Neurourology/Neurogenic Bladder

Why Yale Urology?

At Yale, we are committed to providing you with the highest level of up-to-date, excellent and compassionate care. We understand that a diagnosis of neurogenic bladder can have a significant impact on your quality of life. Yale Urology is staffed by experts who respect you and understand your concerns and needs. We look forward to working with you, and we will develop a treatment plan that works for your individual lifestyle and we will coordinate that plan with the treatments provided by the rest of your healthcare team, including neurologists, physiatrists, and primary care specialists. We value communication and cooperation as vital components of your healing process. 

Innovative Treatments

Yale is a premier academic health center, affiliated with one of the best research institutions in the world. Our mission in the Department of Urology at Yale is to perform research and discover next generation methods for treatments of diseases like neurogenic bladder. Our faculty members participate in cutting edge clinical trials, and we are continually looking for new ways to adopt innovative treatments from around the globe as new advances come to light. We are well equipped to deliver currently available treatment options for neurogenic bladder, including sacral neuromodulation, onabotulinumtoxin A bladder injections, and complex bladder reconstructive surgery. (See section on Reconstructive Urology for more information.)

What is Neurogenic Bladder?

What is a neurogenic bladder?  The muscles and nerves of the urinary system efficiently work together to hold urine in the bladder and then release urine at the appropriate time. Nerves carry messages or signals from the bladder (which is mostly composed of muscle) and urethral sphincter muscle (USM, this is a “valve-like” area in the urethra urine tube just beyond the bladder) to the spinal cord and brain.  The brain coordinates the messages coming from the bladder and USM to store urine in the bladder (continence) or to empty urine out of the bladder (micturition or voiding) at times convenient to the person.   Continence and micturition involves the bladder muscles and USM to work in tandem; though their functions are always complementary.  What this means is that during continence (urine storage), the bladder muscle is relaxed, the USM is contracted.  During voiding, the bladder muscle is contracted and the USM is relaxed.  A neurogenic bladder is the condition when the bladder and USM functions abnormally due to any nerve or neurologic problem, such as spinal cord injury, spina bifida, cauda equina syndrome, multiple sclerosis, stroke, transverse myelitis, brain tumors, cerebral aneurysms,  Parkinsons, Alzheimers, multiple system atrophy (MSA), and other degenerative nerve disorders.

In a neurogenic bladder, because of the neurologic condition, nerves carrying  these messages do not communicate properly with the bladder muscle and the USM leading to problems with continence or voiding.  One problem neurogenic bladder patients experience is urine leakage (loss or urine control). Urine leakage often occurs when the bladder muscle does not get the right message and contracts without the patient’s permission.  Another problem is inability of the bladder to completely empty (called urinary retention).  Urine retention often happens if the bladder muscles do not get a signal from the nerve to contract, or if the USM does not get the message to relax during voiding.  The ability for the neurogenic bladder patient to sense bladder fullness or to feel urine flow during voiding varies depending on the type of neurologic condition he/she has.  While counter-intuitive, some neurogenic bladder patients have frequent sensations to urinate even with low bladder volumes. This may be secondary to loss of inhibitory signals (inability to block unwanted signals) which are also necessary for normal bladder function.  The symptoms of neurogenic bladder may resemble other conditions and medical problems. Always consult your physician for a diagnosis.

Complications of Neurogenic Bladder

A complication of a neurogenic bladder is a bladder infection (urinary tract infection).  While bladder infections can occur in anyone, neurogenic bladder patients have a higher risk of urinary tract infections because of inability of the bladder to empty normally, lack of sensation of bladder fullness resulting in holding urine too long before being eliminated, lack of bladder muscle and USM working in complementary fashion during voiding leading to higher bladder pressures, and for some because they are performing bladder self-catheterization.  Another complication from neurogenic bladder (usually untreated ones) is kidney damage.  Damage to the kidney might happen if abnormal high pressures in the bladder are transmitted to the kidneys, causing kidney injury or allowing infection from the bladder to go into the kidney.  Urinary tract stones (in kidneys and/or bladder) are also more common in those patients with neurogenic bladder, especially those who have had recurrent bladder infections.  Other complications might relate to the type of neurogenic bladder management being utilized.  Those patients using self-catheterization have risks beyond urinary tract infection including urethral strictures, urethral bleeding.  Those patients with chronic (permanent) indwelling catheters have risks of severe urinary tract infections, bladder stones, bladder cancer and urethral injuries. 

How is Neurogenic Bladder Evaluated?

How is neurogenic bladder evaluated by the urologist?  Patients with known, established neurologic diseases, and who also have bladder symptoms are referred to the urologist for further evaluation to manage their bladder symptoms. Tests done by the urologists include checking urine for infection, looking into bladder with lighted flexible tube (cystoscopy), performing a bladder pressure test with a catheter into the bladder (urodynamics), and doing a dye test to see if urine is backing up into the kidney.  Urologists may also order kidney imaging tests such as ultrasounds and CT scans to make ensure that kidneys are not damaged.  These tests guide the urologist to optimum treatments for neurogenic bladder.  On a rare occasion, a patient who has no known neurologic disease, but has bladder symptoms will see a urologist who will end up helping to diagnose a previously unknown neurologic condition.  But this is a very uncommon situation. 

What is the Treatment for Neurogenic Bladder?

What is the treatment for neurogenic bladder? Specific treatment for neurogenic bladder will be determined by your urologist based on: Your age, overall health, and medical history, Severity of symptoms, Cause of the nerve damage or neurologic condition, Type of bladder symptoms (incontinence versus retention – these are opposite problems), Your tolerance for specific medications, procedures, or therapies, Expectations for the course of the condition, Your opinion or preference. Treatment may include: Oral pharmacologic (drug) management, onabotulinumtoxinA injection into bladder, self-insertion of a catheter or hollow tube (to empty the bladder) at regular intervals (this is called self-catheterization), Prophylactic (preventive) antibiotic therapy (to reduce the incidence of infection), Bladder reconstructive surgery (last option).  Most urologists are not in favor of chronic indwelling catheter for long term bladder management for neurogenic bladders (because of increased risks stated above); however it is accepted that in some special circumstances, a chronic catheter in the bladder (either through the urethra tube or a suprapubic tube through the lower abdomen) is the best option.