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Neurogenic bladder

Dr Frank Gaillard et al.

A neurogenic bladder is a term applied to a dysfunctional urinary bladder that results from an injury to the central or peripheral nerves that control and regulate urination. Injury to the brain, brainstem, spinal cord or peripheral nerves from various causes including infection, trauma, malignancy or vascular insult can result in a dysfunctional bladder ³.

Epidemiology

In a large cohort study, the mean age of neurogenic bladder patients was 62.5 years and resultant aetiologies included ⁴

multiple sclerosis : ~ 17%
Parkinson disease : ~ 15%
cauda equina syndrome : ~ 9%
paralytic syndrome : ~ 8%
stroke complications : ~ 6%

Clinical Presentation

Depending on the location of the injury in the nervous system, patients typically present with increased frequency, nocturia, urinary incontinence/urgency, urinary tract infection and urinary retention. Bladder may be hyperreflexic, hyporeflexic or areflexic with impaired to no sensation³.

Classification

A number of classification schemes exist for neurogenic bladders, including the Lapides classification which remains popular.

sensory neurogenic bladder : posterior columns of the spinal cord or afferent tracts leading from the bladder
motor paralytic bladder : damage to motor neurons of the bladder
uninhibited neurogenic bladder : incomplete spinal cord lesions above S2 or cerebral cortex or cerebropontine axis lesions
reflex neurogenic bladder : complete spinal cord lesions above S2 - may lead to pine cone bladder
autonomous neurogenic bladder : conus or cauda equina lesions

Radiograpic Features

Generally a markedly contracted or distended bladder.

Fluoroscopic/IVP

Sensory neurogenic bladder

Inability to sense bladder fullness results in a large rounded and smooth bladder. Voiding is often preserved.

Motor paralytic bladder

Atonic large bladder with inability of detrusor contraction during voiding.

Unhibited neurogenic bladder

Rounded bladder with a trabeculated apperance to the mucosa above the trigone from detrusor contractions. On voiding large interureteric ridge is noted

Reflex neurogenic bladder

Results from detrusor hyperreflexia with a dyssynergic sphincter. This leads to contrast extension to the posterior urethra and an elongated pointed urthera with pseudodverticula.

Autonomous neurogenic bladder

Intermediate between detrusor hyperreflexia (contracted) and dysreflexia (atonic).

Ultrasound

Detailed images of the bladder often demonstrate a thick wall with a small contracted or large atonic bladder. A large post void residual is often noted.

Treatment

Depending on the aetiology, various techniques can be employed to maintain renal function and prevent urinary tract infections. Self catheterization, medication or surgical interventions including cystoplasty or sphincterotomy can be employed.