revue neurologique 177 (2021) 589–593

Available online at

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International meeting of the French society of neurology 2020

How to treat neurogenic bladder and sexual

dysfunction after spinal cord lesion

P. Denys a,*, E. Chartier-Kastler b, A. Even a, C. Joussain a

a
Neurourology and andrology unit, department of physical medecine and rehabilitation, Raymond-Poincaré Hospital
AP–HP; Université Paris-Saclay; UMR 1179 Inserm, Paris, France
b
Department of urology, Hôpital de la Pitié, Paris-Sorbonne Université, Paris, France

info article abstract

Article history: Neurogenic bladder and sexual dysfunction after spinal cord lesions are highly prevalent.
Received 1st July 2020 The treatment algorithm for neurogenic bladder is well described. Clean intermittent self-
Accepted 6 July 2020 catheterisation associated with treatment of neurogenic detrusor overactivity is the gold
Available online 18 February 2021 standard. Goals of treatment are twofold: i) control risk factors to avoid upper urinary tract
complications, and ii) improve quality of life by treating incontinence when feasible. Lower
Keywords: urinary tract dysfunction is still a major cause of complications and hospitalisation. Sexual
Neurogenic bladder dysfunction must be addressed and treated and is at the top of patient expectations one year
Urinary tract infection after injury.
Erectile dysfunction # 2020 Elsevier Masson SAS. All rights reserved.
Spinal cord injury

detrusor contracts and the sphincters relax to obtain a

1. Introduction voluntary, complete and easy emptying of urine.

Continence and micturition are controlled both by autonomic

and somatic centres in the spinal cord and the brain. They
coordinate the activity of the smooth muscle of the bladder,
the internal sphincter, and the external striated sphincter of
the urethra during the two major physiological phases,
continence and micturition. This neurologic control acts as
a switch from storage to emptying. During the storage or
continence phase, the low pressure inside the bladder allows
the ureters to fill the bladder continuously with urine
produced by the kidneys, and urethra remains closed even
during stress. On the opposite, during micturition, the
2. Pathophysiology
2.1. Neurogenic bladder
Pathophysiology of the neurogenic bladder after spinal cord
injury (SCI) was clearly described in the 1990s [1]. Basically,
after the spinal shock phase, the detrusor is acontractile and
the sphincters closed, leading to urinary retention and
overflow incontinence; neuroplasticity progressively modifies
the properties of bladder afferences (C fibres) and spinal

* Corresponding author at: Neurourology and andrology unit, department of physical medecine and rehabilitation, Raymond-Poincaré
Hospital AP–HP, 104, boulevard Raymond-Poincaré, 92380 Garches, France.
E-mail address: pierre.denys@aphp.fr (P. Denys).
Abbreviations: NDO, neurogenic detrusor overactivity; CISC, clean intermittent self-catheterisation; SCI, spinal cord injury.
https://doi.org/10.1016/j.neurol.2020.07.013
0035-3787/# 2020 Elsevier Masson SAS. All rights reserved.
590 revue neurologique 177 (2021) 589–593
circuitry. If the lesion is suprasacral and infrapontine, both
continence and micturition are modified. During the storage
phase, the bladder spontaneously contracts [neurogenic
detrusor overactivity (NDO)] leading to incontinence. During
micturition, there is a loss of coordination between detrusor
contraction and sphincter relaxation (detrusor sphincter
dyssynergia), leading to high detrusor pressure and dysuria.
Patients are at the same time incontinent (by NDO), and suffer
from chronic urinary retention due to the functional obstruc-
tion by dyssynergia. The association of high detrusor pressure
and urinary retention is the major cause of upper urinary tract
complications that was the first cause of mortality in this
population until the 1980s [2].
Clean intermittent self-catheterisation (CISC) was descri-
bed by Lapides [3] and strongly modified the prognosis of
neurogenic bladder due to SCI. Despite major progress in the
management of neurogenic bladder, complications remain
frequent and are the first cause of re-hospitalisation in the
long term [4]. Altogether, there are still two major goals in the
management of neurogenic bladder: prevention of complica-
tions by avoiding high detrusor pressure and improvement of
quality of life by improving continence when possible.
2.2. Sexual function
Sexual function is under the control of the same centres in the
spinal cord. Spinal lesions induce severe sexual dysfunction
and can alter fertility in men. Erection can be achieved both by
psychological stimulation and reflexively by local perinea
stimulation. But in the end, even if the patient may achieve an
erection, depending on the level and completeness of the
lesion, it is often unstable and too short to permit a
satisfactory sexual life [5]. Moreover, even with the modifica-
tion of SCI epidemiology with more cervical lesions preserving
sacral and low thoracic centres, ejaculation is impaired in 85%
[6] of patients, impacting sexual life and fertility. Recent
scientific evidence of a spinal generator of ejaculation was
demonstrated in animals and in humans [7]. In females, there
are some differences in sexual response after SCI. This is due
to differences in the physiology of sexual response. Loss of
sensation depends on the completeness of the lesion. Erection
of the clitoris and lubrication are regulated in the same centres
as those involved in erection and ejaculation in males.
Moreover, the percentage of women with SCI who can
experience orgasm is much higher than in men, reaching
50% with a more prolonged stimulation [8].
3. Management of neurogenic bladder after
SCI
The algorithm of treatment for patients with SCI is now well
established and resumes the progress made in the manage-
ment of neurogenic bladder over the last 30 years: new
treatments for NDO, development of new surgical solutions
including both neuro-orthopedic surgeries to improve prehen-
sion and CISC abilities and urologic surgery, specially continent
cystostomy, to permit catheterisation through an abdominal
access, functional neurosurgery, and new preventive treat-
ments to prevent recurrent urinary tract infections (Fig. 1).
In fact, the major stratification is based both on gender
and level of injury impacting the ability to perform CISC. The
gold standard of treatment when possible or feasible is CISC
associated with treatment of NDO. Intermittent catheterisa-
tion is a mode of micturition and not the treatment of risk
factors and incontinence that require an association of
treatments to control NDO. Four rules are the key to success:
more than five catheterisations per day, a clean method
avoiding the use of antiseptic on the perineum, volume at
catheterisation below 450 mL, and diuresis of more than
1.5L. Intermittent catheterisation is feasible even by tetra-
plegic patients up to C6 level [9]. An educational program
including occupational therapy enables verification of the
physical ability to perform catheterisation, but also patient
education concerning prevention of urinary tract infection
by respecting the rules. In fact, intermittent catheterisation
is associated with urine colonisation raising the point that an
isolated positive urine culture does not mean that there is a
urinary tract infection requiring antibiotic therapy. The most
important difficulty is to achieve appropriate diagnosis of
symptomatic urinary tract infection based on often non-
specific symptoms (spasticity, autonomic dysreflexia, fati-
gue, etc.) and urine culture results [10]. The risk of acquiring
multi-resistant germs is high in this population and can
reach 50% of patients at one year due to overuse of
antibiotics.
NDO treatment is mandatory to control incontinence and
risk factors. A three-step strategy should be managed from
injury to grave [11]. Antimuscarinics are the first line of
treatment. Their prescription can be based on symptoms and
urodynamics with proven NDO. There is enough evidence to
recommend antimuscarinics as first-line treatment. Side
effects of antimuscarinics are well described in the literature;
constipation deserves specific attention in this population [12].
Cognitive effects of anticholinergics make this prescription
difficult in the older population [13].
In case of lack of efficacy, secondary failure or treatment,
intolerance/contraindication to anticholinergics, intradetru-
sor onabotulinumtoxinA injection is proposed. A dose of 200U
is a recognised and very efficient therapy to control inconti-
nence and urodynamics risks factors and to improve quality of
life [14,15]. The injection is made under cystoscopic guidance
and local anesthesia, with 30 sites of injection into the
detrusor with 1 mL each and avoiding the trigone. Efficacy
appears earlier and longer than with botulinum toxin
injections in striated muscles as was previously described
in other clinical indications in autonomic disorders, such as
hyperhydrosis. The efficacy of detrusor botulinum toxin was a
real revolution in the field, because it mimics the efficacy of
major surgery. Unfortunately, long-term studies recently
demonstrated secondary failure to control NDO after five
years, thus requiring close follow-up both clinically and
urodynamically [16].
Third-line treatment is augmentation cystoplasty that was
the second-line treatment for a long time.
The efficacy of augmentation is now well described in the
long term both to control incontinence risk factors and long-
term complications [17]. Augmentation cystoplasty can be
associated in the same surgical procedure with continent
cystostomy for patients for whom intermittent catheterisa-
 revue neurologique 177 (2021) 589–593 591

Fig. 1 – Algorithm of treatment of neurogenic bladder after SCI. Reiss B. Urodynamic evaluation and Spinal cord injury.
communication 19th European Congress of Physical and Rehabilitation Medicine, Marseille, 26-31 May 2014 / 29ème
Congrès de la Société Française de Médecine Physique et de Réadaptation, Marseille, 26-31 mai 2014.

tion is only feasible via an abdominal hole [18]. This surgery
was initially described in children by a French surgeon using
the appendix to create the conduit between the bladder and
the abdominal wall. This surgery in adults is particularly
helpful for female tetraplegics when undressing and difficult
access to urethra is a barrier to catheterisation. The major
advantage is that catheterisation can be done on the wheel
chair with limited undressing. Tendon transfer to improve
prehension can be done before urological surgery for the
purpose of catheterisation [9].
These three treatments, as previously mentioned, are
associated with intermittent catheterisation to empty the
bladder.
If intermittent catheterisation is impossible, a careful
analysis is needed to understand the cognitive or functional
barriers preventing catheterisation.
For male and female patients alike, one solution is sacral
anterior root stimulation developed in the 1980s by Brindley
[19,20]. This solution associates complete sacral posterior
rhizotomy to abolish the abnormal micturition reflex, and on
demand voluntary sacral anterior root stimulation to induce
micturition. Though this micturition remains dyssinergic,
the evidence is that there is no risk for the kidneys. The
efficacy of this neurosurgical method of treatment is very
good, permitting continence and voluntary micturition
without catheterisation, and reducing the risk of urinary
tract infection. But, there are several severe limitations that
hamper access to this strategy. Posterior sacral rhizotomy
from S2 to S5 induces side effects altering sexual function
with disappearance of sexual reflexes that are important for
sexual response. It also creates a complete anesthesia of the
skin in the sacral dermatomes. Moreover, micturition implies
transfer to and from the toilet that is less convenient than
catheterisation on the wheel chair. Altogether, the paraplegic
female with a complete lesion and a preserved micturition
reflex is a good indication.
For high tetraplegic females, there are few alternatives if
catheterisation is not feasible even through an abdominal
hole. In this case, a non-continent urinary diversion can be
discussed with the patient. The advantage is that there are few
constraints in terms of human assistance and less risk than an
indwelling catheter, but the modification of body image is a
real subject that requires deep discussion. The risk for the
kidneys is low. Cystectomy needs to be done at the same time
to reduce the infectious risk [21].
For high tetraplegic men, and if the detrusor is contractile,
sphincterotomy reduces the functional obstruction and the
ultimate goal is to achieve a balanced bladder. This includes
complete micturition even by tapping at low pressure. This
solution requires penile sheaths to collect urine and must be
tested before surgery to secure clinical results [22].
An indwelling catheter is never a mid- or long-term option,
because it is perfectly proven that this strategy involves a very
high medical risk for the patient. Some, such as urinary tract
infection or bladder lithiasis, are well known, but bladder
cancer, upper urinary tract complications, and renal failure
are more frequent in chronic users of indwelling catheters.
Moreover, ureteral dilatation or stenosis, frequent in the long
term, constitute an etiology of urine leakage around the
catheter. All those complications argue in favour of severe
restriction for the use of an indwelling catheter.
A long-term follow-up is mandatory and recommended by
all scientific societies. A preventive strategy is very important
in light of the high prevalence of complications.
592 revue neurologique 177 (2021) 589–593
4. Management of sexual disorders
4.1. In men
Treatment for sexual dysfunction is one of the first patient
expectations one year after injury [23]. Several factors
contribute to sexual dysfunction and impaired satisfaction
related to sexual life, loss of sensation, erectile dysfunction,
anejaculation and modification of orgasmic sensation, but
desire is usually preserved in this population.
4.1.1. Erectile dysfunction
Erectile dysfunction is very common in the SCI population.
The patient will experience after spinal shock the reappea-
rance of reflexogenic erection even out of erotic context, after
local stimulation that can be masturbation, but also cathete-
risation or stimulation for defecation. Phosphodiesterase 5
inhibitors, either daily or on demand, improve the quality of
erection as it has been demonstrated for all drugs on the
market in double-blind studies in SCI populations with a very
good safety profile [24]. No significant effect on ejaculation, as
well as local sensation, has been reported. These drugs do not
work if there is no beginning of erection meaning that the
patient has to stimulate to induce reflexogenic erection to
benefit from the treatment. Another option is intracavernous
injection on demand of vasoactive drugs, such as prosta-
glandin-E1. Those drugs are reimbursed in France for
neurogenic impotence and work very well even if there is
no erection initiated and can be first-line or second-line
treatment. Other options, such as vacuum, can be discussed in
selected patients. The inflatable or rigid penile prosthesis is
not used in this population, because of the high risk of
infection probably due to frequent urinary tract infection and
intermittent catheterisation.
4.1.2. Ejaculatory dysfunction
Ejaculation is not present during intercourse or masturbation
in 85% of the population. This symptom can be improved for
sexual or reproductive purposes by a submaximal stimulation
using vibration of the glans [25]. In case of lesions above T10,
70% respond to penile vibration that can be used both during
intercourse or for sperm retrieval and at home intravaginal
insemination.
Sperm has specific characteristics in this population
affecting the quality of spermatozoids rather than the count;
in case of anejaculation or in the process of procreative
medical assistance, sperm retrieval can be done surgically or
with intrarectal electrical stimulation.
4.2. In women
Literature about sexual dysfunction after SCI in women is
more recent. Similarities regarding patient expectations and
symptoms are reported, but with major differences [26].
Fertility is not impaired, but needs specific follow-up to
prevent complications during pregnancy. Regarding sexual
disorders, most of the authors emphasise the role of education
to improve sexual satisfaction. As well as for men, the first
barrier is incontinence that must be controlled also for this
purpose. Local treatment with lubricants can be used in case of
loss of reflexogenic lubrification. Orgasm can be preserved in
more than 50% of patients, but often requires longer and
stronger stimulation. Vibrators may help in this case.
During pregnancy, depending on the level of injury, several
medical interventions are mandatory. Prevention of urinary
tract complications implies a specific follow-up. Depending on
the level of injury, the uterine contraction sensation can be
preserved (T10). In high thoracic or cervical lesions, close
follow-up and medical intervention are mandatory to prevent
autonomic dysreflexia. Regional anesthesia helps to control
autonomic dysreflexia during delivery [27].
5. Conclusion
Lower urinary tract dysfunction and sexual disorders are a
major challenge for spinal cord injured patients in the long
term. Major advances in therapeutic management practices
modify mortality and life expectancy. Morbidity related to the
lower urinary tract is still an unmet medical need, and is
mostly related to urinary tract infection. Sexual disorders are
at the top of patient expectations, and deserve special care by
medical teams to achieve patient benefit.
Disclosure of interest
The authors declare that they have no competing interest.
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