Neurogenic bladder: causes, symptoms and management in the UK

Normal bladder control depends on signals passing between the bladder, the spinal cord and the brain, so that the bladder stores urine comfortably and empties when you decide. A UK clinical reference article explains that any condition that impairs these signals can cause a neurogenic bladder.

The article describes two broad patterns. In a flaccid (hypotonic) bladder, the bladder volume is large, pressure is low and contractions are absent. In a spastic bladder, volume is normal or small and involuntary contractions occur, usually after brain damage or spinal cord damage above a certain level. Mixed patterns also occur, and the pattern can change over time after a spinal injury.

Because the bladder and the muscle valve around the urethra (the sphincter) may not work in a co-ordinated way, the result can be both leakage and incomplete emptying at the same time. This is why neurogenic bladder is managed by specialists rather than by a single, standard approach.

The clinical reference article groups causes by where the nerve damage lies. It lists central nervous system causes such as stroke, multiple sclerosis, spinal injury, meningomyelocele and motor neurone disease; peripheral nerve causes such as diabetes, vitamin B12 deficiency neuropathies, a herniated disc and damage due to pelvic surgery; and mixed causes such as Parkinson's disease and tumours.

Bladder outlet obstruction can co-exist and make symptoms worse, the article notes, so assessment usually considers the prostate in men and other blockages as well as the nerves.

A neurogenic bladder may be present from birth, for example in spina bifida, or develop later in life after injury or illness. Which type you have, and how severe it is, depends on the site and extent of the nerve damage.

According to the article, overflow incontinence is the primary symptom of both flaccid and spastic bladder: patients retain urine and have constant overflow dribbling. Men typically also have erectile dysfunction. Those with a spastic bladder may have frequency, nocturia (waking at night to pass urine) and urgency.

Complications listed include reduced quality of life with social isolation and embarrassment, more frequent urinary tract infections and stones, and, because large urine volumes put pressure on the ureters, back-flow of urine towards the kidneys, which in severe cases can damage the kidneys. People with high spinal cord injuries are at risk of autonomic dysreflexia, a life-threatening syndrome of very high blood pressure, headache and sweating, which can be triggered by a full bladder or bowel.

• Leakage or dribbling, or sudden urgency.

• Difficulty starting or emptying fully.

• Repeated urinary tract infections.

• Waking at night to pass urine.

• For people with high spinal injuries: sudden severe headache, flushing and sweating with a full bladder or bowel, which needs urgent help.

The article says diagnosis is suspected clinically and a large post-void residual volume, the amount of urine left after passing urine, confirms it. Investigations may include a blood test for kidney function (serum creatinine), a renal ultrasound to look for swelling of the kidneys, and urodynamics, which measure pressure and flow in the bladder and are mandatory before any surgery is considered.

A full clinical history and examination are needed, including bowel and sexual symptoms and any problems with mobility, cognition or hand function, because these affect which treatments are practical. Anyone with red-flag features such as blood in the urine or worsening kidney function should be referred.

NICE guideline CG148 covers recommendations on assessment, information and support, treatment to improve bladder storage and emptying, and monitoring for complications. The UK clinical reference article summarises the main options.

The article stresses that patients and carers need adequate support and education and that the effect on relationships and quality of life should not be underestimated. The NHS notes that most people with a long-term catheter can live a relatively normal life, including working, exercising, swimming and having sex, and that you will be given detailed advice about looking after a catheter and reducing infection risk.

The clinical article says that if a urinary tract infection is suspected, treatment should be guided by symptoms and a urine culture rather than a dipstick alone, because bacteria can colonise a catheter without causing illness. It also says a high fluid intake can lower the risk of infections and stones, although it may worsen incontinence, and that absorbent products can protect skin and clothing. Attending regular reviews and kidney monitoring, and telling any new clinician about your bladder condition, are sensible steps.

NHS care usually involves a GP, a continence service and a urologist or a specialist neuro-urology service, working with the team treating the underlying neurological condition. Catheter supplies are normally arranged through the GP or specialist nurse.

Private urology and neuro-urology consultations are available for those who want quicker access to assessment such as urodynamics or a second opinion. Because lifelong follow-up is usually needed, ask who will monitor your kidney health, who provides catheter supplies and where to turn if you develop an infection.