Neurogenic bladder

Urinary bladder dysfunction caused by injury or disease of the nervous system that impairs bladder control (e.g., spinal cord or peripheral nerve damage).

• Untreated neurogenic bladder can lead to recurrent UTIs, hydronephrosis, and renal failure. It commonly occurs in patients with conditions like spina bifida or spinal cord injury, so early recognition and management are critical to protect the kidneys and improve quality of life.

• Infant with myelomeningocele (spina bifida) having dribbling incontinence, recurrent UTIs, and hydronephrosis on ultrasound.
• Patient with spinal cord injury or multiple sclerosis experiencing urinary urgency, incontinence, or retention requiring catheterization.
• Physical exam may show a distended bladder (if retention) or signs of upper motor neuron lesion (if spastic bladder, e.g., brisk reflexes) or lower motor neuron lesion (if flaccid bladder, e.g., decreased perineal sensation).

1. Differentiate high-pressure vs low-pressure neurogenic bladder: hyperreflexic (spastic) bladder holds little urine and leaks under high pressure (risking VUR and kidney damage), whereas areflexic (flaccid) bladder overfills with large residual volumes (risking retention and UTI).
2. Always measure a post-void residual (PVR) in patients with incontinence or retention to detect incomplete emptying.
3. In a child with risk factors (e.g., spina bifida) or recurrent UTIs, evaluate for neurogenic bladder early (ultrasound, VCUG, urodynamics) to prevent silent kidney damage.

1. Clean intermittent catheterization (CIC) on a regular schedule to empty the bladder fully.
2. Anticholinergic medications (e.g., oxybutynin) to relax an overactive bladder and lower intravesical pressures.
3. Surgical interventions if needed: e.g., bladder augmentation (to increase capacity), vesicostomy or other urinary diversions, or sphincter procedures to improve emptying or continence.

• Spina bifida = assume neurogenic bladder (most myelomeningocele patients have it and need early bladder management).
• Lesion location matters: Spinal lesions above T12 often cause a hyperreflexic bladder (↑ tone, small capacity, DSD), while sacral (S2–S4) lesions cause an areflexic bladder (flaccid, large capacity).
• The combo of clean intermittent catheterization (CIC) plus anticholinergics is a classic regimen to protect the upper tract in high-pressure neurogenic bladder.

• Untreated high-pressure bladder can cause hydronephrosis and renal scarring – always act on new imaging changes or rising creatinine.
• Autonomic dysreflexia in a spinal cord injury patient (headache, flushing, hypertension triggered by a full bladder) is a medical emergency – immediately relieve bladder distension.
• Frequent febrile UTIs in a neurogenic bladder patient are warning signs – evaluate for VUR or improper catheterization.

1. Known risk (e.g., spina bifida) → screen early with renal ultrasound ± VCUG; get baseline urodynamics.
2. If high-pressure (hyperreflexic) bladder on urodynamics → start CIC + anticholinergic to protect kidneys.
3. If low-pressure (areflexic) bladder → ensure complete emptying (CIC) to avoid retention (± consider bethanechol).
4. Follow-up regularly with renal ultrasound and renal function tests; escalate to surgical options if bladder pressures remain unsafe or incontinence is unacceptable.

• Newborn with open spina bifida + urinary dribbling → neurogenic bladder (requires catheterization to prevent renal damage).
• Patient with multiple sclerosis + sudden urinary urgency/incontinence → detrusor overactivity from neurogenic bladder.