A neurogenic bladder is any type of bladder or lower urinary tract dysfunction related specifically to a neurologic disease. Any conditions that disrupt the nervous pathways from the brain to the spinal cord and to the peripheral nerves that supply the bladder can lead to a neurogenic bladder.
Common conditions include:
- Spinal cord injury.
- Multiple sclerosis (MS).
- Parkinson’s disease.
- Diabetes mellitus.
- Spina bifida.
How do patients with neurogenic bladders present?
There is a whole spectrum of presentations, from the people who are able-bodied or ambulatory to the patients who are already debilitated from immobility and who are in wheelchairs. Most of the time, the bladder symptoms are related either to failure to empty or failure to store.
Failure to empty the bladder
Patients present with:
- The feeling of fullness and difficulty emptying their bladder:
- A slow stream.
- Having to strain.
- Feeling as though they are not emptying all the way.
- Sometimes waking during the night with a need to urinate.
- Urinary incontinence:
- ‘Overflow’ leakage. As the bladder does not empty well, it refills and overflows faster. This is often described as a continuous, unaware dribble with no pattern.
- Urinary tract infections and bladder stones:
- Urine that is not cleared from the bladder easily gets infected or precipitates to form stones.
- Loss of bladder sensation in some cases:
- Patients have very little urge or need to void and would present with leakage (with no warning) or infection.
- Urinary retention:
- This can occur acutely or in a chronic insidious manner. Some patients with chronic retention may not be aware they are in urinary retention. Some patients may have a ‘bloated’ abdomen due to a distended bladder.
Failure to store urine in the bladder
A lot of these patients actually present a lot sooner because they have more bothersome symptoms.
Patients present with ‘irritative’ symptoms:
- An uncomfortable sensation that compels the patient to pass urine. It can lead to urine leakage if the patient does not void in the immediate future.
- Voiding many times during the day.
- Often the most bothersome symptom that patients present with. This is usually associated with a sensation of urgency prior to the leakage (urge incontinence). It can be due to an overactive bladder or a bladder with reduced compliance (stiff-walled, non-elastic bladder).
- If patients are immobile, this can lead to severe skin breakdown in the groin area.
Both groups of patients can present with more worrying conditions:
- Haematuria (blood in the urine).
- Severe infection.
- Urinary tract stones.
- Worsening of kidney function.
What is involved in the evaluation?
Evaluation involves a detailed medical history, physical examination and investigations.
In the history, other than the neurological history, other urological conditions that may be co-existing are benign prostatic enlargement, and erectile dysfunction. Bowel dysfunction like constipation can worsen bladder problems.
A history of autonomic dysreflexia needs to be elicited. Autonomic dysreflexia is a dangerous response seen in patients with a spinal cord lesion at T6 or above, to stimuli below that level of injury. This is often due to bladder distension, constipation or procedures like urodynamics or cystoscopy. This results in uncontrolled hypertension, which usually causes a sensation of facial flushing, tingling, or headache. If left untreated, it can lead to a stroke or rarely, even death.
Physical examination is focussed on looking for a palpable bladder and checking the local nerve reflexes and sensation. A rectal examination is very useful to test for this reflex.
In terms of investigations, they are aimed at evaluating kidney function and bladder function.
To evaluate kidney function:
- A kidney ultrasound can be done to look for kidney obstruction, urine reflux and stones.
- A blood test looking at creatinine levels is also done.
To evaluate bladder function:
- A bladder diary or questionnaire can give voiding information on a day-to-day basis and its impact on quality of life.
- A cystoscopy can be done to visualise the inner lining and content of the bladder and rule out pathology like bladder stones and tumours.
- Urodynamics study (bladder function test) is an essential part of the workup as it can give detailed information on the current voiding problems, so as to tailor the treatments. In neurogenic patients, it is recommended that fluoroscopy (Xray scanning) is done at the same time during the urodynamics. This is called video-urodynamics or fluoro-urodynamics.
What are the treatments?
There are 3 main goals when treating the patient with neurogenic bladder:
1) Evaluate the whole patient, including medical and psychosocial.
Specify their goals:
- Do patients have the ability to ambulate?
- Can they care for themselves, or do they require other caregivers?
- Do they have good hand function? Certain styles of management require good hand function.
- If they don't have good hand function, do they have attendant care? Caregivers have to be around to do the possible intermittent catheterization
2) Protect kidney function and prevent complications.
3) Improve quality of life.
It is more important to protect the kidneys first, as kidney failure can be the number one cause of death in this patient group. Once that is under control, then one can aim to improve quality of life (i.e., "What is it that is bothering you?").
Treatment is again divided into two main groups of patients; those with failure to empty and those with failure to store the bladder.
Failure to empty the bladder
- Decrease outlet resistance:
- The use of alpha-blocker medications is one methodology. Performing pelvic relaxation techniques to allow voiding to occur is another.
- Intermittent catheterization program:
- Patients may spend less time throughout the day managing their bladder by doing this. A continence nurse can teach this and also provide contacts for supplies. May be difficult in obese people or those with poor hand or eye function.
- Injecting an anti-spasm agent into the sphincter:
- Helps to relax the sphincter muscle and make voiding easier. The downside is that it has to be repeated every 2-3 months, and it's currently off-label, so it may not be covered by insurance.
- Surgery to create a catheterisable tube from the abdomen to the bladder (using a part of the bowel):
- Something that patients with poor hand mobility can still reach. They wouldn't have to undress to catheterize. It could significantly improve their quality of life.
- Indwelling catheters are a last resort:
- A suprapubic tube (inserted in the lower abdomen into the bladder) would be better than a urethral catheter mainly because of hygiene, the distance to the rectal area, and the bacteria that could come into the vaginal area. It is also easier and more comfortable to change regularly.
- May have problems with catheter blockages, leakage around the catheter, the catheter ‘splitting’ the urethra (in men) and infections. The catheter can occasionally cause bladder spasms which can lead to pain or urine leakage.
- Men have more options like a condom catheter (if adequate penile length).
- Surgery to open up the sphincter (sphincterotomy):
- This is an irreversible procedure but may be suitable in some patients. It is done to treat a condition called detrusor sphincter dyssynergia (DSD), which is poor relaxation of the sphincter during voiding, that can potentially cause kidney damage.
- Another alternative is to put a temporary stent (e.g., Memokath) across the sphincter.
Failure to store urine in the bladder
- Behavioural modifications like altering diet, reducing fluid intake and stimulants in their diet (e.g., caffeine and alcohol).
- Review medications, especially diuretics medications:
- When are they taking their diuretics? If patients are bothered at night time, are they taking their diuretics before they go to bed?
- Timed voiding or bladder retraining:
- Patients either void by schedule instead of waiting until they get that urge or
- Try and reduce the urge by squeezing down on the pelvic floor and preventing that urge from occurring.
- Medications (anticholinergics or beta-agonist):
- Anticholinergic medications:
- They are effective in the majority of patients, but they have side effects. The typical side effects are dry mouth, dry eyes and constipation.
- Constipation can be a problem in the neurogenic population because these patients already have baseline bowel dysfunction.
- Long-term use of anticholinergics may lead to confusion in the elderly.
- Many patients are not compliant because of the side effects.
- Can potentially worsen bladder emptying.
- Some of the patients are already on anticholinergic agents for their neurologic conditions and may get worse systemic side effects with additional ones.
- Beta-agonist medications:
- These have a better side effect profile than anticholinergics, and are well tolerated.
- Anticholinergic medications:
- Anti-spasm agent (Anti-spasm bladder injection):
- It reduces bladder pressure, and in clinical trials, reduces the number of incontinence episodes by 32%-100%.
- The most common adverse events reported are injection-site pain, procedure-related urinary tract infection, urinary retention (unable to void) and blood in the urine (mild).
- Onabotulinum Toxin A is usually the agent used for the bladder.
- May need to be repeated every 6 - 9 months.
- Sacral neuromodulation (bladder pacemaker):
- In general, this is not as effective in the neurogenic population as compared to non-neurogenic. However, there may still be some improvement.
- Major surgery:
- Bladder augmentation with a segment of bowel, to increase volume and decrease pressure.
- Urinary diversion: diverting the urine away from the bladder by attaching the ureters to a segment of the bowel and bringing that to the surface of the abdomen either as a bag (incontinent) or as a catheterisable channel (continent).
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