USMLE® Step 1 style questions USMLE
A 75 year-old African-American male comes to the office because of continuous dribbling of urine which began one month ago. In addition, the patient endorses difficulty initiating and maintaining a urinary stream. Past medical records indicate that he has hypertension and type 2 diabetes mellitus. The patient has a 40-pack-year smoking history. His temperature is 37.0°C (98.6°F), blood pressure is 150/86 mmHg, pulse is 70/min, and respirations are 15/min. Cardiac, pulmonary, and abdominal examinations are non-contributory. Digital rectal exam reveals an enlarged, symmetrical, and smooth prostate. Laboratory study results are as follows:
*Normal PSA < 4.0 ng/ml
Laboratory value Result Glucose 118 mg/dL HbA1c 6.9% Prostate-specific antigen (PSA)* 3.6 ng/ml
Which of the following is the most likely cause of the patient’s urinary symptoms?
Content Reviewers:Rishi Desai, MD, MPH
Contributors:Tanner Marshall, MS
With neurogenic bladder, neurogenic means arising from the nervous system, so neurogenic bladder is typically some difficulty emptying the bladder normally, as a result of either damage to the peripheral nerves, brain, or spinal cord.
As urine flows from the kidney, through the ureters and into the bladder, the bladder starts to expand into the abdomen. The bladder is able to expand and contract because it’s wrapped in a muscular layer, called the detrusor muscle, and within that, lining the bladder itself is a layer of transitional epithelium containing “umbrella cells”. These umbrella cells get their name because they physically stretch out as the bladder fills, just like an umbrella opening in slow-motion.
Okay - so when the urine is collecting in the bladder, there are basically two “doors” that are shut, holding that urine in. The first door is the internal sphincter muscle, which is made of smooth muscle and is under involuntary control, meaning that it opens and closes automatically. Typically, the internal sphincter muscle opens up when the bladder is about half full.
Now the second door is the external sphincter muscle, and it’s made of skeletal muscle and is under voluntary control, meaning that it opens and closes when a person wants it to. This is the reason that it’s possible to stop urine mid-stream by tightening up that muscle, which is called doing kegel exercises. Once urine has passed through the external sphincter muscle, it exits the body, in women the exit is immediate and in men the urine flows through the penis before it exits.
So, when specialized nerves called stretch receptors in the bladder wall sense that the bladder is about half full, they send impulses to the spinal cord, specifically the sacral spinal cord at levels S2 and S3, known as the micturition center, and the brain, specifically two locations in the pons—the pontine storage center and pontine micturition center.
The spinal cord response is part of the micturition reflex. And it causes an increase in parasympathetic stimulation and decrease in sympathetic stimulation which makes the detrusor muscle contract and the internal sphincter relax. It also decreases motor nerve stimulation to the external sphincter allowing it to relax as well.
If we want to delay urination, or hold it in, the pontine storage center overrides the micturition reflex, and when we want to urinate, the pontine micturition center allows for the micturition reflex to happen.
Now with neurogenic bladder - the exact pattern of symptoms depends on the nerve that is damaged.
In diabetes mellitus, excess glucose levels in the blood attaches to various proteins - a process called glycation. This process can damage sensory nerve fibers in the bladder wall, in the pelvic nerve, or in dorsal nerve roots entering the spinal cord, all of which interferes with the initial stretch signal that gets sent out as the bladder fills.
Also, with herpes, the virus takes up a home in the dorsal nerve roots for months to years and it can also disrupt the sensory fibers that they carry within them.
This all means that as the bladder fills to capacity and stretches, that sensory information is not received, and the bladder starts to overflow, drop by drop, out of the urethra. This is called overflow incontinence.
Neurogenic bladder is a type of bladder dysfunction that is caused by damage to the nerves related to the bladder control. It is characterized by difficulty emptying the bladder normally, as a result of either damage to the peripheral nerves, brain, or spinal cord.
Neurogenic bladder can occur as a result of various conditions, such as spinal cord injuries, multiple sclerosis, and diabetes. Related bladder dysfunctions could be overflow incontinence, where the bladder fills up to capacity and then dribbles out of the urethra, or urge incontinence, where an individual feels frequent urges to urinate.