Neurogenic Bladder Physiology, Pathogenesis, and Management after Spinal Cord Injury

J. Pers. Med., 2022 · DOI: 10.3390/jpm12060968 · Published: June 14, 2022

Simple Explanation

Urinary incontinence is common after spinal cord injury (SCI) due to loss of supraspinal coordination and unabated reﬂexes in both autonomic and somatic nervous systems; if unchecked, these disturbances can become life-threatening. This manuscript will review normal anatomy and physiology of the urinary system and discuss pathophysiology secondary to SCI. Recent guidelines for diagnosis, evaluation, treatment and follow up of the neurogenic bladder will be reviewed and options provided for risk stratiﬁcation and management.

Study Duration

Not specified

Participants

282,000 patients in the U.S. living with spinal cord injury

Evidence Level

Review of literature

Key Findings

1
Individuals with SCI above T6 are at high risk for autonomic dysreﬂexia (AD), a hypertensive crisis brought on by noxious stimuli below the level of SCI, with reﬂex sympathetic outﬂow to the splanchnic vascular bed that is uninhibited by supraspinal inﬂuence
2
The most common cause for life-threatening AD is bladder dysfunction, including bladder distension, bladder or kidney stones, blocked indwelling bladder catheter, catheterization itself, detrusor sphincter dyssynergia, shock wave lithotripsy, urinary tract infection UTI), or urological instrumentation
3
Patients with NLUTD who experience urinary tract infections (UTIs) are at higher risk of complications, such as renal complications and increased mortality

Research Summary

Urinary incontinence is common after spinal cord injury (SCI) due to loss of supraspinal coordination and unabated reﬂexes in both autonomic and somatic nervous systems; if unchecked, these disturbances can become life-threatening. Recent guidelines for assessment [15] and treatment [16] of NLUTD have identiﬁed those with SCIs of unknown risk until the initial evaluation has been completed, with recommendations for annual H and P, renal function assessment, upper tract imaging and repeat urodynamic studies when clinically indicated for those at high risk The management of patients with neurogenic bladder following spinal cord injury necessitates a multidisciplinary care approach, due to the complicated nature of the dysfunction.

Practical Implications

Improved Diagnostics

Highlights the importance of history, physical examination, and invasive tests for initial evaluation of NLUTD for risk stratification.

Pharmacological Advancements

Discusses the role and benefits of antimuscarinics, α1 adrenergic antagonists and Beta 3 Adrenergic Agonists.

Surgical Interventions

Reviews surgical management including sphincterotomy, sacral neuromodulation, bladder augmentation, and urinary diversion for severe cases.

Study Limitations

1
The presentation and management of neurogenic bladder vary based on the level of SCI; however, it is important to note that even patients with similar levels of SCI may not present in the same way.
2
Studies suggest that daily oral antibiotic prophylaxis is more effective in reducing asymptomatic bacteriuria than symptomatic UTIs.
3
The AUA/SUFU Guidelines indicate clinicians should not offer sacral neuromodulation to NLUTD patients with SCI due to the high variability in bladder dysfunction in this population

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