What is Neurogenic Bladder and Neurogenic Lower Urinary Tract Dysfunction?
urinating normally needs both the bladder and the valves in the tube that carries urine (urethra) to work properly. A healthy bladder muscle (detrusor muscle) and well-functioning internal and external urethra valves are essential to keep our urinary system healthy and to control peeing. Our central nervous system, which includes the brain and spinal cord, plays a key role in this by managing the activity of two of our body’s communication systems- the sympathetic and parasympathetic networks, and the skeletal nervous system.
The process of voluntarily urinating includes three stages – the bladder filling up, storing, and finally emptying. The kidneys produce about 1.5 liters of urine each day. This urine travels through the ureters into the bladder, where it is stored until it almost reaches the bladder’s maximum normal capacity, usually about 500 cc. (The bladder’s ability to hold fluid without causing a rise in inside bladder pressure is known as compliance and is a crucial part of peeing normally.)
Physically, the bladder is divided into two parts: the dome and the base. The dome of the bladder consists of interlinked smooth muscle fibers that tighten when signaled by a neurotransmitter called acetylcholine, while the base consists of the trigone and bladder neck. These are closely connected to the floor of the pelvis. Two valves in the urethra control voluntary urinating or micturition. The internal urethra valve is in the bladder neck and the upper part of the urethra. Meanwhile, the external valve is in the membranous urethra (the part of the urethra that passes through the pelvic floor). Injuring or falling ill could affect the normal function of these structures and cause bladder problems.
What Causes Neurogenic Bladder and Neurogenic Lower Urinary Tract Dysfunction?
Neurogenic bladder, a condition where a person has trouble controlling their bladder due to nerve damage, can be caused by many different factors. Here are some common sources:
Normal-pressure hydrocephalus – a condition where excess cerebrospinal fluid leads to brain swelling.
Spinal cord injuries – damage to the spinal cord can disrupt nerve signals involved in bladder control.
Cerebral palsy – a disorder affecting muscle tone and movement, caused by brain damage before or at birth.
Traumatic brain injury – damage to the brain caused by a violent blow or other physical trauma to the head.
Stroke – when blood flow to a part of your brain is cut off, causing harm to brain cells.
Parkinson’s disease – a progressive nervous system disorder that affects movement.
Multiple sclerosis – a disease where the body’s immune system mistakenly attacks the protective covering of nerve fibers in your brain and spinal cord.
Meningomyelocele – the most serious type of spina bifida, where a portion of the spinal cord and the surrounding structures develop outside, instead of inside, the body.
Spina Bifida – a condition where the spinal cord and its surrounding structures do not fuse properly during development, leaving a gap.
Diabetes mellitus – a condition that causes high blood sugar levels, leading to damage of many organs, including nerves.
Dementia – an overall term for diseases and conditions characterized by a decline in memory or other thinking skills that affect a person’s ability to perform everyday activities.
Guillain-Barre syndrome – a rare neurological disorder where the body’s immune system mistakenly attacks your nerves.
Tumors involving the central nervous system or spine – abnormal growths in the brain or spinal cord that can disrupt nerve function.
Risk Factors and Frequency for Neurogenic Bladder and Neurogenic Lower Urinary Tract Dysfunction
The average age of people suffering from a neurogenic bladder is around 62.5 years. This condition is highly prevalent among those with certain ailments: it’s found in 40% to 90% of people with multiple sclerosis, 37% to 72% of those with Parkinson’s disease, and 15% of all stroke patients. Studies indicate that 70% to 84% of individuals with spinal cord injuries encounter neurogenic bladder issues at some point in their lives. Across the globe, 12 to over 65 new cases per million people each year arise from spinal cord injuries leading to this bladder dysfunction.
In the United States, approximately 1,427 babies are born with spina bifida, which equates to around one in every 2,758 live births. All these babies are likely to have some form of permanent bladder malfunction. Among these, the condition called vesicoureteral reflux affects up to 40% of the children by the age of 5, while 60.9% of adults with spina bifida will experience some level of urinary incontinence. Voiding dysfunctions could include a flaccid or spastic pelvic floor, excessive bladder activity, a disconnect between the bladder and the sphincter, or a combination of these disturbances. When these are associated with high bladder pressures, there’s a spike in risk for developing vesicoureteral reflux, which may subsequently lead to kidney damage.
Signs and Symptoms of Neurogenic Bladder and Neurogenic Lower Urinary Tract Dysfunction
If you’re experiencing issues with your bladder, it may be due to a neurogenic bladder. This simply means there’s a problem with the nerves that control your bladder’s function. To figure this out, doctors will first ask about your bladder and any possible nerve-related symptoms. They’ll want to know when you first noticed these problems, how the problems have changed, and whether you have any other relevant issues such as digestive issues, sexual dysfunction, or other nerve issues.
Doctors might use a questionnaire to learn more about your bladder function. You might be asked about:
- How often you urinate
- How much you urinate
- Whether you feel you’ve fully emptied your bladder
- Any symptoms of a urinary tract infection, like burning or fever
- Any bowel issues, like constipation, stool impaction, or bowel incontinence
They’ll also want to know whether you’ve had any injuries, certain diseases like diabetes or Parkinson’s, what medications you’re taking, what surgeries you’ve had, and your family medical history.
Your overall health will also be considered, as well as factors such as your mobility, cognitive abilities, hand strength and coordination, and the support you have at home. These factors all play a role in determining the best course of treatment for you.
An examination will also be carried out to check your abdomen and, depending on your gender, your external genitalia or pelvis. Your rectum might be examined to check your anal sphincter tone. A focused neurological examination could also be performed, where your cognitive abilities, gait, hand functionality, sensation in the urogenital area, and reflexes may be tested.
For patients with spinal cord injuries, a urological evaluation is recommended. This should be done after the initial shock from the injury subsides. This might be around three months after the injury, but no longer than six months. It’s worth noting that bladder dysfunction can begin very quickly following a spinal cord injury, even if you’re able to walk and don’t have any symptoms.
Testing for Neurogenic Bladder and Neurogenic Lower Urinary Tract Dysfunction
If you’re experiencing new urinary symptoms, your doctor may recommend a “urine dipstick” test. This quick and easy test can help rule out a urinary tract infection. They may also check your kidney function with a blood test that looks at creatinine levels and your glomerular filtration rate (GFR), both of which indicate how well your kidneys are working.
Your doctor will want to know how well you’re emptying your bladder, and will likely use a special type of ultrasound for this. Alternatively, they might use a catheterization procedure. All this information can help your doctor understand your patterns of urination and your bladder function.
To evaluate the quality of your life related to your bladder function, your doctor may use a specific questionnaire. This can help your doctor understand what issues are most important to you and can guide treatment decisions.
It’s also important to check the upper part of your urinary system (where your kidneys and ureters are) if you’re newly diagnosed with a neurogenic bladder (a condition where nerve damage has caused bladder dysfunction). This could be done with an ultrasound or a CT scan. Doctors generally recommend checking this area once a year if you have a spinal cord injury. No specific guidelines have been set for other conditions, but a yearly check-up could be beneficial if your symptoms or kidney function change.
Other tests such as uroflowmetry (a test that measures the volume and speed of your urine) and cystoscopy (a test that allows your doctor to see inside your bladder and urethra) may be used as needed. These tests can help your doctor identify potential problems such as a blockage in your urinary tract.
Urodynamics is a test that assesses how well your bladder and urethra are storing and releasing urine. It’s especially useful for patients with a neurogenic bladder because it can help detect any risks for kidney damage, which can happen without showing any symptoms. This test includes a complex set of measurements assessing bladder sensation, bladder compliance (or flexibility), and sphincter function, among others.
When conducting urodynamics, special care is needed for patients at risk for autonomic dysreflexia (a serious condition that causes a sudden and dangerous increase in blood pressure). Lastly, your doctor might do additional tests if high-risk factors, such as high bladder pressures, are present.
Your doctor will categorize your neurogenic bladder based on whether your bladder fails to store or fails to empty urine properly. This will be determined by a variety of tests and can aid your doctor in providing the best treatment plan possible.
Treatment Options for Neurogenic Bladder and Neurogenic Lower Urinary Tract Dysfunction
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What else can Neurogenic Bladder and Neurogenic Lower Urinary Tract Dysfunction be?
Diagnosing a neurogenic bladder, a condition where a person lacks bladder control due to a brain, spinal cord or nerve problem, in a timely manner is very important as it can greatly affect the patient’s health. Health care professionals typically review the patient’s medical history and conduct neurological exams to determine the underlying causes. Lab tests also play an important role in confirming the diagnosis.
The main cause of neurogenic bladder is injuries or tumors in the spinal cord. Any type of damage to the spinal cord, whether from accidents, aging, birth defects, blood vessel diseases, infections, surgical side effects, radiation therapy, or unknown causes, can disrupt normal bladder function and lead to incontinence. It’s important to remember that people with injuries at or above the sixth thoracic vertebrae (T-6) have a higher risk of experiencing issues with involuntary body functions (autonomic dysreflexia).
Apart from spinal cord issues, there can be many other causes of bladder problems including:
- Alzheimer’s Disease
- Benign prostatic hyperplasia (enlarged prostate)
- Bladder decompensation (a tired bladder)
- Brain problems including injuries and tumors
- Cauda equina syndrome (nerve damage in the lower spine)
- Dementia
- Diabetes
- Side effects of certain medications
- Functional incontinence (urinary leaks due to physical or mental limitations)
- Herniated disc
- Infections that affect the nervous system
- Interstitial cystitis (painful bladder syndrome)
- Issues with mobility
- Severe obesity
- Multiple sclerosis
- Myelomeningocele (a birth defect where the spinal cord doesn’t form properly)
- Neurosyphilis (an infection of the brain or spinal cord caused by late-stage syphilis)
- Overactive bladder
- Parkinson’s disease
- Injury or surgery affecting the pelvis
- Pernicious anemia (vitamin B12 deficiency)
- Radiotherapy
- Spina bifida (birth defect affecting the spine)
- Sacral fractures
- Spinal and sacral tumors
- Stress incontinence (urinary leaks due to pressure on the bladder)
- Stroke
- Transverse myelitis (inflammation of the spinal cord)
- Urethral foreign bodies
- Urethral strictures
- Urinary tract infections
What to expect with Neurogenic Bladder and Neurogenic Lower Urinary Tract Dysfunction
The main aim of treating a condition called ‘neurogenic bladder’, where the nerves that control bladder function are damaged, is to protect the kidneys and help the patient control their urine. This is usually achieved through regular self-catheterization (inserting a tube to drain urine from the bladder) and medication that helps control bladder activity. About 90% of patients with this condition can successfully keep their bladder under control and their kidneys healthy with this method.
Patients need long-term monitoring to check on kidney health, measure urine-related parameters, and spot possible complications that might require further treatment. Regular check-ups also help doctors gauge if the current treatment is still working effectively.
In cases where patients face bladder function issues due to nerve problems, there are no standard rules on ideal ways to measure kidney health. In clinical practice, doctors often use imaging technology (like ultrasounds) and lab tests to assess kidney and bladder function. Patients can also track their bladder activity at home using a 24-hour bladder diary, and doctors can measure the amount of urine left in the bladder after urination.
While no hard and fast rules exist on how often patients with neurogenic bladder should be checked, a reasonable approach is a yearly assessment. This includes checking on symptoms, recording urine patterns for 24 hours, checking kidney health via lab tests, and measuring post-urination urine left in the bladder.
The American Urological Association (AUA) advises conducting these checks every year for patients at moderate risk, and also suggests imaging tests every 1-2 years. This includes patients with a catheter who have a higher chance of developing urinary stones. Also, doctors do not usually recommend routine urine cultures unless the patient shows symptoms. If a patient develops a urinary tract infection that doesn’t respond to antibiotics, they should get imaging tests and further checks if they repeatedly have unexplained urinary infections.
For high-risk patients, the AUA suggests yearly imaging in addition to the above checks. The Canadian Urological Association also recommends annual bladder imaging for patients with spinal cord injuries and those at moderate or high risk for neurogenic bladder.
If there’s any significant change in symptoms or new problems arise, further check-ups may be necessary. These could include a procedure called cystoscopy to check bladder functioning or look for bladder cancer in patients with chronic catheter use.
The practice of regularly using catheters to empty the bladder is common in many more developed countries such as India, Iran, Pakistan, Turkey, Malaysia, Brazil, and Mexico. However, in some countries like Kenya, Ethiopia, and Thailand, access to catheters is difficult. Reusable ones significantly cut down costs and are often donated by wealthier nations or charities. Despite this, acceptance of self-catheterization is low in less developed countries and has been linked to unfounded fears around infertility, cultural resistance, and practical issues like cost, access to medical facilities, and basic sanitation measures. Instead, alternatives like specially fitted condoms for males or pads for females might be used, but these can result in serious complications like kidney failure in cases where self-catheterization isn’t used when needed.
Possible Complications When Diagnosed with Neurogenic Bladder and Neurogenic Lower Urinary Tract Dysfunction
The problems a person can experience due to a neurogenic bladder, a condition where a person can’t control their bladder because of brain or nerve damage, might be either short-term or long-term. If left untreated, a neurogenic bladder can result in constant kidney infections, urinary tract infections, permanent damage to the bladder, kidney failure, development of kidney stones, complete loss of bladder elasticity, damage to the urethra, and blood in urine.
Long-term complications can include more persistent kidney stones, lasting urinary incontinence (inability to control urine), a deteriorating bladder condition, and in some rare cases, cancer.
Here are the potential issues:
- Constant kidney infections
- Urinary tract infections
- Permanent bladder damage
- Kidney failure
- Kidney stones
- Loss of bladder elasticity
- Damage to the urethra
- Blood in urine
- Persistent kidney stones (long-term)
- Lasting incontinence (long-term)
- Deteriorating bladder condition (long-term)
- Rare cases of cancer (long-term)
Preventing Neurogenic Bladder and Neurogenic Lower Urinary Tract Dysfunction
If you’re a patient dealing with a condition known as a neurogenic bladder and using a catheter for draining urine, it’s important for you to learn about how to take care of your catheter (Foley care), how to recognize a urinary tract infection, and how to monitor your urinary output. Wherever possible, traditional urethral Foley catheters should ideally be changed to what’s known as a suprapubic tube.
If you’re conducting clean periodic self-catheterization, it’s very important for you to learn the correct techniques to avoid complications. Similarly, if you’re using suprapubic tubes, you should adhere to the recommended care methods for your catheter. This includes maintaining cleanliness around the tube insertion area, possibly using medications to relax your bladder, and taking steps to avoid leakage of urine – this is important to prevent a skin condition called dermatitis. You should also be aware that if your suprapubic tube accidentally falls out, you need to rush to replace it immediately. If not quickly fixed, the opening for the tube (called a cystostomy) may close and potentially require another surgical procedure to replace.
You should also know how to recognize any potential complications, and understand how to look after yourself at home after treatment. Periodically, you may need to return to the hospital or clinic for medical follow-ups to check on your progress.
If you also have a condition called benign prostatic hyperplasia, it might be possible for you to try urinating naturally without catheterization. You should discuss this and any necessary subsequent care with your doctor. Potential surgical solutions and their associated risks, benefits, and possible complications should also be thoroughly discussed with your doctor. If your condition can be treated using medication, make sure you are aware of potential side effects of the drugs and the possibility that other medication options might have to be explored.
