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Neurogenic Bladder. Ayman Mahdy,MD, PhD Associate Professor of Surgery Division of Urology Director Voiding Dysfunction and Female Urology UC. Anatomy and physiology. Bladder wall : smooth muscle/3 layers Urethral sphincter: Internal/involuntary /smooth part: BN

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Neurogenic Bladder

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Neurogenic bladder

Neurogenic Bladder

Ayman Mahdy,MD, PhD

Associate Professor of Surgery

Division of Urology

Director Voiding Dysfunction and Female Urology


Anatomy and physiology

Anatomy and physiology

  • Bladder wall : smooth muscle/3 layers

  • Urethral sphincter:

    • Internal/involuntary /smooth part: BN

    • External/voluntary/striated part: mid urethra

  • Spinal cord ends at L1/L2 vertebral level

  • Lower urinary tract nerve supply:

    • Parasympathetic : S2-S4 spinal segments

    • Sympathetic: T10-L2 spinal segments

    • Somatic: S2-4 (Pudendal N)

  • Two types of the afferent nerves within the pelvic nerves: A and C (Morrison JW 1986).

Urine storage

Urine Storage

Sensory perception


Medial pontine micturation center

Lateral pontine micturation center

Lateral Spinothalamic tract

Stimulation of sympathetic neurons

Sacral cord

Inhibit sacral parathympathetic

Stimulate sacral somatic

Contraction SS and bladder outlet

Dorsal ganglion

Contraction of sphincter

Relaxation of detrusor

Receptors in muscle wall and mucosa

Micturation reflex

Micturation reflex

Sensory perception


Medial pontine micturation center

Medial pontine micturation center

Lateral Spinothalamic tract

Stimulate sacral parathympathetic

Inhibit sacral somatic

Sacral cord

Dorsal ganglion

Receptors in muscle wall and mucosa

Contraction of detrusor

Relaxation of sphincter

What is ngb

What is NGB?

Any bladder abnormality of micturation caused by neuromuscular disease, injury or dysfunction

Most common patterns of ngb with different neurological disease

Most common patterns of NGB with different neurological disease

Most common patterns of ngb with different neurological disease1

Most common patterns of NGB with different neurological disease

Obstructive luts

Obstructive LUTS

  • Hesitancy

  • Slow stream

  • Intermittency

  • Straining to void

  • Spraying (splitting) of urinary stream

  • Feeling of incomplete (bladder) emptying

  • Need to immediately re-void

  • Post-micturition leakage

  • Position-dependent micturition

  • Dysuria

  • Urinary retention

Storage luts

Storage LUTS

  • Urinary frequency

  • Urinary urgency

  • Nocturia

  • OAB , urgency syndrome

Urinary incontinence

Urinary incontinence

  • Stress UI

  • Urgency UI

  • Postural UI

  • Nocturnal enuresis

  • Mixed UI

  • Continuous UI

  • Insensible UI

  • Coital UI

Dynamics of voiding dysfunction

Dynamics of voiding dysfunction

  • Bladder

  • Bladder outlet

  • Both



Dynamics of obstructive luts

Dynamics of obstructive LUTS

  • Bladder:

    • Weak or absent detrusor contraction e.g. diabetic cystopathy

  • Bladder outlet:

    • Bladder outlet obstruction e.g. DESD

  • Combination

Dynamics of storage symptoms ui

Dynamics of storage symptoms/UI

  • Bladder:

    • Detrusor overactivity (overactive bladder)

  • Bladder outlet:

    • Intrinsic sphincter deficiency

  • Combination

Normal sphincter



Initial management

Initial management



  • Urinary tract symptoms

  • Neurological symptoms and diagnosis (if known)

  • Clinical course of the neurological disease

  • Bowel symptoms

  • Sexual function

  • Comorbidities

  • Use of prescription and other medication and therapies.

History cont

History (Cont.)

  • Acute (reversible) UI:

    • Acute onset and subsides with underlying condition

    • Causes outside the urinary tract

    • DRIP:

      • Delirium

      • Restricted mobility/Retention

      • Infection/Inflammation/Impaction

      • Polyuria/Pharmaceuticals

Evaluation of voiding dysfunction in the elderly patient cont

Evaluation of voiding dysfunction in the elderly patient (Cont.)

  • Neurologic history:

    • Duration (MS and Parkinsonism)

    • Back surgery patients: time, level, type of lesion and affected sensation

    • CVA: UI before or after the onset of CVA

    • MS: duration, onset of exacerbations, motor deficits

Neurogenic bladder


  • Assess the impact of the underlying neurological:

    • Mobility

    • Hand function

    • Cognitive function

Initial management1

Initial management

  • Assure bladder emptying:

    • CIC

    • Urethral Foley

  • Assure hyegenic measures:

    • Palliative

    • Antimuscarinics

    • Timed void

Initial management cont

Initial management (Cont.)

  • Refer:

    • Hematuria

    • Reurrent urinary tract infections

    • Hydronephrosis

    • kidney stones on imaging

    • biochemical evidence of renal deterioration.

Clean intermittent catheterization cic

Clean Intermittent Catheterization (CIC)

  • First introduced in 1972 by Lapides et al

  • Proffered treatment if patient has the manual dexterity

  • Staff support

  • 4-6/day

  • With or without anti-muscarinic use

  • Poor candidates:

    • Cognitive and physical factors

    • Lack of support

    • Deformities

    • Anatomical

Clean intermittent catheterization cic1

Clean Intermittent Catheterization (CIC)

  • Incidence of bacteruria 1-3% catheterization

  • 1-4 Bacteruria/100 catheterization

  • Use of antibiotic prophylaxis is controversial

Indwelling catheter

Indwelling catheter

  • Higher risk for:

    • Renal failure

    • Bladder stones

    • UTIs

    • Bladder cancer

Suprapubic tube versus urethral foley

Suprapubic tube versus urethral Foley

  • Easy to exchange

  • Avoid urethral trauma

  • Sexual function

  • Less EO in male

Autonomic dysrelflexia

Autonomic Dysrelflexia

  • SCI above T6

  • Loss of supraspinal inhibition of throaco-lumbar sympathetic outflow

  • Massive discharge of the sympathetic system

  • Clinically:

    • Sweating and cutaneous flushing

    • Pounding H/A, nasal congestion, piloerection

    • HTN (may be life threatening)

    • Bradycardia

Autonomic dysrelflexia1

Autonomic Dysrelflexia

Textbook of NGB 2008

Autonomic dysrelflexia treatment

Autonomic Dysrelflexia: Treatment

  • Remove the stimulus!!

  • Other:

    • Nifedipine

Long term management

Long term management

Long term management1

Long term management

  • Usually 3 months after the episode

  • Sooner if:

    • Renal function deterioration

    • Hematuria

    • Hydronephrosis

    • Renal stones

    • Recurrent UTIs

Goals of evaluation management

Goals of Evaluation/Management

  • Prevent upper tract deterioration

  • Restore hygiene and social acceptance (UI)

  • Assure efficient bladder emptying

  • Avoid NGB bladder related complications

Complications of ngb

Complications of NGB

  • UTI

  • VURD


  • Renal amyloidosis (rare)

  • ED

  • Autonomic dysreflexia

Office requirements

Office Requirements

  • Handicap accessibility

  • Cystoscopy

  • VUDS

  • EMG

  • Crash Cart

  • Ostomy care

  • Multi-team members

Work up

Work up

  • History

  • Voiding diary

  • QOL assessment

  • PE

  • Neurological exam

  • Urine bacteriologic studies

  • RFTs

  • Radiologic evaluation

    • Upper tract

    • Lower tract


  • Endoscopic examination

Neurogenic bladder


Vuds 56 yo with ms

VUDS : 56 YO with MS



No leak

Stop filling

Resume filling

No leak



Post void




Neurogenic bladder


Management algorithm ngb

Management algorithm: NGB

Management algorithm ngb obstructive

Management algorithm: NGB/obstructive

Management algorithm ngb storage

Management algorithm: NGB/storage



  • *Benefits:

    • Improve compliance

    • Relieve frequency, urgency and UUI

    • Decrease intra-vesical pressure

    • Decrease DO

    • Helps protect the upper tract from deterioration

      *(Storher M et al 2007, Amend B et al 2008 and Kim YH et al 1997)

Antimuscarinics cont

Antimuscarinics (Cont.)

  • Higher doses are usually needed in NGB population compared with non neurogenic OAB

    • Constipation

    • Dry mouth

  • Patients with CNS disease (impaired cognition with oxybutinin):

    • Darifenacin

    • Trospium

Treatment algorithm of oab uui

Treatment algorithm of OAB/UUI



Voiding Diary

Urodynamic Workup

R/O Obstruction



Behavioral Techniques







Surgical Intervention


Urgent PC

Botulinum toxin a botox

Botulinum toxin A (Botox)

  • FDA approved 2011 for 200 unites

  • In patient with neurogenic detrusor overactivity

  • Indications:

    • Antimuscarinic drugs ineffective or poorly tolerated.

    • Medication cost

    • Compliance

  • Two RCT proved efficacy

  • Mean duration of effect 36-42 weeks

Surgical treatment

Surgical treatment

  • Sphicterotomy

  • Bladder augmentation

  • Urinary diversion:

    • Continent

    • Incontinent

Bladder outlet enhancing procedures

Bladder outlet enhancing procedures

Female sui treatment

Female SUI: Treatment

  • Guidelines defined the five major types of procedures:

    • Injectables

    • Laparoscopic suspensions

    • Midurethral slings

    • Pubovaginal slings

    • Retropubic suspensions

Bulking agent

TOT Sling

Sui in men

SUI in men

  • Less common

  • After prostate surgery

  • Treatments:

    • Conservative

    • Male sling

    • Artificial urinary sphincter (AUS)

Male sling




  • Indications

    • Spinal cord injury or spina bifida

    • Impaired bladder compliance

    • Detrusor-sphincter dyssynergia

    • Vesico-ureteric reflux.

  • Methods:

    • Upper tract function: renal scans/serum creatinine)

    • Lower tract function: urodynamics

    • Anatomy: ultrasound or CT scan/cystogram/cystoscopy



  • NGB management is a complex process and should be approached in a multidisciplinary fashion

  • Goals should address bladder emptying and storage and to avoid complications and assures QOL

  • NGB patients should obtain baseline anatomical and functional evaluation

  • Surveillance should be offered especially for high risk patients



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