What is a neurological bladder?

By Cristiano Antonino Last updated Jun 20, 2023

Neurological bladder is a bladder disorder caused by neurological damage. The patient suffering from it sees the lower urinary tract impaired, and experiences difficulty urinating: the bladder filling and emptying mechanism does not function as it should and the person either loses urine (incontinence) or retains it unconditionally (retention)

Underlying neurological bladder disease are numerous pathologies, mainly affecting the central nervous system or peripheral nerves.

And it is precisely the severity of the disease that causes it that is decisive for its prognosis, along with the timeliness with which treatment is initiated.

What is it?

The urinary bladder is a vitally important hollow organ.

It serves to collect the urine produced and store it until it is expelled.

Located in the pelvis, in men it is positioned in front of the rectum and above the prostate while in women it resides in front of the uterus and vagina.

Produced by the kidneys, urine reaches the bladder via the ureters.

From there it is then excreted outwards through the urethra.

During urination, an automatic reflex of the spinal cord – which stimulates the detrusor muscle – causes the bladder to empty periodically.

Those with a neurological bladder, due to damage to the spinal cord itself or to the peripheral nerves involved in urination, suffer from retention or incontinence: in the first case it is the ability to empty the bladder that is impaired, in the second case it is the mechanisms that hold urine inside the bladder that are impaired.

Neurological bladder can be flaccid or spastic

A flaccid bladder is characterised by its high volume, low pressure and absence of contractions. Due to damage to the peripheral nerves or the spinal cord (typically at the level of the S2-S4 vertebrae), a flaccid bladder results, first acutely and then in the long term (but it is also possible that the function improves over time).
Spastic bladder is characterised by a normal or reduced volume and the presence of contractions: due to a brain damage or a spinal cord injury above the T12 vertebra, the disorder is generated.

The severity depends on the extent of the damage. The flaccid and spastic forms can also coexist and be determined by the presence of a pathology that can affect both types. (diabetes mellitus, stroke, brain or spinal cord tumours, multiple sclerosis, etc.).

Neurological bladder is caused by an impairment of peripheral sensory or motor nerves

The former, also called afferent nerves, inform the central nervous system when the bladder is full; the latter, also called efferent nerves, transmit the impulses necessary for emptying the bladder from the central nervous system to the bladder.

Alterations of these nerves can be caused by:

spinal cord pathologies
spinal cord injuries
neural tube defects (the most common is spina bifida, a congenital malformation of the spine)
brain tumours, when they affect the area of the brain that controls the bladder
peripheral neuropathy (functional disorder of the peripheral nervous system)
multiple sclerosis
Parkinson’s disease
amyotrophic lateral sclerosis
syphilis
diabetes mellitus
herniated disc
stroke
alcohol abuse

The primary cause is diseases of the spinal cord.

The most common is syringomyelia: fluid-filled cysts form in the spinal canal where the spinal cord is located.

These can be caused by trauma to the spinal cord, Arnold-Chiari syndrome (congenital malformation of the cerebellum), meningitis or a number of other diseases/conditions.

The patient suffering from syringomyelia suffers damage to the spinal cord, at the base of the neurological bladder.

Other frequent causes of neurological bladder include conditions affecting the spinal column, starting with herniated discs: a vertebral disc ruptures and causes disc material to leak out, compressing the surrounding nerves.

Herniated discs are typically caused by the natural ageing process or trauma.

In some cases, neurological bladder can be caused by pregnancy: as the foetus grows, pressure on the uterus increases, which in turn pushes on the nerves involved in bladder control.

The symptoms of neurological bladder depend on the type

those who suffer from a flaccid bladder develop urinary retention (the bladder does not empty completely, even though it overfills) and suffer from dribbling after urination. In men, erectile dysfunction is also common;
sufferers of spastic bladder experience a frequent need to urinate, especially during the night and even when the bladder is not full.

If left untreated, a neurological bladder can cause kidney stones, predispose to urinary infections and cause hydronephrosis (accumulation of urine inside the kidney).

If the spinal cord injury causing the disorder is a cervical or high thoracic cord injury, the patient may develop autonomic dysreflexia: this condition causes malignant hypertension, bradycardia or tachycardia and can lead to death if not treated immediately.

It is therefore essential to see a doctor at the first symptoms, and to follow the right treatment right away to prevent the kidneys from suffering serious consequences.

Diagnosis

The diagnosis of neurological bladder disease starts with an anamnesis and an objective test, and includes X-rays and urological and urodynamic investigations.

Urological investigations include:

urinoculture;
ultrasound of the urinary apparatus;
cystoscopy (necessary to assess the duration and severity of urinary retention).

Urodynamic investigations include:

cystometry (test that studies bladder filling);
uroflowmetry with evaluation of the post micturition residual;
urethral pressure profilometry, to measure the pressure in the urethra at rest and its variations.

The urologist may also request an MRI or CT scan of the central nervous system, cystometrography (using a small bladder catheter and a rectal probe to record bladder function during filling) and excretory urography.

Therapy

Neurological bladder disease requires therapy on two levels: it is necessary to work on its symptoms, but also on the cause.

However, the cause cannot always be solved.

If the cause of the neurological bladder is a herniated disc, the therapy will focus on eliminating the compression of the spinal nerves; if it is caused by pregnancy, the woman will regain normal bladder function after delivery.

If the cause is syringomyelia, the cyst in the spinal canal will have to be removed; if the cause is diabetes mellitus, the patient will have to constantly monitor her blood sugar levels; if the cause is a tumour, it will be resolved once it is removed.

However, there are some conditions that cannot be cured, such as spina bifida.

As for the treatment of symptoms, there are several options:

those who suffer from a spastic bladder can take anticholinergics to relax the bladder wall;
those who suffer from a spastic bladder but are unable to retain normal volumes will be treated with drugs used for urge incontinence;
a flaccid bladder can be treated with permanent or intermittent catheterisation: a catheter is passed through the urethra or through a hole in the abdomen to empty the bladder of urine;
if the patient risks serious consequences, or other treatments have not produced the desired results, the last option is surgery: with sacral rhizotomy a spastic bladder becomes flaccid, with sphincterotomy the male bladder becomes an open duct, with ureterostomy a urinary diversion can be performed;
for ‘cooperative’ patients, with normal bladder capacity and able to follow instructions, a mechanically controlled artificial sphincter can be inserted.

The prognosis of neurological bladder disease depends on the severity of the underlying cause and whether it can be resolved, but also on the severity of the symptoms and the timeliness of diagnosis and treatment.

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