Neurogenic Bladder

1. LOWER URINARY TRACT
DYSFUNCTION
IN THE NEUROLOGICAL
PATIENT
Ade Wijaya, MD
August 2018

2. INTRODUCTION
~ Neurogenic bladder
Can result from a wide range of neurological disorders.
Quality of life
Panicker, J. N., Fowler, C. J., & Kessler, T. M. (2015). Lower urinary tract dysfunction in the neurological patient: clinical assessment and management. The Lancet Neurology, 14(7), 720-732.

3. NEUROLOGICAL CONTROL OF
MICTURITION
Scottish Acquired Brain Injury Network

4. LUT DYSFUNCTION AFTER NERVOUS
SYSTEM DAMAGE
Panicker JN, de Sèze M, Fowler CJ. Rehabilitation in practice: neurogenic lower urinary tract dysfunction and its management. Clin Rehabil
PVR = post void residual

5. DIAGNOSIS
Panicker, J. N., Fowler, C. J., & Kessler, T. M. (2015). Lower urinary tract dysfunction in the neurological patient: clinical assessment and management. The Lancet Neurology, 14(7), 720-732.

6. STROKE
• More than 50% of stroke patients have urinary incontinence during
the acute phase of stroke.
• Risk factors for incontinence include large lesion size, presence of
comorbid illnesses (diabetes and older age), lesions in the
anteromedial frontal lobe, paraventricular white matter, and putamen.
• Urodynamics provides evidence of detrusor overactivity.
• Urinary retention has been reported after haemorrhagic and
ischaemic stroke, and urodynamics shows evidence of detrusor
underactivity.
• Small-vessel disease of the white matter, leukoaraiosis, is associated
with urgency incontinence, and it is becoming increasingly apparent
that this is an important cause of incontinence in functionally
independent people older than 60 years
Han KS, Heo SH, Lee SJ, et al. Comparison of urodynamics between ischemic and hemorrhagic stroke patients; can we suggest the category of urinary dysfunction in patients with
cerebrovascular accident according to type of stroke? Neurourol Urodyn 2010; 29: 387–90.
Kuchel GA, Moscufo N, Guttmann CR, et al. Localization of brain white matter hyperintensities and urinary incontinence in community-dwelling older adults. J Gerontol
A Biol Sci Med Sci 2009; 64: 902–09.
Tadic SD, Griffi ths D, Murrin A, et al. Brain activity during bladder fi lling is related to white matter structural changes in older women with urinary incontinence.Sakakibara R, Hattori T, Yasuda K, et al. Micturitional disturbance after acute hemispheric stroke: analysis of the lesion site by CT and MRI. J Neurol

7. DEMENTIA
• Incontinence in late stage (AD)
• Occur early in NPH, DLB, VD, FTD
• Pharmacological treatment of one disorder can exacerbate the other
• Detrusor overactivity, cognitive and behavioural problems, urological
causes, and immobility.
Sakakibara R, Kanda T, Sekido T, et al. Mechanism of bladder dysfunction in idiopathic normal pressure hydrocephalus. Neurourol Urodyn 2008; 27: 507–10.
Ransmayr GN, Holliger S, Schletterer K, et al. Lower urinary tract symptoms in dementia with Lewy bodies, Parkinson disease, and Alzheimer disease. Neurology 2008; 70: 299–303.
Sink KM, Thomas J, Xu H, et al. Dual use of bladder anticholinergics and cholinesterase inhibitors: long-term functional and cognitive outcomes. J Am Geriatr Soc 2008; 56: 847–53

8. PARKINSON’S DISEASE AND MSA
• Association between dopaminergic neurodegeneration and LUT
dysfunction.
• LUT symptoms in multiple system atrophy (MSA) can precede other
neurological manifestations.
• Arises from detrusor overactivity and external sphincter weakness.
• Incomplete emptying worsens as the disease progresses.
• An open bladder neck on video-urodynamics is a sign highly suggestive
of MSA in men
Uchiyama T, Sakakibara R, Yamamoto T, et al. Urinary dysfunction in early and untreated Parkinson’s disease. J Neurol Neurosurg Psychiatry 2011; 82: 1382–86.
Sakakibara R, Uchiyama T, Yamanishi T, et al. Genitourinary dysfunction in Parkinson’s disease. Mov Disord 2010; 25: 2–12.
Sakakibara R, Hattori T, Uchiyama T, et al. Videourodynamic and sphincter motor unit potential analyses in Parkinson’s disease and multiple system atrophy. J Neurol Neurosurg

9. MULTIPLE SCLEROSIS AND
OTHER DEMYELINATING
DISORDERS
• Symptoms occur around 6 years into the illness and almost all
patients report LUT symptoms 10 years or more after symptom onset.
• Most commonly, both storage and voiding dysfunction occur.
• LUT dysfunction is common in acute disseminated encephalomyelitis
and can persist after other neurological deficits have resolved.
Panicker JN, Nagaraja D, Kovoor JM, et al. Descriptive study of acute disseminated encephalomyelitis and evaluation of functional outcome predictors. J Postgrad Med

10. SPINAL CORD INJURY
• Patients might initially be in urinary retention during the spinal shock
phase that follows SCI, and develop the typical pattern of DSD and
detrusor overactivity subsequently as spinal refl exes return.
• Sustained high intravesical pressures can ensue, increasing the risk
of upper urinary tract damage.
• Autonomic dysreflexia can occur after lesions at or above the T6
spinal cord level, triggered by urinary tract infections (UTIs),
interventions of the LUT and bowel, or sexual activity.
• This is a potentially life-threatening disorder and is characterised by
an increase in systolic blood pressure (>20 mm Hg above baseline),
headache, fl ushing, piloerection, stuff y nose, sweating above the
level of the lesion, vasoconstriction below the level of the lesion, and
dysrhythmias.
Schöps TF, Schneider MP, Steff en F, Ineichen BV, Mehnert U, Kessler TM. Neurogenic lower urinary tract dysfunction (NLUTD) in patients with spinal cord injury: long-term urodynamic fi ndings.
BJU Int 2015; 115 (suppl 6): 33–38.
Blok B, Pannek J, Castro-Diaz D, et al. Guidelines on Neuro-Urology. European Association of Urology. 2015. http://uroweb.org/wpcontent/uploads/21-Neuro-Urology_LR2.pdf (accessed May 4,

11. SPINA BIFIDA
• More than 90% of children with spina bifida have LUT dysfunction.
• Symptoms usually start in infancy or childhood, although
occasionally they are delayed until adulthood.
• Video-urodynamic studies can identify a variety of features, such as
detrusor overactivity, detrusor underactivity, or low compliance with
ineffective contractions.
• Findings at the bladder outlet include DSD, or a static or fixed
external urethral sphincter.
• Young patients with apparently normal LUT function initially can
develop LUT dysfunction later on in life because of spinal cord
tethering. They should therefore be monitored regularly by
urologists, because they could be at risk of developing upper urinary
tract complications.
Kessler TM, Lackner J, Kiss G, Rehder P, Madersbacher H. Predictive value of initial urodynamic pattern on urinary continence in patients with myelomeningocele. Neurourol Urodynam
2006: 25: 361–67.

12. CAUDA EQUINA SYNDROME
AND PERIPHERAL NEUROPATHY
• Reduced or absent detrusor contractions.
• Reduced sensation of bladder fullness, inability to initiate micturition
voluntarily, and bladder distension, to the point of overflow
incontinence.
• However, in a subset of patients, there might be detrusor
overactivity, which could be a result of bladder decentralisation due
to preserved peripherally sited post-ganglionic neurons.
Podnar S, Fowler C. Pelvic organ dysfunction following cauda equina damage. In: Fowler C, Panicker J, Emmanuel A, eds. Pelvic organ dysfunction in neurological disease: clinical
management and rehabilitation. Cambridge: Cambridge University Press, 2010: 266–77

13. FOWLER’S SYNDROME
• A primary disorder of urethral sphincter relaxation, which results in
an inhibition of detrusor contractions.
• Investigation with urethral sphincter electromyography (EMG) shows
a characteristic pattern of activity and the urethral pressures are
usually raised.
• Opiates seem to compound incomplete emptying or retention in
women who have fairly mild sphincter abnormalities.
• The only treatment modality shown to be effective in restoring
voiding is sacral neuromodulation.
Panicker JN, Game X, Khan S, et al. The possible role of opiates in women with chronic urinary retention: observations from a prospective clinical study. J Urol 2012; 188: 480–84.
Panicker J, DasGupta R, Elneil S, et al. Urinary retention. In: Fowler C, Panicker J, Emmanuel A, eds. Pelvic organ dysfunction in neurological disease: clinical management and rehabilitation. Cambridge:
Cambridge University Press, 2010: 293–306.
Datta SN, Chaliha C, Singh A, et al. Sacral neurostimulation for urinary retention: 10-year experience from one UK centre. BJU Int 2008; 101: 192–96.

14. MANAGEMENT
1. Achieve urinary continence
2. Improve quality of life
3. Prevent UTIs
4. Preserve upper urinary tract function
Blok B, Pannek J, Castro-Diaz D, et al. Guidelines on Neuro-Urology. European Association of Urology. 2015.

15. MANAGEMENT
Panicker, J. N., Fowler, C. J., & Kessler, T. M. (2015). Lower urinary tract dysfunction in the neurological patient: clinical assessment and management. The Lancet Neurology, 14(7), 720-732.

16. Gajewski JB, Awad SA. Oxybutynin versus propantheline in
patients with multiple sclerosis and detrusor hyperrefl exia. J
Urol 1986; 135: 966–68.
Stohrer M, Murtz G, Kramer G, et al. Propiverine compared to
oxybutynin in neurogenic detrusor overactivity—results of a
randomized, double-blind, multicenter clinical study. Eur Urol
2007; 51: 235–42.
van Rey F, Heesakkers J. Solifenacin in multiple sclerosis patients
with overactive bladder: a prospective study. Adv Urol 2011;
2011: 834753.
Ethans KD, Nance PW, Bard RJ, et al. Effi cacy and safety of
tolterodine in people with neurogenic detrusor overactivity. J
Spinal Cord Med 2004; 27: 214–18.
Mazo EB, Babanina GA. Trospium chloride (spasmex) in the
treatment of lower urinary tract symptoms in patients with
neurogenic hyperactive urinary bladder caused by vertebrogenic

17. REFERRAL TO UROLOGIST
Symptoms refractory to first-line treatments •
Recurrent urinary tract infections •
Suspicion of concomitant pathologies such as bladder outlet
obstruction due to prostate enlargement, stress incontinence •
Renal impairment •
Demonstrated hydronephrosis •
Presence of haematuria •
Pain suspected to be originating from the urinary tract •
National Institute for Health and Care Excellence. Urinary incontinence in neurological disease (CG148). 2012. https://www.

18. OTHER MANAGEMENTS
• Nocturia: melatonin
• LUTS in movement disorders: deep-brain stimulation of the
subthalamic nucleus, pallidum, and thalamus
• Spina bifida: tissue engineering
• SCI: anti-Nogo-A antibody
Panicker, J. N., Fowler, C. J., & Kessler, T. M. (2015). Lower urinary tract dysfunction in the neurological patient: clinical assessment and management. The Lancet Neurology, 14(7), 720-732.

19. SUMMARY
• LUT dysfunction is common in neurological patients and has a
pronounced effect on quality of life.
• The high prevalence of dysfunction reflects the wide distribution of
neural control of LUT functions in health.
• The site and nature of the neurological lesion determine the pattern
of dysfunction.
• Video urodynamic
• Management partnership with urologist