusor, experts advise:
- Perform electrophoresis with Atropine, Eufillin or Plathillin (15 minutes daily, the course is 12 procedures),
- To conduct electrophoresis with drugs that eliminate the spasm,
- To be exposed to ultrasound (5 minutes for each affected area, every day for 10-12 days),
- Paraffin applications (the duration of one session is from 30 to 45 minutes, performed every day for 12-15 days).
When it is necessary to restore the work of muscle structures, it is recommended to carry out specific treatment in which the body is affected by certain types of currents (it is worth doing the manipulations every day, and the course is ten days). You can also affect the bladder by diadynamic therapy. The duration of the session is not more than 7 minutes (maximum 10 procedures).
In addition, experts in the field of urology presented a whole range of physiotherapy effects on the body, which allows you to normalize the work of the autonomic nervous system. For this, the following is shown:
- Ultraviolet irradiation
- Infrared laser therapy,
- Mud treatment.
It is important to consider the duration of the procedures, as well as their number. When there is a state of incontinence, it helps to cope with the problem of urethral or rectal stimulation of the bladder neck. However, the procedure can be done only under the condition of preservation of the system of innervation.
Immediately it should be noted that surgery for such problems is more symptomatic treatment. There are a lot of options for the operation, but the main preference is given to procedures aimed at restoring the innervation of the bladder.
Such intervention is difficult and time consuming, but due to the fact that it has been practiced for more than 20 years, it is possible to achieve the most positive results. After such treatment, the patient must perform gymnastics, take medications, be exposed to physiotherapy.
If a neurogenic bladder has been diagnosed in a man or a woman, treatment should not be postponed for long. The sooner the therapeutic complex is developed and fully implemented, the higher the likelihood that the patient will soon fully recover and return to normal life.