Neurogenic Bladder
All types of bladder dysfunction caused by an interruption of normal bladder innervation by the nervous system are referred to as neurogenic bladder. (Other names for this disorder include neuromuscular dysfunction of the lower urinary tract, neurologic bladder dysfunction, and neuropathic bladder.) Neurogenic bladder can be hyperreflexic (hypertonic, spastic, or automatic) or flaccid (hypotonic, atonic, or autonomous).
An upper motor neuron lesion (at or above the second to fourth sacral vertebrae) causes spastic neurogenic bladder, with spontaneous contractions of detrusor muscles, increased intravesical voiding pressure, bladder wall hypertrophy with trabeculation, and urinary sphincter spasms. A lower motor neuron lesion (below the second to fourth sacral vertebrae) causes flaccid neurogenic bladder, with decreased intravesical pressure, increased bladder capacity, residual urine retention, and poor detrusor contraction.
Causes
At one time, neurogenic bladder was thought to result primarily from spinal cord injury; now it appears to stem from a host of underlying conditions, including:
cerebral disorders, such as cerebrovascular accident, brain tumor (meningioma and glioma), Parkinson’s disease, multiple sclerosis, and dementia
spinal cord disease or trauma, such as spinal stenosis (causing cord compression) or arachnoiditis (causing adhesions between the membranes covering the cord), cervical spondylosis, spinal cord tumors, spina bifida, myelopathes from hereditary or nutritional deficiencies and, rarely, tabes dorsalis
disorders of peripheral innervation, including autonomic neuropathies, resulting from endocrine disturbances, such as diabetes mellitus (most common)
metabolic disturbances, such as hypothyroidism, porphyria, or uremia (infrequent)
acute infectious diseases, such as Guillain-Barré syndrome and transverse myelitis
heavy metal toxicity
chronic alcoholism
collagen disease such as systemic lupus erythematosus
vascular diseases such as atherosclerosis
distant effects of certain cancers such as primary oat cell carcinoma of the lung
herpes zoster
sacral agenesis.
Complications
Conditions that can complicate neurogenic bladder include incontinence, residual urine retention, urinary tract infection (UTI), calculus formation, hydronephrosis, and renal failure.
Assessment
The patient’s history includes a condition or disorder that can cause neurogenic bladder. The patient may have some degree of incontinence or interruption of micturition or an inability to completely empty the bladder. He also may have a history of frequent UTIs. Other assessment findings may be present. (See Assessing neurogenic bladder, page 616.)
Diagnostic tests
These tests will help assess bladder function.
Voiding cystourethrography evaluates bladder neck function, vesicoureteral reflux, and continence.
Urodynamic studies help evaluate how urine is stored in the bladder, how well the bladder empties, and the rate of movement of urine out of the bladder during voiding. These studies consist of four components:
Urine flow study (uroflow) shows diminished or impaired urine flow.
Cystometry evaluates bladder nerve supply, detrusor muscle tone, and intravesical pressure during bladder filling and contraction.
Urethral pressure profile determines urethral function with respect to length of the urethra and outlet pressure resistance.
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