Nowadays, neurogenic bladder (NB) diseases are common. Neurogenic disease of the bladder is related to the nerves that affect bladder functions. The main function of the bladder is to store the urine filtered from the kidneys until the time of micturition. Various degrees of neurogenic bladder diseases occur due to many diseases, poisoning and accidents affecting the bladder nerves. In addition, as a result of the improvement in health conditions in our age, life expectancy has also increased. This situation has brought with it an increase in diseases related to the central nervous system. As a result, there is a significant increase in patients with neurogenic bladder problems. These patients are seriously in need of medical care.

In this article, I will give general and up-to-date information about neurogenic diseases of the bladder, taking into account our own experiences.

What does neurogenic bladder mean?

Neurogenic bladder is a general condition that includes bladder dysfunction resulting from the involvement of bladder nerves. Nerve damage may originate from the central nervous system (brain), spinal cord, or peripheral nerves. Diseases such as diabetes mellitus (DM), Parkinson’s disease, and multiple sclerosis can also cause neurogenic bladder disease by causing nerve damage.

What are the causes of neurogenic bladder disease?

The main function of the bladder is to store urine until urination. In order for this to occur in a healthy way, the bladder muscle and nerves, the sphincter (urine-retaining mechanism) must work in a coordinated manner. Normally, relaxation of the bladder muscle and contraction of the external sphincter are required for the storage of urine. During urination, the bladder muscle must contract and the external sphincter must relax. If these nerves are damaged, these mechanisms do not function properly and micturition problems occur.

Sometimes the bladder muscle (detrusor muscle) contracts frequently before the bladder is full, and as a result, patients urinate more often than usual. This situation is called overactive bladder. Sometimes patients cannot reach the toilet and leak urine.

In some patients, although the bladder is filled with urine in amounts exceeding its capacity, the patient does not feel the urine and the bladder muscle cannot get the urine out by contracting. This condition is called under-active bladder (flask type). Sometimes the external sphincter fails to contract and relax properly.

Neurogenic bladder causes may be congenital, that is, due to congenital developmental disorders or subsequent diseases.

Congenital (congenital) causes of neurogenic bladder include:

• Spina bifida (myelomeningocele): It is a disease that occurs as a result of the spinal cord not fully developing during the prenatal development period.
• Cerebral palsy disease: It can occur during the developmental period of the child or after birth. There is damage to the motor areas of the brain. Patients cannot control body movements and normal posture of the body.
• Sacral agenesis: There is a developmental disorder in the lower levels of the spinal cord (sacral region). As a result, bladder innervation is adversely affected.

Acquired causes of NB: NB may also develop as a result of some subsequent diseases. The most common causes of neurogenic bladder other than congenital diseases are:

• Having a stroke
• Alzheimer’s disease
• Parkinson’s disease
• Multiple sclerosis disease
• Central nervous system (brain) tumors
• Spinal cord injuries (due to trauma or as complications during surgery)
• Spinal cord cancers
• Encephalitis
• Hydrocephalus
• Attention deficit and hyperactivity disorder
• Dementia
• Gullian-Barré syndrome
• Neurosyphilis disease
• Past pelvic surgery interventions
• Nerve damage due to spinal canal stenosis or disc herniation
• Development of neuropathy as a result of long-term alcohol use

Who are at risk for neurogenic bladder?

Some diseases have a higher risk of developing NB. Conditions that most commonly cause neurogenic bladder include:

• People with spinal cord injury (the risk is 90% in these patients)
• Those with spina bifida disease (95%)
• Multiple sclerosis patients (50-80%)

What are the complaints (symptoms) in neurogenic bladder patients?

Symptoms seen in this group of diseases, which affect the nerves of the bladder and impair its functions, are mostly seen as lower urinary system complaints. Common complaints suggestive of neurogenic bladder are summarized below;

• Frequent recurrent urinary tract infections
• Sudden need to urinate
• Urinary incontinence (may be day or night)
• Frequent urination
• Inability to feel that the bladder is full
• Inability to urinate
• Drop by drop, forced urination
• Groin pain
• Midline swelling in the lower abdomen
• Bladder and kidney stones
• Erectile dysfunction (ED) in male patients

Evaluation of NB patients

Patients with bladder dysfunction (function disorders) due to nerve damage should be evaluated in detail. In this way, many diseases that can be confused with this disease should be ruled out and appropriate treatment planning should be made. A general evaluation is made by considering the following points:

• Detailed patient history and examination
• Evaluation of the general nervous system of the patient
• Neurology and neurosurgery consultation if necessary
• Evaluation of the quality of life score
• Urine test, kidney function tests
• A 24-hour voiding diary should be kept.
• Measurement of the amount of urine after micturition in the bladder (by inserting ultrasound, USG or end-voiding catheter)
• Radiological evaluation of the upper urinary system (USG, CT, kidney scintigraphy if necessary)
• Urodynamic research (cystometry, uroflowmetry, sphincter EMG, videourodynamics)
• Investigation of vesicoureteral reflux (VUR)
• Classification of the disease and determination of the location of the actual lesion

Neurogenic bladder disease is confused with which diseases?

NB disease can be confused with many diseases. First of all, the diseases that can be confused should be excluded and a definite diagnosis should be made. Diseases that have similar symptoms and can be confused with this disease are as follows:

• Alzheimer’s disease
• Benign prostatic enlargement (BPH)
• Bladder neck height in men
• urethral stricture
• Bladder decompression
• Central nervous system (brain) diseases, tumors, traumas
• Cauda equina syndrome
• Decompensated bladder
• Dementia patients
• Diabetes mellitus (DM)
• Diabetes insipidus disease
• Side effects of long-term and high-dose anticholinergics
• Functional urinary incontinence
• Spinal cord hernia (disc hernia)
• Infectious diseases involving the nervous system
• Painful bladder syndrome (interstitial cystitis)
• Excessive obesity and related bladder dysfunctions
• Multiple sclerosis
• Myelomeningocele disease
• Neurosyphilis
• Overactive bladder disease
• Parkinson’s disease
• Pelvis and sacral region trauma and fractures
• Post pelvic surgery
• B12 deficiency anemia (Pernicious anemia)
• Result of radiation therapy
• Spina bifida disease
• Sinal and sacral region tumors
• Spinal cord traumas and tumors
• Patients who have had a stroke
• Tabes dorsalis disease (Neurosyphilis)
• Transverse myelitis disease
• Foreign bodies that prevent urine flow in the urethra
• Urethra strictures
• Urinary tract infections

What are the types/ types of neurogenic bladder?

NB is classified in different ways. The most commonly used classification is the classification made by the International Continence Association according to the storage and voiding phases and the Lapides classification.

The classification according to the storage phase made by the International Continans Association is briefly as follows:

• Bladder function: There is a normal or overactive state
• Bladder sensory status: Normal, hypersensitive, hyposensitive, or no sensation at all
• Bladder capacity: May be at normal, above-normal, or below-normal levels
• Bladder compliance: may be normal, high or low
• Urethra function: There may be normal or partial closure

Bladder and urethra functions are based on the classification according to the storage phase made by the International Continanas Association. According to this;

• Bladder function: Normal, Low activity, no contractions, no reflexes
• Urethral function: Normal, mechanically occluded, overactive, dysfunctional, detrusor sphincter dyssynergia, non-reflex urethral sphincter dysfunction.

Lapides classification: In the classification of NM disease according to the Lpides system, only bladder functions are taken as a basis instead of urethral functions. We can summarize the classification of neurogenic bladder disease according to the Lapides classification system as follows:

• Sensory neurogenic bladder: Motor functions are normal, only sensory nerves are damaged.
• Motor paralytic neurogenic bladder: There is damage to the parasympathetic motor innervation of the bladder. There is a high amount of residual urine in the bladder.
• Uninhibited neurogenic bladder: Patients urinate frequently, urinary incontinence may be seen with a sudden sense of urination. There is no or very small amount of residue.
• Reflex neurogenic bladder: There are few involuntary bladder contractions here, but no voluntary contractions or the feeling of bladder fullness is lost.
• Autonomic neurogenic bladder: There is complete damage to the motor and sensory nerves of the bladder. Patients are unable to urinate, there is no sense of urination.

What are the complications of neurogenic bladder?

If NB is not treated, it can lead to serious complications up to kidney failure. In this respect, diagnosis, treatment and care of these patients are very important. We can list the common complications as follows:

• Recurrent urinary tract infections
• Formation of bladder stones
• Kidney and ureteral stones
• Loss of kidney functions (kidney failure)
• Disruption of the upper urinary system
• Development of bladder cancer
• Irritations on the skin due to urine leakage
• Impairment in quality of life
• Urethral erosions, urethral stricture development due to long-term catheterization
• Hematuria
• Epididymitis, orchitis, prostatitis: As a result of infection to the genital system due to long-term catheterization
• Erection problems
• Physiological problems

Treatment of neurogenic bladder

There is no single standard treatment for this disease. Appropriate treatment is made only after a detailed clinical evaluation of the disease. We can list the treatment principles of the disease as follows:

• Behavior and conservative treatment:
• Medication:
  • Alpha blockers
  • Anticholinergic drugs
  • Beta-3 adrenoreceptor agonists:
  • Desmopressin:
  • Botulinum toxin (Botox):
• Catheterization: It is aimed to empty the bladder that cannot be emptied completely with catheterization. Normally, there should be no urine left in the bladder after micturition. In these patients, a large amount of urine remains because the bladder cannot be completely emptied. As a result, stones in the bladder and urinary system, urinary tract infection and VUR develop. The purpose of bladder catheterization is to prevent these complications. This procedure should be done in a sterile manner. There are different forms of catheterization. Clean intermittent catheterization (CIC) is the most common.
  • Clean intermittent catheterization
  • Urethral foley catheter
  • Suprapubic catheter

• Sacral neuromodulation

• Percutaneous tibial nerve stimulation

•Surgical treatment. There are different surgical options depending on the condition of the disease. Surgical treatment is the last option in patients who do not respond to other conservative treatments. The operations we frequently perform in the treatment of neurogenic bladder disease are as follows:

• Augmentation cystoplasty (ileocystoplasty) surgery
  • Sphincterotomy surgery
  • Urinary diversion surgeries
  • Artificial sphincter

How is the prognosis/course of the disease in patients with neurogenic bladder?

There are two goals in the treatment of NB disease: First, to protect kidney functions, and secondly, to prevent the patient’s urinary incontinence. With conservative treatments (clean intermittant cathetherisation, drugs), kidney functions and urinary incontinence problems can be controlled by 90%. Patients should be followed up for life. Renal functions should be evaluated regularly and precautions should be taken against infection. Follow-ups concern branches such as Nephrology and Neurology as well as Urology. There should be close cooperation with these departments. In this type of chronic diseases, patient education and nursing services are also very important. Patients and their families should be informed about patient care.

In summary: Neurogenic bladder is a chronic disease that requires serious care, follow-up and treatment. Follow-up and treatment require many disciplines to work together. The most important problem in follow-up is to ensure the continuation of kidney functions. Appropriate treatment planning is made according to the condition of the disease. In cases that do not respond to drug therapy and conservative treatments, appropriate surgical treatment should be applied to the patient as the last option. With appropriate treatment and regular follow-up, it is possible to maintain kidney functions and keep the patient dry by maintaining urine control.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY