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Neurogenic Bladder - Treatment
Last reviewed: 04.07.2025
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Treatment of neurogenic bladder should pursue the following goals: preserving kidney function, creating conditions for adequate emptying of the bladder or continence of urine, and improving the quality of life. In each specific case, an individual approach is important to determine the treatment tactics. Treatment of neurogenic bladder depends on the type of dysfunction of the lower urinary tract, taking into account the function of the detrusor and sphincters of the bladder.
Disruption of urine accumulation in the bladder
Impaired urine accumulation in the bladder due to neurological diseases and injuries is expressed as neurogenic detrusor overactivity (one of the forms of overactive bladder). Approaches to the treatment of overactive bladder are described in detail in the corresponding chapter of this guide.
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Impaired bladder emptying
Detrusor-sphincter dyssynergia, impaired contractile activity of the detrusor and impaired adequate relaxation of the sphincters lead to impaired emptying of the bladder.
Intermittent autocatheterization of the bladder, proposed by Lapides in 1972, is still the best method of treating patients with impaired bladder emptying due to neurological diseases. However, in patients with impaired hand function (who cannot perform intermittent self-catheterization), as well as in patients who, for one reason or another, refuse this type of bladder emptying, other methods are used.
The smooth muscles of the bladder neck and proximal urethra are controlled by tonic sympathetic stimuli via alpha-adrenergic receptors. Alpha-adrenergic receptor blockade can improve bladder emptying. Although alpha-adrenergic blockers (tamsulosin, alfusazine, doxazosin, and others) are successfully used in the treatment of patients with prostate adenoma, they have not found wide application in functional disorders of bladder emptying. Nevertheless, most authors consider it appropriate to use alpha-adrenergic blockers in mild forms of bladder emptying dysfunction.
In case of detrusor-sphincter dyssynergia, accompanied by high detrusor pressure (more than 40 cm H2O), it is very important to choose an adequate method of emptying the bladder during urination.
Drug treatment of neurogenic bladder includes benzodiazepines and centrally acting muscle relaxants. Centrally acting muscle relaxants are most commonly used. They reduce excitation of motor neurons and interneurons and are able to inhibit transmission of nerve impulses in the spinal cord, reducing spasticity of striated muscles. However, when using these drugs, even in maximum permissible doses, a positive effect is noted in only 20% of patients.
Drug treatment of neurogenic bladder (metoclopramide) is also of no significant importance in the treatment of patients with decreased or absent contractile activity of the detrusor. Some patients with decreased or absent contractile activity of the detrusor and with a paralytic state of the striated sphincter of the urethra can empty the bladder by artificially increasing intra-abdominal pressure with digital compression of the lower abdomen (the Creda technique). In the case of a spastic state of the external sphincter of the urethra, the use of Creda does not lead to adequate emptying of the bladder.
If autocatheterization is impossible or the patient refuses it, and if drug treatment is ineffective, patients with both detrusor-sphincter dyssynergia and impaired contractile activity of the detrusor in combination with a spastic state of the external sphincter of the urethra are prescribed surgical treatment methods to eliminate obstruction in the area of the said sphincter. In particular, they use an injection of botulinum neurotoxin type A into the area of the striated sphincter of the urethra. TUR of the bladder neck, incision of the striated sphincter of the urethra and implantation of special stents into the area of the external sphincter of the urethra.
100 U of botulinum neurotoxin type A are diluted in 8 ml of sterile 0.9% sodium chloride solution. The drug is injected into the external sphincter of the urethra. In men, the drug is injected transurethrally at four points at 3, 6, 9 and 12 o'clock on a conventional clock face, and in women - paraurethrally at two points to the left and right of the urethra. Chemodenervation of the external sphincter of the urethra reduces intraurethral resistance, thereby improving bladder emptying, and in some cases restoring spontaneous urination.
TUR of the bladder neck is used in cases of obstruction of the bladder neck and proximal urethra, established by the results of a video-urodynamic study. The bladder neck is dissected through all layers at 5 and/or 7 o'clock on a conventional clock face (in men - from the base of the bladder to the seminal tubercle).
Incision of the striated sphincter of the urethra (sphincterotomy) is performed with a cold knife or with a laser at 12 o'clock on a conventional clock face. Positive results are noted in 70% of patients. Possible complications: bleeding, impotence, urinary leaks.
Treatment of neurogenic bladder also requires the use of permanent metal stents. Stents are installed transurethrally in such a way as to splint only the striated sphincter of the urethra. In this position, the smooth muscle fibers of the bladder neck ensure urine retention. The most common complications are spontaneous stent migration and stent encrustation with salts.
Electrical stimulation of the anterior sacral roots is also used in the treatment of neurological patients with impaired bladder emptying function. The technique was first proposed by Brindley. It is used in patients with complete spinal cord injury. Electrical stimulation of the anterior sacral roots simultaneously stimulates the autonomic fibers of the detrusor and the somatic fibers of the external sphincter of the urethra and pelvic diaphragm. Due to the fact that striated muscle fibers are not capable of prolonged tonic contraction, there is a decrease in intraurethral pressure, and contraction of the smooth muscle fibers of the detrusor promotes urination.
In special cases of severe neurogenic dysfunction of the lower urinary tract and severe disability of the patient, urine is diverted from the bladder by installing a permanent urethral catheter or suprapubic cystostomy.
Treatment of sphincter urinary incontinence with impaired innervation of the striated sphincter of the urethra is performed by surgical intervention. In women, a urethral sling and an artificial sphincter are used, in men - an artificial sphincter.
Thus, the manifestations of urination disorders in patients with neurogenic dysfunction of the lower urinary tract are quite diverse. In all cases, it is necessary to conduct a comprehensive UDI to clarify the functional state of the bladder and its sphincters. Unfortunately, modern treatment of neurogenic bladder in the vast majority of patients does not allow for the complete restoration of normal function of the lower urinary tract, and then the treatment consists of choosing an adequate and suitable method of emptying the bladder for a particular patient.