Neurogenic bladder

Last revised by Dr Rohit Sharma on 24 Jun 2022

Neurogenic bladder is a term applied to a dysfunctional urinary bladder that results from any lack of coordination between the central nervous system and the somatic nervous system, 5 including injuries to the central or peripheral nerves that control and regulate urination. Injury to the brain, brainstem, spinal cord or peripheral nerves from various causes such as infection, trauma, malignancy or vascular insult can also lead to dysfunctional bladder 3.

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

Depending on the level of the injury in the nervous system, patients typically present with increased frequency, nocturia, urinary incontinence/urgency, urinary tract infection and urinary retention. The bladder may be hyperreflexic, hyporeflexic or areflexic with impaired to no sensation 3

Several classifications are available for neurogenic bladders, but the Lapides classification has been remained popular and includes the following:

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

Generally a markedly contracted or distended bladder.

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

Atonic large bladder with the inability of detrusor contraction during voiding.

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

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

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

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.

Preserving continence and renal function are the main objectives of treatment and are based on etiology. Various techniques can be employed to maintain renal function and prevent urinary tract infections. Clean and intermittent self-catheterization is the gold standard for detrusor overactivity 5. Medication or surgical interventions, including cystoplasty or sphincterotomy, can be employed. Sacral and pudendal neuromodulations are other options when combined with other treatments. If the neurogenic bladder is not properly managed can lead to short-term complications such as recurrent pyelonephritis and long-term complications such as refractory urinary incontinence and even malignancy 5.  

Imaging differential considerations include:

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Cases and figures

  • Case 1: on MRI
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  • Case 2
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  • Case 3: distended
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  •  Case 4
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  • Case 5
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  • Case 6
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  • Case 7
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  • Case 8
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  • Case 9: CT
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  • Case 10
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  • Case 11
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  • Case 12
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