Neurogenic Bladder: Epidemiology, Diagnosis, and Management

Abstract

Lower urinary tract dysfunction is a common sequel of neurological disease resulting in symptoms that significantly impacts quality of life. The site of the neurological lesion and its nature influence the pattern of dysfunction. The risk for developing upper urinary tract damage and renal failure is considerably lower in patients with slowly progressive nontraumatic neurological disorders, compared with those with spinal cord injury or spina bifida. This acknowledged difference in morbidity is considered when developing appropriate management algorithms. The preliminary evaluation consists of history taking, and a bladder diary and may be supplemented by tests such as uroflowmetry, post-void residual measurement, renal ultrasound, (video-)urodynamics, neurophysiology, and urethrocystoscopy, depending on the clinical indications. Incomplete bladder emptying is most often managed by intermittent catheterization, and storage dysfunction is managed by antimuscarinic medications. Intra-detrusor injections of onabotulinumtoxinA have revolutionized the management of neurogenic detrusor overactivity. Neuromodulation offers promise for managing both storage and voiding dysfunction. In select patients, reconstructive urological surgery may become necessary. An individualized, patient-tailored approach is required for the management of lower urinary tract dysfunction in this special population.

Fig. 1

The pattern of lower urinary tract dysfunction following neurological disease is influenced by the site of lesion. PVR, post-void residual. (Used with permission from Panicker et al. 5 )

Fig. 2

Two types of afferent nerves convey sensations of bladder filling. ( A ) In health, thinly myelinated Ad fibers have a lower threshold for activation and are responsible for conveying sensations of bladder filling, whereas unmyelinated C-fibers have a greater threshold for activation and are thought to be quiescent. ( B ) Following spinal cord damage, C-fibers become sensitized and are mechanosensitive at lower bladder volumes. A segmental spinal reflex emerges that is mediated by C-fibers afferents nerves and results in involuntary detrusor contractions, the basis for NDO. LUT, lower urinary tract; NDO, neurogenic detrusor overactivity. (Used with permission from Panicker et al. 7 )