• Areas of Concern heading
  • Areas of concern Autonomic Dystrifexlia Link
  • Areas of concern Neurogenic Bladder link
  • Areas of concern Neurogenic Bowel link
  • Areas of concern Pressure Ulser link
  • Areas of concern Respiratory complications link
  • Health promotion and maintenance link
  • resources link

Neurogenic bladder

  • Although all individuals with a spinal cord injury will have a neurogenic bladder, the type and symptoms will depend on the level and completeness of the lesion. Individuals with lesions L1 and above may have detrusor sphincter dyssynergia, while those with lesions below L1 may have detrusor areflexia
  • Neurogenic bladder symptoms have a large impact on quality of life so proper management is important
  • Noxious stimulation to the bladder, including bladder distension, is the most common cause of Autonomic Dysreflexia (AD), which is a life threatening condition
  • There are many methods of bladder management; these need to be tailored to the individual's needs with consideration of concurrent conditions. Most of these approaches will be initiated and followed by a specialist; however, it is important for family physicians to be aware of the different methods and possible complications
  • UTIs are a frequent complication of neurogenic bladder and may present with atypical signs and symptoms

Definitions

Neurogenic Bladder: A malfunctioning urinary bladder due to neurologic dysfunction or insult emanating from internal or external trauma, disease, or injury. There are three types of neurogenic bladder:

Detrusor Sphincter Dyssynergia: Refers to a lack of coordination between contraction and relaxation of the detrusor muscle and external sphincter. Both contract at the same time causing urinary retention. May occur in individuals with lesions L1 and above.

Detrusor Hyperreflexia: Refers to increased activity of the detrusor muscle. This is usually combined with impaired contractility of the muscle, which leads to overactive bladder symptoms including bladder distention and incontinence.

Detrusor Areflexia: Refers to the inability of the detrusor muscle to contract, leading to an inability to empty the bladder. May occur in individuals with lesions below L1.

Prevalence

The majority of persons with spinal cord injury will experience some component of neurogenic bladder. UTIs are a frequent complication for individuals with spinal cord injury.

Pathophysiology

The image below shows the innervation of the bladder.

innervation of the bladder

Lesions above L1: Detrusor sphincter dyssynergia

Injuries affecting the upper motor neurons, level L1 and above, result in a lack of coordination between the sphincter and the detrusor. Both the detrusor and the sphincter are overactive due to lack of control and descending inhibition from the pons and cortex, and both sphincter and detrusor contract reflexively when stretched. The detrusor becomes overactive, reflexively contracting at small volumes, and contracting against an overactive sphincter, to cause high pressures in the bladder. This leads to:

  • Incontinence (when the detrusor contracts hard enough to overcome the sphincter contraction)
  • Incomplete emptying (due to the sphincter co-contraction)
  • Reflux (due to the high bladder pressures)

These result in recurrent bladder infections, stones, hydronephrosis, pyelonephritis, and renal failure.

(used with permission from www.scireproject.com)

Lesions below L1: Detrusor areflexia

In the case of a flaccid bladder, loss of detrusor muscle tone prevents bladder emptying and leads to bladder wall damage from over-filling, urine reflux, and an increase in infection risk due to stasis. The sphincter tone also tends to be flaccid (at least the external sphincter) causing incontinence, especially with manoeuvres that increase intraabdominal pressure (so-called “Valsalva” manoeuvres). These manoeuvres include sneezing, coughing, but more relevant for the individual with spinal cord injury, straining during transfers. Internal sphincter tone may be intact due to the higher origin of the sympathetic innervation, thus complete emptying, even with externally applied suprapubic pressure, may be difficult.

(used with permission from www.scireproject.com)

Signs and symptoms

  • Variable depending on level of lesion and type of neurogenic bladder. Include:
    • Incontinence
    • Overactive bladder
    • Urinary retention
  • May also have signs and symptoms of UTI. Patients with spinal cord injury are less likely to have typical symptoms of UTI. Look for:
    • Pelvic pain
    • Dysuria
    • Incontinence
    • Increased spasticity
    • Autonomic Dysreflexia (AD)
    • Malaise
    • Fever/chills
    • Nausea
    • Headache

Management and recommendations

As a family physician, your role is in the prevention and early recognition and treatment of UTIs and Autonomic Dysreflexia (AD) (AD may occur in individuals with T6 thoracic spinal cord lesions or above) and to refer them to a specialist when appropriate.

When to refer

Consider referral to urologist if:

  • Current bladder management method is not working (e.g., episodes of incontinence, not voiding regularly (high filling pressures))
  • >3 UTIs per year
  • Kidney or bladder stones
  • Urethral complications
  • Changing or worsening symptoms
  • Hydronephrosis on ultrasound (do ultrasound every 1-2 years)
  • Repeated episodes of Autonomic Dysreflexia (AD) that are secondary to urological issues
  • Patient has high level spinal cord lesion as they will be more prone to complications
  • Have had an indwelling or suprapubic catheter for >15 years (for cystoscopy due to increased risk of bladder cancer as a result of prolonged catheter use)  

Goals of bladder management

  1. Achieve regular bladder emptying and avoid stasis
  2. Avoid high filling and voiding pressures and preserve kidney function
  3. Maintain continence and avoid symptoms of frequency and urgency
  4. Prevent and treat complications and UTIs (avoid overtreating asymptomatic bacturia)

Approaches for bladder management

Approaches used to achieve bladder management goals will vary depending on the level and severity of the lesion. Most of these approaches will be initiated and followed by a specialist; however, it is important for family physicians to be aware of the different methods and possible complications. Many of these may be used in combination.

Intermittent catheterisation (IC)

  • Typically done every 4-6 hours to keep bladder volume under 500 ml
    • If high bladder volumes, increase frequency of catheterisation or consider alternative method
  • Patient or caregiver must have sufficient hand dexterity
  • Changes in prostate over time can affect patient’s ability to use this method
  • Patient must be willing to spread fluid consumption of 1.8-2 litres every 24 hours over the day
  • Complications: UTI, bladder overdistension, incontinence, urethral trauma or stricture, bladder stones, Autonomic Dysreflexia (AD)

Suprapubic pressure: Credé and Valsalva

Credé: "Credé is a method of applying suprapubic pressure to express urine from the bladder. Credé is usually used when the bladder is flaccid or a bladder contraction needs to be augmented. The effectiveness of Credé is limited by sphincter pressure" (Consortium for Spinal Cord Medicine Clinical Practice Guidelines, p. 19).

Valsalva: "Valsalva is a method in which an individual uses the abdominal muscles and the diaphragm to empty the bladder. Valsalva is used when the bladder is flaccid from spinal cord injury affecting the sacral reflex arc or when the bladder contracts but does not empty completely. Valsalva increases intraabdominal pressure but does not ensure complete bladder emptying" (Consortium for Spinal Cord Medicine Clinical Practice Guidelines, p. 19).

  • Used with patients with a flaccid bladder but generally not effective
  • Complications: Incomplete emptying, high pressures, hydronephrosis, abdominal bruising, hernias, haemorrhoids

Indwelling catheterisation

  • Urethral or suprapubic
  • Long-term use of indwelling catheter has a higher rate of urological and kidney complications than other bladder management methods
  • Requires more frequent cystoscopic evaluation due to greater incidence of squamous cell bladder carcinoma with indwelling catheter. Consider cystoscopy if indwelling catheter >15 years
  • May be used in combination with anticholinergics (which relax the detrusor muscle causing urinary retention)
  • Complications: Kidney or bladder stones, urethral erosions, epididymitis, UTI, incontinence, hydronephrosis, bladder cancer

Reflex voiding

  • Bladder emptying by means of overactive detrusor contractions and urine containment. Contractions can be triggered by squeezing the penis or scrotum or tapping the suprapubic area. However, most occur spontaneously in response to stimuli, such as intravesical volume and the chemical composition of the urine
  • Requires intact sacral micturation reflex and requires urodynamic testing to determine if it is suitable
  • Usually limited to males because a condom catheter is often used
  • May require intermittent catheterisation to ensure bladder is being emptied and low pressures maintained
  • Changes in prostate over time can affect patient’s ability to use this method
  • Can be used in conjunction with alpha-blockers and/or botulinium toxin injection and after transurethral sphinctereotomy or endourethral stent
  • Complications: Leakage, skin breakdown, urethral fistula, UTI, poor bladder emptying, high bladder pressure, Autonomic Dysreflexia (AD)

Alpha-blockers

  • Examples: Tamsulosin , Terazosin , Moxisylyte , Phenoxybenzamine
  • Used to lower outlet resistance
  • Often used in combination with other methods
  • Complications: Orthostatic hypotension (patients should take at night while lying down), interaction with phosphodiesterase inhibitors

Anticholinergics

evidence icon
  • Examples: Oxybutynin (available as Ditropan, Ditropal XL, Oxytrol, Uromax, etc), Tolterodine (available as Detrol, Detrol LA), Trospium chloride (Trosec), Propiverine hydrochloride (Mictonorm), and M3-receptor specific medications darifenacin (Enablex) and solifenacin (Vesicare)
  • Used for detrusor hyperactivity
  • Side effects: Dry mouth (less so with transdermal oxybutynin), sedation, urinary retention (should check post-void residual before initiating treatment)

Botulinum toxin (botox) injection in detrusor muscle

evidence icon

Level 1 evidence based on two RCTs supports the use of Botox A injections into the detrusor muscle to provide targeted treatment for detrusor hyperreflexia and urge incontinence resistant to high-dose oral anticholinergic treatments with intermittent self-catheterisation in spinal cord injury.

There is level 1 evidence from a single RCT with support from several additional controlled and uncontrolled trials that botulinum toxin injected into the external urinary sphincter may be effective in improving outcomes associated with bladder emptying in persons with neurogenic bladder due to spinal cord injury.

  • Requires a urologist who is trained to do procedure (not available at all tertiary centres)
  • Patients must be able to do intermittent catheterisation or have a caregiver who can
  • Used to relax either sphincter or overactive bladder
    • Can take 1 week before effective and lasts only 3-6 months
  • Often used in combination with other methods
  • Should be avoided in patients with neuromuscular disease and if patient on an aminoglycoside
  • Complications: Autonomic Dysreflexia (AD), haematuria during injection

Urethral stent

  • Used in detrusor-sphincter dyssynergia
  • Results in continuous drainage therefore patient will require collecting device for urine (usually males with condom catheters)
  • Complications: Stent migration, stone encrustation, Autonomic Dysreflexia (AD), urethral trauma, urethral pain, tissue growth in stent, need for removal/replacement, recurrent UTIs

Surgical options (if catheter and medical management are not effective)

  • Transurethral sphincterotomy evidence icon
  • Electrical stimulation and posterior sacral rhizotomy
  • Bladder augmentation evidence icon
  • Continent catheterisable stoma
  • Incontinent urinary diversion (e.g., ileal conduit)
  • Cutaneous ileovesicostomy

There is level 4 evidence from a single case-series study that sphincterotomy, as a staged intervention, can provide long-term satisfactory bladder function.

There is level 4 evidence from a single long-term follow-up study of those having a previous sphincterotomy that the incidence of various upper and lower tract urological complications may be quite high.

Follow-up

  • Review bladder management at least yearly
  • Refer to urologist if >3 UTIs per year (see management section for other times to refer)
  • Check creatinine and electrolytes yearly
  • Ultrasound every 1-2 years
  • Consider cystoscopy if indwelling catheter >15 years due to increased risk of bladder cancer as a result of prolonged catheter use
  • Consider PSA testing after age 50 years

UTIs

  • UTIs are the most common complication of neurogenic bladder.
  • Patients with spinal cord injury are less likely to have typical UTI symptoms. Instead they may present with fever/chills, nausea, headache, increased spasticity, Autonomic Dysreflexia (AD).
  • The majority of persons with spinal cord injury have bacteriuria therefore treatment should only be initiated if symptomatic. This can be a diagnostic dilemma as symptoms are often atypical. Unnecessary antibiotic therapy increases the risk of developing drug resistant infections. Always do a culture and sensitivity of clean/mid-stream urine specimen before treating UTI to ensure organism is not resistant and to guide antibiotic therapy . Patient education is key.
  • Change catheter before taking urine sample to avoid false-positives .
  • Patients should be given requisitions and sample bottles to keep at home so they may submit a sample as soon as they feel symptomatic.
  • Only high risk patients (e.g., single kidney, previous urosepsis) should be treated empirically, all others should await culture results.
  • Management of UTIs in a patient with spinal cord injury usually requires different antibiotics and longer duration of treatment evidence icon. Urine culture should be used to guide choice of antibiotic .
  • Patients with frequent UTIs (>3/year) may require antibiotic prophylaxis and should be referred to a urologist.
  • There is conflicting level 1 evidence to support the effectiveness of cranberry juice/capsule in preventing UTI in patients with neurogenic bladder due to spinal cord injury.

Ciprofloxacin 500 mg BID x 14 days (level 1 evidence)

Ofloxacin 200 mg BID x 7 days (level 1 evidence)

Norfloxacin 400mg BID x 7-10 days (level 4 evidence)

Ciprofloxacin: Level 1 evidence on single RCT that low dose ciprofloxacin may prevent UTI but more research necessary.

Trimethoprim/sulfamethoxazole (TMP-SMX): Potential for drug resistance and adverse events limits use of TMP-SMX for prophylaxis.

Cyclic antibiotic: Level 4 evidence for weekly oral cyclic antibiotic in decreasing UTI but needs more research.

There is level 1 evidence from a single RCT that supports the use of 14 vs 3 days of Ciprofloxcin for improved clinical and microbiological outcomes in the treatment of UTI in persons with SCI.

There is level 1 evidence from a single RCT suggesting that 3 or 7 day Ofloxacin treatment is more effective than trimethoprim-sulfamethoxazole in treating UTI and results in significant bladder bacterial biofilm eradication in persons with SCI patients.

Level 4 evidence from a single study suggests that norfloxacin may be a reasonable treatment choice for UTI in SCI but subsequent resistance must be monitored.

A low success rate of aminoglycosides in the treatment of SCI UTI is supported by level 1 evidence from a single RCT.

References

Consortium for Spinal Cord Medicine. (2006). Bladder management for adults with spinal cord injury: A clinical practice guideline for health-care providers. Washington, DC: Paralyzed Veterans of America.

The Canadian Continence Foundation

Wathen, N., Watson, G., Caldwell, S., & Lewis, N. (2007). Research summary: Improving continence care in complex continuing care. Ontario Women’s Health Council.