Neurogenic Bladder

  1. Overview
  2. The Micturition Control System
  3. Etiology and Neurological Levels
  4. Detrusor-Sphincter Dyssynergia
  5. Clinical Presentation
  6. Urodynamic Evaluation
  7. Complications and Upper Tract Protection
  8. Treatment Strategies
  9. Special Populations
  10. Key Research Papers
  11. Connections

1. Overview

Neurogenic bladder is a broad term for any dysfunction of the urinary bladder caused by a neurological disease or injury that disrupts the micturition control circuits. Because the nervous system governs every aspect of bladder filling and emptying — sensation, storage, coordination, and voluntary voiding — damage at different levels tends to produce different patterns, although history and examination do not always predict the urodynamic findings (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

The clinical spectrum is wide: some bladders are overactive and can generate high storage pressures, some are underactive or acontractile and empty poorly, and in some the bladder contracts against a closed sphincter — detrusor-sphincter dyssynergia (PubMed PMID: 18490916).

The 2021 American Urological Association / Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU) guideline describes understanding the risk of upper urinary tract damage, and managing patients so that risk is minimized, as one of the main goals of care. It notes that before World War II the primary cause of death after spinal cord injury was renal failure from poorly managed bladders, and that with a better understanding of bladder storage pressures, renal complications are now less common causes of death (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Neurogenic lower urinary tract dysfunction is a common consequence of neurological disease, and the pattern depends on the site and nature of the lesion (PubMed PMID: 26067125). Causes named in the AUA/SUFU guideline include stroke, Parkinson's disease, brain tumors, normal pressure hydrocephalus, traumatic brain injury, multiple sclerosis (MS), spinal cord injury (SCI), diabetes, and nerve injury from pelvic surgery such as abdominoperineal resection and radical hysterectomy. A US claims-database study of 46,271 people with neurogenic bladder found frequent urinary tract infections (29%–36%), urinary retention (9%–14%) and hospitalization (33.3% within a year) (PubMed PMID: 20882676).

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2. The Micturition Control System

Normal micturition requires coordination between the bladder (the detrusor, a smooth muscle) and the urethral outlet, including the striated external urethral sphincter. The neural circuits involved are distributed across the brain, spinal cord and peripheral nerves (PubMed PMID: 18490916). Understanding these circuits is the foundation of understanding neurogenic bladder.

Sacral Micturition Center (S2–S4, Conus Medullaris)

Parasympathetic preganglionic fibers arise from the S2–S4 spinal segments and travel in the pelvic nerves to ganglia in the pelvic plexus and bladder wall. Postganglionic nerves release acetylcholine, which contracts the bladder mainly through M3 muscarinic receptors. Somatic motor nerves to the striated external urethral sphincter also arise from S2–S4 motor neurons and run in the pudendal nerves (PubMed PMID: 18490916).

Pontine Micturition Center (Barrington's Nucleus)

The pontine micturition center (PMC, Barrington's nucleus) drives voiding: it excites the parasympathetic outflow to the bladder and inhibits the sympathetic and pudendal outflow to the urethral outlet, so the bladder contracts while the outlet relaxes. Ascending bladder signals are thought to pass through relay neurons in the periaqueductal gray (PAG) before reaching the PMC. In people with spinal cord lesions that disconnect the sacral cord from the brainstem, bladder contractions occur together with sphincter contractions — detrusor-sphincter dyssynergia (PubMed PMID: 18490916).

Suprapontine Control (Cortex and Forebrain)

Functional imaging studies show the prefrontal cortex, anterior cingulate, insula, thalamus and PAG active during urine storage. The prefrontal cortex is thought to be responsible for the tonic suppression of voiding that is relaxed only when voiding is desired and socially appropriate. Anterior cerebral lesions, or the loss of dopaminergic neurons in Parkinson's disease, remove this tonic inhibitory control over the PMC, resulting in decreased bladder capacity and detrusor overactivity (PubMed PMID: 18490916).

Sympathetic Nervous System (T11–L2)

Sympathetic fibers originate in the T11–L2 spinal segments and reach the bladder through the hypogastric nerve or the paravertebral chain. Noradrenaline released by these nerves relaxes bladder smooth muscle through beta-3 adrenergic receptors and contracts urethral smooth muscle through alpha-1 adrenergic receptors (PubMed PMID: 18490916).

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3. Etiology and Neurological Levels

Neurogenic lower urinary tract dysfunction is often grouped by the location of the neurological lesion — suprapontine, suprasacral spinal cord, or sacral — and each location tends to produce a characteristic pattern (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Suprapontine Lesions (Brain and Brainstem)

Suprapontine lesions affect the brain centers above the pons that inhibit the PMC. Removing tonic inhibitory control over the PMC results in decreased bladder capacity and detrusor overactivity (PubMed PMID: 18490916), and urodynamics generally show coordinated (synergic) voiding (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Pattern summary: Detrusor overactivity and reduced bladder capacity (PubMed PMID: 18490916). The AUA/SUFU guideline describes urodynamic findings in such patients as generally showing normal compliance and coordinated (synergic) voiding, and notes that these findings are not associated with a significant risk of complications such as hydronephrosis, stones or infections (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Suprasacral Spinal Cord Lesions (C1–S1)

Spinal cord lesions between the sacral cord and the brainstem interrupt the connection with the PMC. A spinal reflex emerges that drives involuntary bladder contractions, but voiding is often inefficient because the bladder and the sphincter contract at the same time — detrusor overactivity with detrusor-sphincter dyssynergia (DSD) (PubMed PMID: 18490916).

Pattern summary: Detrusor overactivity with DSD. The AUA/SUFU guideline places patients with suprasacral lesions in an "unknown-risk" category until urodynamics, upper tract imaging and renal function testing allow fuller risk stratification, and lists high storage pressures with detrusor overactivity and DSD among its high-risk findings (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Sacral and Infrasacral Lesions (S2–S4 and Below)

Lesions of the sacral cord or its peripheral nerves remove the parasympathetic drive to the detrusor, producing an acontractile or underactive bladder. The AUA/SUFU guideline notes that lesions distal to the spinal cord tend to have low bladder storage pressures, but poor contractility can raise post-void residual volumes, and bladder compliance can be lost over time (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Pattern summary: Acontractile or underactive detrusor, urinary retention and large post-void residual volumes. The AUA/SUFU guideline lists neurogenic retention with incomplete emptying among its moderate-risk findings (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

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4. Detrusor-Sphincter Dyssynergia

Detrusor-sphincter dyssynergia (DSD) is the urodynamic description of bladder outlet obstruction caused by a detrusor contraction occurring together with involuntary activation of the urethral sphincter. It is associated with spinal cord injury, multiple sclerosis and spina bifida (PubMed PMID: 26904418). Normally the PMC relaxes the outlet as the bladder contracts; when the sacral cord is disconnected from the brainstem, this reciprocal relationship is lost (PubMed PMID: 18490916).

The result is functional outlet obstruction: the bladder contracts against a closed sphincter, and emptying is hindered (PubMed PMID: 18490916).

Detrusor Leak Point Pressure and the 40 cmH₂O Finding

The detrusor leak point pressure (DLPP) is the bladder pressure at which urine leaks past the outlet. In McGuire's 1981 study of 42 myelodysplastic patients, the pressure at the time of urethral leakage was 40 cmH₂O or less in 20 patients and above it in 22. No patient in the low-pressure group had vesicoureteral reflux (VUR) and only 2 showed ureteral dilatation; in the higher-pressure group, 15 (68%) had reflux and 18 (81%) had ureteral dilatation (PubMed PMID: 7196460). A 1983 follow-up by the same group described 6 patients with myelodysplasia and detrusor hypertonia whose previously normal upper tracts later deteriorated or developed reflux, as late as the mid-teenage years (PubMed PMID: 6842712).

The 2021 AUA/SUFU guideline states that sustained intravesical pressures above 40 cmH₂O are associated with an increased risk of upper urinary tract deterioration, but also that the exact DLPP and storage pressure at which the upper tract is at risk is unclear, and that there is no universally agreed value for abnormal bladder compliance (values below 12.5 mL/cmH₂O have been suggested) (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Clinical Consequences of DSD

Some patients with DSD may be at risk for autonomic dysreflexia, recurrent urinary tract infections, or upper tract compromise if the condition is not followed and treated (PubMed PMID: 26904418).

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5. Clinical Presentation

The clinical presentation of neurogenic bladder depends on the site and nature of the neurological lesion (PubMed PMID: 26067125).

Overactive Pattern (Suprapontine and Suprasacral)

The overactive pattern brings urinary urgency — a sudden, compelling need to void that is difficult to defer — together with increased daytime frequency, nocturia, and urgency incontinence when contractions cannot be suppressed. Bladder capacity is reduced (PubMed PMID: 18490916). In suprasacral lesions with DSD, urgency can coexist with inefficient emptying because the bladder and sphincter contract together (PubMed PMID: 18490916).

Underactive Pattern (Sacral and Infrasacral)

In the underactive pattern, poor bladder contractility can raise post-void residual volumes (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688). In diabetes, symptoms may at first be absent, and the bladder may later evolve to incomplete emptying with possible overflow incontinence (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Autonomic Dysreflexia (SCI Above T6)

Autonomic dysreflexia (AD) is a medical emergency specific to SCI at the T6 level or above (a few people with T7 or T8 injuries may also be at risk); people with cervical or upper thoracic injuries are at greatest risk. A noxious stimulus below the injury — bladder distension is the most common trigger — sets off a spinal reflex that causes vasoconstriction and hypertension; compensatory activity above the lesion is thought to cause headache, visual disturbance, flushing, sweating and nasal congestion, and a reflex bradycardia can follow. The 2021 AUA/SUFU guideline describes initial management as draining the bladder, placing the patient upright, loosening tight clothing and monitoring blood pressure, and treats a systolic pressure above 150 mmHg and/or 20 mmHg above baseline with persisting symptoms as not adequately managed, calling for drug treatment and/or escalation of care; it names nitrates as the most commonly used medicines for refractory AD (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Recurrent Urinary Tract Infections

Urinary tract infections are frequent in neurogenic bladder: in the US claims study, 29%–36% of patients had lower urinary tract infections, and UTI accounted for over 20% of hospitalizations in the year after diagnosis (PubMed PMID: 20882676). The 2021 AUA/SUFU guideline recommends against surveillance urine cultures in people without symptoms and against treating asymptomatic bacteriuria; it recommends against daily antibiotic prophylaxis for people with indwelling catheters and for people using clean intermittent catheterization who do not have recurrent UTIs, and recommends imaging and cystoscopy of the urinary tract for people who do have recurrent UTIs (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

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6. Urodynamic Evaluation

Clinical symptoms and the neurological diagnosis identify that a patient has neurogenic bladder, but in some types — including infrapontine lesions — history and examination may not predict the urodynamic findings. The 2021 AUA/SUFU guideline recommends multichannel urodynamics, upper tract imaging and renal function testing at initial evaluation for unknown-risk patients, and recommends against routine urodynamics for low-risk patients (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Cystometry (Filling Cystometry)

Filling cystometry fills the bladder slowly while recording bladder pressure. Detrusor pressure is the component of bladder pressure generated by the bladder itself (PubMed PMID: 18490916). Studies report measures such as bladder volume at first sensation, maximum cystometric capacity and compliance. Involuntary detrusor contractions during filling indicate detrusor overactivity. Compliance is calculated as volume change divided by pressure change; a poorly compliant bladder is listed by the AUA/SUFU guideline as a high-risk finding (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Pressure-Flow Study

The voiding phase of urodynamics records detrusor pressure while urine flows. DSD is diagnosed most commonly during this voiding phase (PubMed PMID: 26904418).

Electromyography of the External Urethral Sphincter

Electrodes record electrical activity of the sphincter during filling and voiding. In a healthy adult, sphincter activity falls as the detrusor contracts; in a paraplegic patient each wave of bladder contraction is accompanied by sphincter contraction (PubMed PMID: 18490916). DSD is diagnosed most commonly with EMG recordings and voiding cystourethrograms during the voiding phase; urethral pressure monitoring could also potentially be used (PubMed PMID: 26904418).

Leak Point Pressures

The detrusor leak point pressure (DLPP) is the detrusor pressure at which urine leaks past the outlet during filling. The AUA/SUFU guideline states that elevated storage pressures and unfavorable DLPPs, alone or with other factors, are correlated with upper urinary tract deterioration in many people with neurogenic lower urinary tract dysfunction (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Video-Urodynamics

Video-urodynamics adds fluoroscopic imaging with contrast to the pressure recordings. The AUA/SUFU guideline lists vesicoureteral reflux "if UDS done with fluoroscopy" among its high-risk findings and allows multichannel urodynamics "with or without fluoroscopy" in high-risk surveillance (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688). Voiding cystourethrograms are one of the most common ways DSD is diagnosed (PubMed PMID: 26904418).

Upper Tract Imaging

The 2021 AUA/SUFU guideline sets surveillance by risk: for low-risk patients with stable symptoms, no surveillance upper tract imaging, renal function testing or multichannel urodynamics; for moderate-risk patients, an annual history and examination, annual renal function assessment and upper tract imaging every 1–2 years; for high-risk patients, the same annual assessments plus annual upper tract imaging and urodynamics repeated when clinically indicated. It notes that serum creatinine is a weak predictor of renal deterioration in people with low muscle mass, and that nuclear renal scans are best reserved for investigating declining renal function or obstruction (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

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7. Complications and Upper Tract Protection

The complications of neurogenic bladder range from those that threaten kidney function to those that mainly affect daily life.

Renal Complications

Vesicoureteral reflux (VUR): Urine flowing back from the bladder toward the kidneys. In McGuire's 1981 series, reflux was found in 68% of patients whose bladders leaked only at pressures above 40 cmH₂O and in none below it (PubMed PMID: 7196460).

Hydronephrosis and renal scarring: Dilation of the kidney's collecting system. The AUA/SUFU guideline lists hydronephrosis, new renal scarring, loss of renal parenchyma, and abnormal or unstable renal function among its high-risk findings (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Kidney failure: The AUA/SUFU guideline notes that before World War II renal failure from poorly managed bladders was the primary cause of death after SCI, and that renal complications are now less common causes of death (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Urological Complications

Urinary tract infection: In the US claims study, 29%–36% of neurogenic bladder patients had lower urinary tract infections, and UTI made up over 20% of hospitalizations in the following year (PubMed PMID: 20882676). In Weld and Dmochowski's review of 316 people with SCI, complications (infection, stones, urethral complications and imaging abnormalities) occurred in 53.5% of those with chronic urethral catheters, 27.2% using clean intermittent catheterization, 32.4% voiding spontaneously and 44.4% with suprapubic catheters (PubMed PMID: 10687973).

Bladder and kidney stones: The AUA/SUFU guideline describes indwelling catheters as a source of chronic bacteriuria and a nidus for biofilm and crystal formation; calculus shells left in the bladder when the balloon is deflated for catheter changes can seed bladder stones. It cites upper tract stones in 6%–32% of patients (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Bladder cancer: A 2017 meta-analysis of 18 studies estimated bladder cancer incidence in people with SCI at 6 per 1,000, with a mean age at diagnosis of 50 years and an average of 24 years from injury to diagnosis; 36.8% of the cancers were squamous cell carcinoma and 46.3% transitional cell carcinoma (PubMed PMID: 27824057). The AUA/SUFU guideline states that indwelling catheter management in SCI carries an increased risk of squamous cell carcinoma compared with CIC, and that gross hematuria is the most common presenting symptom of bladder cancer in neurogenic lower urinary tract dysfunction. It nonetheless recommends against screening or surveillance cystoscopy, including in people with chronic indwelling catheters, citing screening studies of 614 patients that found one malignancy, and recommends cystoscopy for hematuria, recurrent UTI or suspected anatomic problems (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Loss of compliance: Poor bladder compliance with high storage pressures is listed by the AUA/SUFU guideline among high-risk findings, and compliance can be lost over time even in lesions distal to the spinal cord (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

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8. Treatment Strategies

The 2021 AUA/SUFU guideline describes management as balancing urologic symptoms and urodynamic findings with cognition, hand function, the type of neurological disease, mobility, bowel function and caregiver support, with decisions made with the patient through shared decision-making (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Clean Intermittent Catheterization (CIC)

Lapides and colleagues reported clean, intermittent self-catheterization for urinary tract disease in 1972 (PubMed PMID: 5010715). In Weld and Dmochowski's study of 316 people with SCI followed for a mean of 18.3 years, the intermittent catheterization group had significantly lower complication rates than the chronic urethral catheter group and no significantly higher rates than any other method; the authors concluded that CIC was the safest bladder management method in terms of urological complications (PubMed PMID: 10687973). The 2021 AUA/SUFU guideline recommends intermittent catheterization rather than indwelling catheters to facilitate bladder emptying (Strong Recommendation; Evidence Level: Grade C) (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Antimuscarinic Agents

Antimuscarinics act on the muscarinic receptors (mainly M3) through which acetylcholine contracts the detrusor (PubMed PMID: 18490916). Incomplete bladder emptying is most often managed by intermittent catheterization and storage dysfunction by antimuscarinic drugs (PubMed PMID: 26067125). The AUA/SUFU guideline states that clinicians may recommend antimuscarinics or beta-3 agonists, or both, to improve bladder storage parameters (Conditional Recommendation; Grade C). It summarizes evidence that antimuscarinics can increase capacity and decrease maximum detrusor pressure, and that intravesical oxybutynin, instilled through a catheter, increased capacity and compliance in small studies, with adverse events that may occur less often than with oral forms (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Beta-3 Adrenergic Agonists

Beta-3 adrenergic receptors relax bladder smooth muscle (PubMed PMID: 18490916). The AUA/SUFU guideline summarizes evidence that the beta-3 agonist mirabegron may increase capacity and compliance and decrease detrusor pressure, frequency and incontinence episodes with minimal associated adverse events; it describes combination with an antimuscarinic as a reasonable option after shared decision-making (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Intradetrusor Botulinum Toxin A

OnabotulinumtoxinA is injected into the detrusor at cystoscopy. In the Cruz 2011 trial (275 patients with MS or SCI and urinary incontinence from neurogenic detrusor overactivity), 200 U and 300 U reduced incontinence episodes per week by 21.8 and 19.4 at week 6, against 13.2 with placebo, and improved maximum cystometric capacity, detrusor pressure and quality of life; median time to retreatment request was 42.1 weeks for both doses versus 13.1 weeks with placebo (PubMed PMID: 21798658). In the DIGNITY phase 3 trial by Ginsberg and colleagues (416 patients), 200 U and 300 U reduced incontinence by 21 and 23 episodes per week against 9 with placebo; median time to retreatment request was 256 and 254 days versus 92, and 300 U gave no clinically relevant benefit over 200 U (PubMed PMID: 22503020). The most common adverse events in both trials were urinary tract infection and urinary retention; among patients not catheterizing at baseline, 35% (200 U) and 42% (300 U) started catheterization in the Ginsberg trial, against 10% on placebo. The AUA/SUFU guideline recommends onabotulinumtoxinA for patients with SCI or MS whose condition is refractory to oral medicines (Strong Recommendation; Grade A) and states it may be offered in other neurogenic causes (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688). Botulinum toxin injected into the sphincter has shown temporary efficacy in reducing outlet obstruction from DSD (PubMed PMID: 26904418).

Alpha-Adrenergic Blockers

Alpha-1 adrenergic receptors contract urethral smooth muscle (PubMed PMID: 18490916), and alpha-blockers such as tamsulosin and doxazosin have been studied to lower outlet resistance. The AUA/SUFU guideline states that clinicians may recommend alpha-blockers to improve voiding parameters in patients who void spontaneously (Conditional Recommendation; Grade C) (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Neuromodulation

Sacral neuromodulation (SNM): An implanted electrode stimulates a sacral nerve root. The AUA/SUFU guideline states that it may be offered to selected patients with urgency, frequency and/or urgency incontinence (Conditional Recommendation; Grade C), but that it should not be offered to people with SCI or spina bifida (Moderate Recommendation; Grade C) (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688). Long-term data come largely from non-neurogenic patients: in a 5-year study of 60 women with refractory idiopathic (non-neurogenic) urge incontinence, success fell from 87% at 1 month to 62% at 5 years, with 15% completely continent (PubMed PMID: 21791355).

Posterior tibial nerve stimulation (PTNS): Office-based stimulation of the tibial nerve. The AUA/SUFU guideline states that it may be offered to selected spontaneously voiding patients with urgency, frequency and/or urgency incontinence (Conditional Recommendation; Grade C); in one study it cites, patients had twelve weekly sessions, and most of those continuing needed maintenance sessions every 1–4 weeks (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Surgical Options

Augmentation cystoplasty: A segment of bowel is used to enlarge the bladder. The AUA/SUFU guideline states it may be offered to selected patients refractory to, or intolerant of, less invasive treatments for detrusor overactivity and/or poor compliance (Conditional Recommendation; Grade C). In the evidence it reviewed, renal function stabilized after surgery and reflux resolved in 108 of 150 renal units, while the risk of stones, bowel dysfunction and mucus-related complications exceeded 10%; the guideline stresses the need for life-long follow-up and for the hand and cognitive function needed for regular CIC by the patient or a caregiver (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Continent catheterizable channels: A channel from the bladder to the abdominal wall (Mitrofanoff, Monti or Casale tubes, or other designs) allows catheterization through a stoma rather than the urethra. The AUA/SUFU guideline states these may be offered, with or without augmentation, to selected patients to facilitate catheterization (Conditional Recommendation; Grade C); in the reviewed evidence, channel stenosis needing re-operation occurred in 4%–32% (median 14%) of patients (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Bladder neck closure and urinary diversion: The AUA/SUFU guideline states that bladder neck closure, with another bladder drainage method, may be offered to selected patients with refractory stress incontinence after a thorough discussion of risks, benefits and alternatives (Expert Opinion), and that urinary diversion should be offered when other options have failed or are inappropriate. It notes that in women with neurogenic dysfunction, the most common cause of severe urethral damage is a chronic urethral catheter (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Indwelling Catheters

The AUA/SUFU guideline states that for appropriately selected patients who need a chronic indwelling catheter, clinicians should recommend suprapubic rather than urethral catheterization (Strong Recommendation; Grade C). It describes pressure necrosis of the urethra from long-term urethral catheters, with up to 23% of men with neurogenic dysfunction and a urethral catheter having urethral erosion, and in women gradual dilation of the urethra and bladder neck that can lead to leakage around the catheter (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

The Underactive Bladder and Sphincterotomy

Incomplete bladder emptying is most often managed by intermittent catheterization (PubMed PMID: 26067125). For men who cannot or will not perform CIC and who have reflex voiding, the AUA/SUFU guideline states that external sphincterotomy may be offered, with counseling about the high risk of failure or need for further treatment (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

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9. Special Populations

Multiple Sclerosis

A 2026 meta-analysis of 22 studies found neurogenic bladder in about one in two people with MS (pooled 48.8%), with study estimates from 6% to 94%; the authors attribute much of that spread to differences in definitions and assessment tools (PubMed PMID: 42563020). In the Cruz and Ginsberg trials, onabotulinumtoxinA benefits were seen in both MS and SCI patients (PubMed PMID: 21798658; PubMed PMID: 22503020). The AUA/SUFU guideline cites a study of 30 MS patients in which solifenacin reduced frequency and pad use, and lists pelvic floor muscle training as an option particularly for MS or stroke (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Parkinson's Disease

A 2022 meta-analysis found lower urinary tract symptoms in 61% of people with Parkinson's disease and urinary incontinence in 30% (PubMed PMID: 36172485). Loss of dopaminergic inhibition of the PMC leads to reduced capacity and detrusor overactivity (PubMed PMID: 18490916). The AUA/SUFU guideline summarizes Parkinson's studies in which the antimuscarinic solifenacin decreased 24-hour frequency, nocturia and incontinence episodes with minor adverse events, the alpha-blocker doxazosin improved flow rate and symptoms, and onabotulinumtoxinA data were limited by small, uncontrolled, single-center studies (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Spina Bifida

The risk of upper urinary tract damage and renal failure is much higher in spina bifida and SCI than in slowly progressive non-traumatic neurological disorders (PubMed PMID: 26067125). McGuire's 1981 and 1983 studies in myelodysplasia linked high leak pressures and detrusor hypertonia to reflux and upper tract deterioration, which could appear after many years of normal findings (PubMed PMID: 7196460; PubMed PMID: 6842712). In a small 2002 study of 17 children with myelomeningocele already using CIC four or five times a day, botulinum-A toxin injection increased maximal bladder capacity by 56.5% and reduced maximal detrusor pressure by 32.6% at 2–4 weeks (PubMed PMID: 11880062). The AUA/SUFU guideline covers adults only, and recommends against sacral neuromodulation in spina bifida (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

Diabetic Cystopathy

The AUA/SUFU guideline describes diabetic neurogenic dysfunction as possibly asymptomatic at first, progressing to overactive-bladder-type symptoms and later to incomplete emptying with possible overflow incontinence (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688). Incomplete emptying is most often managed by intermittent catheterization (PubMed PMID: 26067125).

Cervical Spinal Cord Injury

People with cervical or upper thoracic SCI are at greatest risk of autonomic dysreflexia, and bladder distension is its most common trigger (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688). The AUA/SUFU guideline lists hand function and caregiver support among the factors that shape bladder management, and requires hemodynamic monitoring during urodynamics or cystoscopy in patients at risk of autonomic dysreflexia (AUA/SUFU guideline: PubMed PMID: 34495687; PubMed PMID: 34495688).

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Key Research Papers

  1. McGuire EJ, Woodside JR, Borden TA. "Upper urinary tract deterioration in patients with myelodysplasia and detrusor hypertonia: a followup study." J Urol. 1983;129(4):823–826 — Six patients with myelodysplasia and detrusor hypertonia whose previously normal upper tracts later deteriorated or developed reflux. (Entry corrected 2026-10-14: previously listed as 1981;121(5):528–529.) — PubMed PMID: 6842712
  2. McGuire EJ, Woodside JR, Borden TA, Weiss RM. "Prognostic value of urodynamic testing in myelodysplastic patients." J Urol. 1981;126(2):205–209 — 42 patients followed a mean of 7.1 years; reflux in 68% of those leaking above 40 cmH₂O and in none at or below it. — PubMed PMID: 7196460
  3. Ginsberg D, Gousse A, Keppenne V, et al. "Phase 3 efficacy and tolerability study of onabotulinumtoxinA for urinary incontinence from neurogenic detrusor overactivity." J Urol. 2012;187(6):2131–2139 — 52-week randomized placebo-controlled trial in 416 patients with MS or SCI. — PubMed PMID: 22503020
  4. Abrams P, Cardozo L, Fall M, et al. "The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society." Neurourol Urodyn. 2002;21(2):167–178 — International Continence Society terminology report. — PubMed PMID: 11857671
  5. Weld KJ, Dmochowski RR. "Effect of bladder management on urological complications in spinal cord injured patients." J Urol. 2000;163(3):768–772 — Retrospective review of 316 SCI patients; intermittent catheterization had lower complication rates than chronic urethral catheterization. — PubMed PMID: 10687973
  6. Fowler CJ, Griffiths D, de Groat WC. "The neural control of micturition." Nat Rev Neurosci. 2008;9(6):453–466 — Comprehensive review of the multilevel neural circuits governing bladder filling and voiding. — PubMed PMID: 18490916
  7. Cruz F, Herschorn S, Aliotta P, et al. "Efficacy and safety of onabotulinumtoxinA in patients with urinary incontinence due to neurogenic detrusor overactivity: a randomised, double-blind, placebo-controlled trial." Eur Urol. 2011;60(4):742–750 — Randomized placebo-controlled trial in 275 patients with MS or SCI. — PubMed PMID: 21798658
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11. Connections

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