Neurogenic Bladder

The normal function of the bladder is to store and expel urine in a coordinated, controlled fashion. This coordinated activity is regulated by the central and peripheral nervous systems. But what happens when the bladder malfunctions as a result of dysfunction, trauma, disease or injury? The information below should help you recognize this problem before it causes serious damage.

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What happens under normal conditions?

The urinary bladder, a spherical organ, has a soft inner lining (similar to the inner cheek) and an outer muscle layer. In addition to the bladder, the bladder neck (funnel-like outlet of the bladder which leads to the urethra), the urethra (tube-like structure which serves as a channel to carry urine from the bladder to the external surface) and the external urethral sphincter muscle (group of muscles which surround the urinary passage below the bladder neck) complete the lower urinary tract.

The muscles and nerves of the urinary system must function in a coordinated fashion with the bladder in order to perform its two major functions of storage and elimination of urine. Nerves carry messages from the bladder to the brain and then from the brain to the muscles of the bladder telling them to either tighten or release, allowing the bladder to empty during urination. 

Neurogenic bladder is the loss of normal bladder function caused by damage to part of the nervous system. The damage can cause the bladder to be underactive, in which it is unable to contract and unable to empty completely, or it can be overactive, in which it contracts too quickly or frequently.

Risk factors for neurogenic bladder include various birth defects, which adversely affect the spinal cord and function of the bladder, including spina bifida and other spinal cord abnormalities. Tumors within the spinal cord or pelvis may also disrupt normal nervous tissue function and place an individual at risk. Traumatic spinal cord injury is also a major risk factor for development of neurogenic bladder. 

Inability to control urination, also known as urinary incontinence, is perhaps the most common symptom associated with the neurogenic bladder. This may be caused by abnormalities in bladder capacity or malfunction of control mechanisms such as the bladder neck and/or external urethral sphincter muscle that are important for the bladder's storage function.

Symptoms including a dribbling urinary stream, straining during urination or inability to urinate may also be associated with neurogenic bladder. Urinary retention may result either from loss of bladder muscle contracting performance or loss of appropriate coordination between the bladder muscle and the external urethral sphincter muscle.

Irritating symptoms, such as urinary frequency and urgency, may be evidence of bladder hyperactivity. Other irritating symptoms may include painful urination (dysuria), which may be a result of a urinary tract infection (UTI) caused by urine being held too long in the bladder. UTI with fever is a sign of potential severe kidney infection (pyelonephritis) and is a more worrisome situation as it may result in permanent damage of the kidney(s).

Stones may also form in the urinary tract of individuals with a neurogenic bladder caused by the stoppage of urine flow and/or infection.

Abnormal backup of urine from the bladder to the kidney(s), also known as vesicoureteral reflux (VUR), may develop as a means of releasing high pressure within the bladder. A UTI is of particular concern as VUR may place the patient at significant risk for a severe kidney infection by transporting infected bladder urine directly to the kidney(s).  

How is neurogenic bladder diagnosed?

When neurogenic bladder is suspected, both the nervous system (including the brain) and the bladder itself are tested. In addition to complete medical history and physical examination, diagnostic procedures may include:

• X-rays of the skull and spine

• an electroencephalogram (EEG) to identify brain dysfunction
• imaging tests of the bladder and ureters
• function tests that involve filling the bladder to see how much it can hold and if it empties completely

Medication for treatment of overactive bladder may improve or relieve irritating symptoms and/or incontinence. Antibiotics are important for treatment and prevention of urinary tract infections (UTIs), especially in patients with vesicoureteral reflux. Other medications may improve bladder control by increasing outlet resistance at the bladder neck.

Clean intermittent catheterization (CIC) was developed by Dr. Jack Lapides in the early 1970s as a means of emptying the bladder in the case of a bladder muscle that is unable to contract or in patients with loss of appropriate coordination between the bladder muscle and the  external urethral sphincter muscle.

Surgical cutting of the external urethral sphincter with the use of an endoscope passed through the urethra may allow free flow of urine into an appropriate receptacle and eliminate the need for CIC in order to empty the bladder. Also, endoscopic injection of paralytic agents directly into the external urethral sphincter muscle is another technique that provides temporary relief.

Permanent stents can also be used in the bladder neck for effective urinary transportation.

At times, however, damage to bladder anatomy and function is so severe that capacity needs to be improved with bladder augmentation (increasing bladder size with various tissues), vesicoureteral reflux needs to be corrected and/or an alternate tube for emptying the bladder may need to be surgically constructed.

A person can expect extensive follow-up evaluation of bladder and kidney function. This may involve repeated X-rays, ultrasound, blood tests and bladder function tests.

Although some characteristics of the neurogenic bladder may improve or resolve, most issues typically require constant attention and reevaluation.

Proactive management of patients with a neurogenic bladder may decrease the risk of damage to the bladder and kidney(s) and, therefore, potentially limit the need for future intervention. This has been shown in management of neurogenic bladder patients with spina bifida.

The risk of neurogenic bladder is significant in this population and, therefore, careful and frequent evaluation of bladder function is recommended.

Limits are typically a function of the cause of neurogenic bladder (such as spinal cord injury, for example), rather than the neurogenic bladder itself.

Some effects of neurogenic bladder are preventable with aggressive management with medication and at times appropriate surgical reconstruction. 

Reviewed December, 2002

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Glossary Terms

anatomy:
	The physical structure of an internal structure of an organism or any of its parts.
bladder:
	The bladder is a thick muscular balloon-shaped pouch in which urine is stored before being discharged through the urethra.
bladder augmentation:
	Operation that uses a piece of the intestine (bowel) to enlarge the bladder.
bladder control:
	The ability to control the timing of urination. Also referred to as continence.
bladder neck:
	Area of thickened muscle fiber where the bladder joins the urethra. Acting on signals from the brain, bladder neck muscles can either tighten to hold urine in the bladder or relax to allow urine out and into the urethra. These muscles also tighten during ejaculation to prevent backflow of semen into the bladder.
catheter:
	A thin tube that is inserted through the urethra into the bladder to allow urine to drain or for performance of a procedure or test, such as insertion of a substance during a bladder X-ray.
catheterization:
	Insertion of a narrow tube through the urethra or through the front of the abdominal wall into the bladder to allow urine drainage.
CIC:
	Also known as clean intermittent catheterization. Periodic insertion of a clean catheter into the urethra after washing your hands to drain the urine from the bladder.
continence:
	The ability to control the timing of urination or a bowel movement.
contract:
	To shrink or become smaller.
dysuria:
	Painful or difficult urination, most frequently caused by infection or inflammation but it can also be caused by certain drugs.
EEG:
	Also known as electroencephalogram. A procedure that records the brain's continuous electrical activity by means of electrodes attached to the scalp.
electroencephalogram:
	Also known as EEG. A procedure that records the brain's continuous electrical activity by means of electrodes attached to the scalp.
endoscope:
	A lighted medical instrument consisting of a long tube inserted into the body, usually through a small incision. It is used for diagnostic examination and surgical procedures.
external urethral sphincter muscle:
	Muscle surrounding the external opening of the urethra, the tube that carries urine outside the body from the bladder.
incontinence:
	Loss of bladder or bowel control; the accidental loss of urine or feces.
infection:
	A condition resulting from the presence of bacteria or other microorganisms.
intermittent catheterization:
	Periodic insertion of a narrow tube through the urethra or through the front of the abdominal wall into the bladder to allow urine drainage.
ions:
	Electrically charged atoms.
kidney:
	One of two bean-shaped organs that filter wastes from the blood and discharge these waste products in urine. The kidneys are located on either side at the level of the 12th ribs toward the back. The kidneys send urine to the bladder through tubes called ureters.
kidney infection:
	Also called pyelonephritis. Urinary tract infection involving the kidney. Typical symptoms include abdominal or back pain, fever, malaise and nausea or vomiting.
nephritis:
	Inflammation of the kidneys.
neurogenic bladder:
	Also called neuropathic bladder. Loss of bladder control caused by damage to the nerves controlling the bladder.
overactive bladder:
	A condition in which the patient experiences two or all three of the following conditions: urinary urgency, urge incontinence or urinary frequency--defined for this condition as urination more than seven times a day or more than twice at night.
paralytic agent:
	Drug used to temporarily paralyze an individual.
pelvis:
	The bowl-shaped bone that supports the spine and holds up the digestive, urinary, and reproductive organs. The legs connect to the body at the pelvis.
peripheral:
	Near the surface of an organ.
pyelonephritis:
	Also referred to as kidney infection usually caused by a germ that has traveled up through the urethra, bladder and ureters from outside the body. Typical symptoms include abdominal or back pain, fever, malaise and nausea or vomiting.
reflux:
	Backward flow of urine. Also referred to as vesicoureteral reflux (VUR). An abnormal condition in which urine backs up from the bladder into the ureters and occasionally into the kidneys, raising the risk of infection.
sphincter:
	A round muscle that opens and closes to let fluid or other matter pass into or out of an organ. Sphincter muscles keep the bladder closed until it is time to urinate.
sphincter muscle:
	Circular muscle that helps keep urine from leaking by closing tightly like a rubber band around the opening of the bladder.
spina bifida:
	A condition at birth in which part of the vertebral bodies (or back bones) fail to seal off completely and some part of the spinal cord protrudes through this opening. This condition is often associated with bladder and bowel control problems as well as lack of control of voluntary movement in the lower body.
stent:
	With regard to treating ureteral stones, a tube inserted through the urethra and bladder and into the ureter. Stents are used to aid treatment in various ways, such as preventing stone fragments from blocking the flow of urine.
tissue:
	Group of cells in an organism that are similar in form and function.
ultrasound:
	Also referred to as a sonogram. A technique that bounces painless sound waves off organs to create an image of their structure to detect abnormalities.
ureter:
	One of two tubes that carry urine from the kidneys to the bladder.
ureteral:
	Pertaining to the ureter. Also referred to as ureteric.
ureters:
	Tubes that carry urine from the kidneys to the bladder.
urethra:
	A tube that carries urine from the bladder to the outside of the body. In males, the urethra serves as the channel through which semen is ejaculated and it extends from the bladder to the tip of the penis. In females, the urethra is much shorter than in males.
urethral:
	Relating to the urethra, the tube tha carries urine from the bladder to outside the body.
urethral sphincter:
	Muscle fibers around the outside of the urethra that tighten to close off the flow of urine or relax to open the urethra to allow the passage of urine.
urinary frequency:
	Urination eight or more times a day.
urinary incontinence:
	Inability to control urination.
urinary tract:
	The system that takes wastes from the blood and carries them out of the body in the form of urine. Passageway from the kidneys to the ureters, bladder and urethra.
urinary tract infection:
	Also referred to as UTI. An illness caused by harmful bacteria, viruses or yeast growing in the urinary tract.
urinate:
	To release urine from the bladder to the outside. Also referred to as void.
urine:
	Liquid waste product filtered from the blood by the kidneys, stored in the bladder and expelled from the body through the urethra by the act of urinating (voiding). About 96 percent of which is water and the rest waste products.
UTI:
	Also referred to as urinary tract infection. An illness caused by harmful bacteria growing in the urinary tract.
vas:
	Also referred to as vas deferens. The cordlike structure that carries sperm from the testicle to the urethra.
vesicoureteral reflux:
	Also referred to as VUR. An abnormal condition in which urine backs up from the bladder into the ureters and occasionally into the kidneys, raising the risk of infection.

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