Brief Overview: Neurogenic bladder is the dysfunction of the urinary bladder due to CNS disease or peripheral nerves involved in the control of urine storage and emptying.
Prevalence: Varies by specific conditions. CVA 20-50%. Parkinson 35-70%. MS 50-90%. DM 5-60%.
Etiology: CNS lesions interfere with sphincter relaxation during bladder contraction, detrusor underactivity or inability to contract, and detrusor overactivity. Peripheral lesions cause varying detrusor underactivity, impaired bladder sensation, and impaired function of sphincters. Peripheral nerve impairment can also be traumatic, a result of injury or abdominal/pelvic surgery.
Risk Factors: Neurologic disease, injury, congenital malformation, diabetes, pelvic surgeries
Commonly Associated Conditions: CVA, MS, hydrocephaly, Parkinson's, spinal cord injury, neural tube defects, and cerebral palsy. Peripheral nerve disease-radical pelvic surgery, diabetes, intervertebral disc disease, spinal stenosis, and Guillain-Barre syndrome
Common Symptoms: Voiding symptoms- incomplete emptying, straining to void, complete retention. Storage symptoms such as frequency and incontinence. Collect history including method of voiding- condom cath, self intermittent cath, indwelling urethral or SP tube, crede/Valsalva voiding; UTIs, urothlithiasis.
Physical Findings: Ureteral obstruction and pyelonephritis can cause flank pain. Distended bladder and urinary retention can result in palpable bladder with or without discomfort depending on sensation. Incontinence of urine.
Common Labs, Imaging, and Tests:
- Labs- CBC to evaluate for anemia and infection. CMP to evaluate renal function. UA- protein in renal dysfunction, acute or chronic infection, hematuria.
- Imaging- Most important for patients with risk factors for upper urinary tract compromise, such as poor bladder compliance and detrusor sphincter dyssynergia (sphincter must relax as bladder muscle contracts in order to empty, when these do not occur simultaneously it is called DSD). When urine backs up into the kidneys, it results in upper tract injury d/t pressure and a decline in renal function.
- Renal ultrasound to screen for calculus, hydronephrosis, and mass.
- Excretory urography- watches contrast excretion and evaluates for delayed excretion, urinary storage pressures, hydroureteronephrosis
- Nuclear medicine renal scan- Mag3Renal scan- assesses for obstruction and renal function.
- Diagnostic procedures/surgeries
- Urodynamics- determines neurogenic lower urinary tract dysfunction by watching EMG activity, detrusor function, emptying, voiding pressures, bladder compliance, etc
- Cystoscopy will show bladder wall thickening with fibrosis and trabeculation or “end-stage architecture”.
- Antimuscarinics- Aims to decrease urinary storage pressure and reduce neurogenic detrusor overactivity. The most common side effects of dry mouth, dry eye, and constipation. Must monitor PVR or make sure they have a way to empty the bladder because this can worsen incomplete retention. Oxybutynin, solifenacin, tolterodine, trospium, fesoterodine.
- Beta 3 agonists- Same function as above- Myrbetriq, Gemtesa. Watch BP, can raise few points.
- Alpha blockers- Decreases internal sphincter resistance, lower voiding pressures, ineffective for detrusor sphincter dyssynergia. Alfuzosin, doxazosin, tamsulosin, terazosin.
- Urinary drainage- Self-intermittent catheterization 4-6x/day or prn, indwelling urethral or suprapubic tubes- both associated with recurrent UTIs, urolithiasis, and urethral erosion with standard foley. SP tube does not change the risk of infection, but prevents urethral erosion. Standard indwelling foley changes are q30d. Many patients/families are able to manage this at home. Others will go to the clinic or have home health.
- Botox injection into external sphincter for DSD, 6 mo average efficacy
- Botox injection into detrusor for neurogenic detrusor overactivity (bladder spasms, frequency, urgency, etc.)
- Cystectomy with continent urinary reservoir made with ileal or colon pouch, continent catheterizable stoma, or ileal conduit. Endoscopic sphincter ablation or stent for males with DSD. Augmentation cystoplasty uses an intestinal segment to enlarge the bladder to increase volume capacity and decrease pressure. Ileovesicostomy-
- Recurrent UTIs, urolithiasis, urethral erosion, hydroureteronephrosis, and chronic renal impairment
- Hydration recommendations, standard 6-8 8oz glasses of water daily.
- For general stone prevention in patients predisposed to stones, see Nephrolithiasis guide for dietary/lifestyle guidance.
- Good management of comorbidities such as HTN, CKD, etc to preserve renal function and peripheral nerve involvement
- Are you keeping routine PCP/urology follow-up appointments for ongoing monitoring ie labs, imaging, etc?
- Are you experiencing recurrent UTIs?
- Do you have flank pain, hematuria, history of stones?
- Are you able to get catheter supplies/DME? If no what is the reason, cost, accessibility, etc.
- Are you having a decline in dexterity or strength that is interfering with your ability to catheterize?
- Tips for keeping up with hydration
- General UTI prevention
- Standard catheterization process, using new supplies each time, daily site care
- Warning signs to call office vs ER for acute retention or infection. Complete urinary retention is an emergency.
- Any urine specimens need to be collected from a brand-new catheter tube. Never recommend samples from the bag or existing tubing due to colonization.
- Overtreatment of asymptomatic bacteriuria with catheterized patients is very common. Cultures should only be collected when the patient is symptomatic or has upcoming surgery. Refer to Infectious Disease and AUA guidelines for antibiotics for chronically catheterized patients.
