Neurogenic Bladder

Background

• Neurogenic bladder is a lower urinary tract dysfunction secondary to any nervous system disturbance. Types of neurogenic bladder include detrusor overactivity and underactivity (overactive and underactive bladder) and detrusor sphincter dyssynergia (DSD).
• Neuro-urologic symptoms are common in patients with neurologic conditions, such as spinal cord injury, stroke, and multiple sclerosis (MS), with incidence varying by neurologic condition.
• Causes of neurogenic bladder include lesions (spinal cord or pelvic nerves) and dysfunction in the nervous system controlling the lower urinary tract as a result of stroke, brain tumor, nerve injuries, or another neurological condition.
• Complications of neurogenic bladder may include damage to the upper and lower urinary tract, autonomic dysreflexia, renal failure or urosepsis, recurrent urinary tract infections (UTIs), and nephrolithiasis.

Evaluation

• Clinical evaluation:
  • Assess the patient's history of:
    • urological, bowel, sexual, and neurologic dysfunction (Strong recommendation).
    • any alarm signs, such as pain, symptoms of infection, hematuria, or fever, which warrant further diagnostic evaluation (Strong recommendation)
  • Request bladder diaries, including:
    • 24-hour bladder diary in adults (Strong recommendation)
    • 2-day voiding diaries and/or structured questionnaires in children (Strong recommendation)
  • Evaluate the quality of life using validated tools in patients with multiple sclerosis (MS) or spinal cord injury (Strong recommendation).
  • Physical exam should assess reflexes (perianal, bulbocavernous, knee and ankle, and Babinski), sensations related to S2-S5 dermatomes, anal sphincter tone, and pelvic floor function (Strong recommendation).
• A diagnosis requires urodynamic testing to document and specify lower urinary tract dysfunction (Strong recommendation).
  • Perform noninvasive testing, such as free uroflowmetry, prior to initiating invasive urodynamics (Strong recommendation).
  • Perform invasive urodynamic testing, such as video-urodynamics or filling cystometry, continuing into a pressure flow study (Strong recommendation).
  • Consider other urodynamic testing, such as ambulatory urodynamics (if other urodynamic testing does not produce symptoms) or fast-filling cystometry with cooled saline (the ‘ice water test’).
• Additional testing should include:
  • uro-neurophysiological testing, such as electromyography to assess the patient's control of pelvic floor muscles
  • urinalysis to check for UTI

Management

• Perform intermittent self- or third-party catheterization in patients unable to empty bladder.
• Use anticholinergics as a first-line medical treatment for neurogenic detrusor overactivity (Strong recommendation).
  • Consider tamsulosin or other alpha-blockers in combination with anticholinergics to improve capacity and compliance (Weak recommendation).
  • If anticholinergics are ineffective for treatment of neurogenic detrusor overactivity:
    • consider combination therapy with alpha-blockers and mirabegron (beta-3-agonist) (Weak recommendation)
    • use botulinum toxin injection in the detrusor in patients with multiple sclerosis or spinal cord injury (Strong recommendation)
    • consider percutaneous tibial nerve stimulation which may improve overactive bladder symptoms
  • To treat refractory detrusor overactivity, perform bladder augmentation (detrusor myectomy) (Strong recommendation).
• For management of detrusor underactivity:
  • Insert an artificial urinary sphincter in men with neurogenic stress urinary incontinence (Strong recommendation).
  • Consider autologous urethral slings in women with neurogenic stress urinary incontinence who are able to self-catheterize (Strong recommendation).
• For management of detrusor sphincter dyssynergia
  • Use alpha-blockers, such as tamsulosin, to decrease bladder outlet resistance (Strong recommendation) or consider alpha-blockers in combination with other treatments such as:
    • transurethral resection of external urinary sphincter (TURS) (Weak recommendation)
    • anticholinergics (Weak recommendation)
  • Consider TURS, specifically laser sphincterotomy, for men with neurogenic bladder who void reflexively and have DSD (Weak recommendation).
  • Consider urethral stent drainage as an alternative to TURS (Weak recommendation).
  • Consider a botulinum toxin injection to urinary sphincter mechanism to improve voiding in patients with DSD and spinal cord injury with:
    • elevated postvoid residual urine volume (PVR) during voiding (Weak recommendation)
    • difficulty performing clean intermittent catheterization due to sphincter spasms (Weak recommendation)
  • Consider electrical stimulation and posterior sacral rhizotomy in patients with DSD (Weak recommendation).
  • Consider biofeedback to reduce daytime incontinence in children with DSD.
• If other treatments are ineffective, consider urinary diversion options (Weak recommendation).
• Follow-up:
  • Perform urinalysis regularly with exact timing based on individual patient's symptoms.
  • In patients at high risk for complications:
    • assess upper urinary tract at least every 6 months with ultrasound (Strong recommendation)
    • perform physical exam and urine laboratory studies annually (Strong recommendation)
    • perform urodynamic testing as mandatory baseline diagnostic intervention and at regular intervals (Strong recommendation)
  • Repeat urodynamic testing annually in young children.