Voiding Dysfunctions:

Neurogenic bladder & its management

Presented by:
Mohd.parvez
MSc.(N) 1st Year
Nephro-Urology Nursing
Anatomy and Physiology of Urinary System
Neural innervation of Bladder
Neural
control
of
Micturition
Introduction

•Both neurogenic and non-neurogenic disorders can cause adult voiding

dysfunction.
•A functional urinary system allows for appropriate bladder filling and complete
bladder emptying.
•If voiding dysfunction goes undetected and untreated, the upper urinary system
may be compromised.
How ? Lets see…
•Chronic incomplete bladder emptying from poor detrusor pressure results in
recurrent bladder infection.
•Incomplete bladder emptying due to bladder outlet obstruction (such as benign
prostatic hyperplasia), causing high-pressure detrusor contractions, can result in
hydronephrosis from the high detrusor pressure that radiates up the ureters to the

renal pelvis.
Classification of Voiding Dysfunctions
Meaning and Definition
Neurogenic bladder dysfunction, or neurogenic bladder, refers to 
urinary bladder problems due to disease or injury of the central nervous system or
peripheral nerves involved in the control of urination. There are multiple types of
neurogenic bladder depending on the underlying cause and the symptoms.
Symptoms include overactive bladder, urinary urgency, frequency, incontinence or
difficulty passing urine.
 Epidemiology

The overall prevalence of neurogenic bladder is limited due to the

broad range of conditions that can lead to urinary dysfunction.
Neurogenic bladder is common with spinal cord injury and multiple
sclerosis.
Among patients with multiple sclerosis, 20–25% will develop
neurogenic bladder although the type and severity bladder dysfunction is
variable.
Causes/Etiology

 Urine storage and elimination (urination) requires coordination between the

bladder emptying muscle (detrusor) and the external sphincter of the bladder.

 This coordination can be disrupted by damage or diseases of the central nervous

system, peripheral nerves or autonomic nervous system.

 This includes any condition that impairs bladder signaling at any point along the
path from the urination center in the brain, spinal cord, peripheral nerves and the
bladder.
Issues with Central nervous system
Damage to the brain or spinal cord is the most common cause of neurogenic bladder.

Damage to the brain can be caused by stroke, brain tumors, multiple sclerosis, Parkinson's
disease or other neurodegenerative conditions. Bladder involvement is more likely if the damage
is in the area of the pons.

Damage to the spinal cord can be caused by traumatic injury, demyelinating disease, 

syringomyelia, cauda equina syndrome, or spina bifida. Spinal cord compression from 
herniated disks, tumor, or spinal stenosis can also result in neurogenic bladder.
Issues with Peripheral nervous system
Damage to the nerves that travel from the spinal cord to the bladder (peripheral
nerves) can cause neurogenic bladder, usually the flaccid type.

Nerve damage can be caused by diabetes, alcoholism, and vitamin B12 deficiency

.

Peripheral nerves can also be damaged as a complication of major surgery of the

pelvis, such as for removal of tumors.
Types/Classification of
Neurogenic Bladder:

Uninhibited

Neurogenic
Mixed Bladder Spastic

Flaccid
1) Uninhibited
 Uninhibited bladder is usually due to damage to the brain from a stroke or 
brain tumor.
 This can cause reduced sensation of bladder fullness, low capacity bladder and 
urinary incontinence.
 Unlike other forms of neurogenic bladder, it does not lead to high bladder
pressures that can cause kidney damage.
2) Spastic
 Upper motor neuron or hyper-reflexive bladder, the muscle of the bladder (detrusor) and 
urethral sphincter do not work together and this phenomenon is also called 
detrusor external sphincter dyssynergia (DESD).

 This leads to urinary retention with high pressures in the bladder that can damage the
kidneys.

 The bladder volume is usually smaller than normal due to increased muscle tone in the
bladder.

 Usually caused by damage to the spinal cord above the level of the 10th 

thoracic vertebrae (T10). This is the more common type as compared to others.
3) Flaccid
 Lower motor neuron or hypotonic bladder, the muscles of the bladder lose ability to
contract normally. This can cause the inability to void urine even if the bladder is full
and cause a large bladder capacity.

 The internal urinary sphincter can contract normally, however urinary incontinence is
common.

 Caused by damage to the peripheral nerves that travel from the spinal cord to the
bladder, commonly resulting from trauma.

 Because sensory loss may accompany a flaccid bladder, the patient feels no
discomfort.
4) Mixed
 Mixed type of neurogenic bladder can cause a combination of the above
presentations.
 In mixed type A, the bladder muscle is flaccid but the sphincter is overactive.
This creates a large, low pressure bladder and inability to void, but does not
carry as much risk for kidney damage as a spastic bladder.
 Mixed type B is characterized by a flaccid external sphincter and a spastic
bladder causing problems with incontinence.
Pathophysiology

Because of causes and Risk factors (damage to CNS or damage to PNS as a result of
Stroke, Brain tumor, Multiple sclerosis, Parkinson's disease or Spina bifida, Spinal cord
injuries, Diabetes, Vitamin B 12 deficiency or other Neurodegenerative disorders).

Brain or Spinal cord stops responding towards Bladder filling or emptying.

Resulting into various manifestations like, urinary urgency, urinary incontinence,

dysuria (because of urinary retention).

Urinary Tract Infection (Frequency, Urgency, Burning micturition and even Hematuria)
Clinical Manifestations
1) Urinary urgency and Urinary incontinence

 Leaking urine when coughing, sneezing, laughing, or exercising

 Feeling sudden, uncontrollable urges to urinate
 Frequent urination
 Waking up many times at night to urinate (Nocturia)
 Urinating during sleep (Enuresis)
 Urinary retention

 the inability to completely empty the bladder when

urinating (residual urine)
 frequent urination in small amounts
 difficulty starting the flow of urine (hesitancy)
 a slow/weak urine stream
 the urgent need to urinate, but with little success
 feeling the need to urinate after finishing urination
 Signs and symptoms of UTI

 A strong, persistent urge to urinate (Urgency)

 A burning sensation when urinating (Burning urination)
 Passing frequent, small amounts of urine (frequency)
 Urine that appears cloudy
 Urine that appears red, bright pink or cola-colored (Hematuria)
*The first sign of bladder dysfunction may be recurrent 
urinary tract infections (UTIs).
Complications
 Hydronephrosis (swelling of a kidney due to a build-up of urine)

 recurrent urinary tract infections, and

 recurrent kidney stones (which may compromise kidney function)

These are especially significant in spastic neurogenic bladder that leads to high bladder
pressures. 

Note: Kidney failure was previously a leading cause of mortality in patients with spinal cord
injury but is now dramatically less common due to improvements in bladder management.
Assessment and Diagnostic Findings

History Collection

History should include information on the onset, duration, triggers, severity, other
medical conditions and medications (including anticholinergics, 
calcium channel blockers, diuretics, sedatives, alpha-adrenergic agonist, 
alpha 1 antagonists).

In children it is important to obtain a prenatal and developmental history.

Physical Examination

• Palpation of bladder above

the level of symphysis pubis
(Urinary Retention).

• Urinary symptoms may

include frequency, urgency,
incontinence or recurrent 
urinary tract infections
 (UTIs).
Lab Investigations
Ultrasound Imaging can give information on the
shape of the bladder, post-void residual volume, and
evidence of kidney damage such as kidney size,
thickness or ureteral dilation. 

Trabeculated bladder on ultrasound indicates high

risk of developing urinary tract abnormalities such as
hydronephrosis and stones. 
Voiding cystourethrography study uses contrast dye to obtain images of the
bladder both when it is full and after urination which can show changes in bladder
shape consistent with neurogenic bladder.
Urodynamic studies/Urodynamics refers to the measurement of the pressure-
volume relationship in the bladder.

The bladder usually stores urine at low pressure and urination can be completed without a
dramatic pressure rise.

Damage to the kidneys is probable if the pressure rises above 40 cm of water during filling. 

Bladder pressure can be measured by cystometry, during which the bladder is artificially filled
with a catheter and bladder pressures and detrusor activity are monitored. Patterns of involuntary
detrusor activity as well as bladder flexibility, or compliance, can be evaluated.

The most valuable test to test for detrusor sphincter dyssynergia (DESD) is to perform cystometry

 simultaneously with external sphincter electromyography (EMG). 
Uroflowmetry is a less-invasive study that can measure urine flow rate and
use it to estimate detrusor strength and sphincter resistance. 

Urethral pressure monitoring is another less-invasive approach to

assessing detrusor sphincter dyssynergia. 

These studies can be repeated at regular intervals, especially if symptoms worsen

or to measure response to therapies.
Imaging of the pelvis with CT scan or magnetic resonance imaging
 may be necessary, especially if there is concern for an obstruction
such as a tumor.
Evaluation of kidney function through blood tests such as 
serum creatinine should be obtained.
Evaluation for neurogenic bladder involves measurement of:
 fluid intake,
 urine output,
 residual urine volume;
 urinalysis;
 assessment of sensory awareness of bladder fullness and degree of motor control
and
 Comprehensive urodynamic studies.
Medical Management
Long-term objectives

 preventing overdistention of the bladder,

 emptying the bladder regularly and completely,

 maintaining urine sterility with no stone formation, and

 maintaining adequate bladder capacity with no reflux.

Specific interventions
 continuous, intermittent, or self-catheterization;
 use of an external condom-type catheter;
 a diet low in calcium (to prevent calculi); and
 encouragement of mobility and ambulation.
A liberal fluid intake is encouraged to reduce the urinary bacterial count, reduce
stasis, decrease the concentration of calcium in the urine, and minimize the
precipitation of urinary crystals and subsequent stone formation.
Bladder retraining program
Use of a timed, or habit, voiding schedule may be established.

To further enhance emptying of a flaccid bladder, the patient may be taught

to “double void.”

*Double voiding - After each voiding, the patient is instructed to remain on

the toilet, relax for 1 to 2 minutes, and then attempt to void again in an effort
to further empty the bladder.
Pharmacological Therapy
 Parasympathomimetic medications, such as bethanechol (Urecholine), may help to increase
the contraction of the detrusor muscle.

 Alpha blockers can also reduce outlet resistance and allow complete emptying if there is
adequate bladder muscle function.

 Oxybutynin is a common anti-cholinergic medication used to reduce bladder contractions

by blocking M3 muscarinic receptors in the detrusor. Its use is limited by side effects such
as dry mouth, constipation and decreased sweating. 

 Tolterodine is a longer acting anticholinergic that may have fewer side effects.
Botulinum Toxin

Botulinum toxin (Botox) can be used through two different approaches:

The bladder muscle (detrusor) can be injected which will cause it to be flaccid for
6–9 months. This prevents high bladder pressures and intermittent catheterization
must be used during this time.

Botox can also be injected into the external sphincter to paralyze a spastic
sphincter in patients with detrusor sphincter dyssynergia.
Neuromodulation

There are various strategies to alter the interaction between the nerves and
muscles of the bladder, including nonsurgical therapies (transurethral electrical
bladder stimulation), minimally invasive procedures (sacral neuromodulation
pacemaker), and operative (reconfiguration of sacral nerve root anatomy).
Intravesical transurethral bladder stimulation
is a rehabilitative and diagnostic technique
for the neurogenic bladder. The goal of
therapy is 3-fold:
1) to achieve the sensation of bladder filling or
the urge to void,
2) to initiate a detrusor contraction and
3) to achieve conscious urinary control.
Catheterization
*Catheterization - Emptying the bladder with the use of a catheter, the most
common strategy for managing urinary retention from neurogenic bladder.

Intermittent catheterization - involves no surgery or permanently attached

appliances using straight catheters (which are usually disposable or single-use
products) several times a day to empty the bladder.

Foley catheter i.e., indwelling catheterization allows continuous drainage of

urine into a sterile drainage bag that is worn by the patient, which are associated
with higher rates of complications.
Surgical Management
1.) Urinary Diversion: Creation of a stoma (from the intestines, called "conduit") that bypasses
the urethra to empty the bladder directly through a skin opening.
Several techniques may be used. One technique is the Mitrofanoff stoma, where the appendix or
a portion of the ileum (‘Yang-Monti’ conduit) are used to create the diversion.
The ileum and ascending colon can also be used to create a pouch accessible for catheterization (
Indiana pouch).
2.) Urethral stents or urethral sphincterotomy are other surgical
approaches that can reduce bladder pressures but require use of an external urinary
collection device.
3.) Urethral slings may be used in both adults and children (for stress
incontinence).
4.) Artificial Urinary Sphincters have shown good term outcomes in adults and
pediatric patients.
Bladder augmentation (augmentation cystoplasty): In this surgery, a surgeon
removes segments of intestine (sigmoid colon) and attaches them to the walls of the
bladder. This reduces the bladder's internal pressure and increases its ability to store
urine.
 Summary
In this seminar we have discussed about the anatomy and physiology of Urinary
system along with the bladder control under the influence of nervous system. We
have also learnt about the introduction, meaning and classification of voiding
dysfunction followed by definition, etiology, classification, pathophysiology,
clinical presentation, diagnostic findings and medical, surgical & nursing
management of Neurogenic bladder.
 Conclusion
Neurogenic Bladder, also known as Neurogenic Lower Urinary Tract Dysfunction, is when the
affected person lacks bladder control due to brain, spinal cord or nerve problems. Several muscles
and nerves must work together for the bladder to hold urine until it is ready to empty. Nerve
messages go back and forth between the brain and the muscles that control when the bladder
empties. If these nerves are harmed by illness or injury, the muscles may not be able to tighten or
relax at the right time. In people with neurogenic bladder, the nerves and muscles do not work
together well. The bladder may not fill or empty in the right way.

Millions of people have neurogenic bladder. This includes people with Multiple Sclerosis (MS),
Parkinson’s disease and spina bifida. It also could include people who have had a stroke, spinal
cord injury, major pelvic surgery, diabetes or other illnesses.
Research Article
Epidemiology and healthcare utilization of neurogenic bladder patients in a us claims database
Abstract

Aims
To characterize the patient profile, medication utilization, and healthcare encounters of patients with neurogenic
bladder dysfunction related to incontinence.

Methods
Medical and pharmacy claims were retrospectively analyzed from April 1, 2002 to March 31, 2007 to characterize
neurogenic bladder patients. There were 46,271 patients in the Neurogenic bladder cohort, and 9,315 and 4,168
patients in Multiple Sclerosis (MS) and Spinal Cord Injury (SCI) subcohorts, respectively. Demographic data,
concomitant diseases, use of overactive bladder (OAB) oral drug, and healthcare encounters were summarized using
descriptive statistics.
Results
The mean age of neurogenic bladder patients was 62.5 (standard deviation 19.6) years. A high frequency of lower urinary tract
infections (UTIs; 29%–36%), obstructive uropathies (6%–11%), and urinary retention (9%–14%), was observed. Overall,
33,100 (71.5%) patients were taking an OAB oral drug; 10,110 (30.5%) patients discontinued and did not restart. During the
one-year follow-up period, 39.0% (8,034) of neurogenic bladder patients had a urology visit, 31.7% (14,679) had a neurology
visit, 33.3% (15,415) were hospitalized, and 14.4% (6,646) were in a nursing home (highest rates observed in SCI subcohort).
UTI diagnoses comprised over 20% of all hospitalizations one-year post-index. Annually, neurogenic bladder patients
averaged 16 office and 0.5 emergency room visits.

Conclusions
This is the largest observational study conducted to address the epidemiology of the neurogenic bladder population, including
healthcare utilization. These data suggest that patients with neurogenic bladder may have suboptimal management, indicated
by high incidences of urinary tract complications and hospitalizations. Neurourol. Urodynam. 30:395–401, 2011. © 2010
Wiley-Liss, Inc.