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Neurogenic bladder - Symptoms and diagnosis

Medical expert of the article

Urologist, andrologist, sexologist, oncourologist, uroprosthetist
, medical expert
Last reviewed: 04.07.2025

Symptoms of neurogenic bladder

Symptoms of neurogenic bladder are mainly represented by characteristic signs of accumulation: urgent (imperative) and frequent urination during the day and night, as well as urgent urinary incontinence. These symptoms are characteristic of neurogenic detrusor overactivity.

Bladder emptying symptoms include a thin weak stream of urine, the need for abdominal pressure during urination, intermittent urination, and a feeling of incomplete bladder emptying. They occur with decreased detrusor contractility and inadequate relaxation of the striated sphincter of the urethra.

Often, a combination of symptoms of bladder storage and emptying is observed. This clinical picture is characteristic of detrusor-sphincter dyssynergia.

It is also necessary to pay attention to such symptoms of neurogenic bladder as pain, hematuria, fever and chills. They occur in acute and chronic pyelonephritis, ureterohydronephrosis, inflammation of the prostate, scrotum and urethra, which often accompany neurogenic dysfunction of the lower urinary tract.

Diagnosis of neurogenic bladder

It is important to remember that late diagnosis of neurogenic bladder is dangerous due to irreversible changes in the anatomical and functional state of the bladder and upper urinary tract, so diagnosis and subsequent treatment of neurogenic disorders of the lower urinary tract should begin as early as possible.

The examination begins with a survey and anamnesis collection, and the patient's complaints are clarified. Often, neurological patients, due to speech or cognitive impairments, cannot clearly describe their complaints and disease history. Therefore, in addition to studying the medical documentation, it is necessary to question the patient's relatives in detail.

The obtained results, along with the data of previous neurological examinations, are extremely important, since only a neurologist can competently establish a neurological disease, conduct topical diagnostics, determine the prevalence of damage to the nervous system and make a prognosis. In addition, they evaluate the patient's mental state and intelligence, memory, attention, attitude to their own position, ability to navigate in space and time, etc.

To determine the integrity of sensory innervation, a study of skin sensitivity is performed in the perineum, perianal area, back of the thighs in the S2 dermatome zone, and in the gluteal region in zones S3 and S4. A decrease or complete loss of skin sensitivity indicates generalized peripheral neuropathy (due to diabetes mellitus, alcohol intoxication, toxic effects), damage to the spinal cord or nerve roots.

The examination of tendon reflexes provides useful information about segmental and suprasegmental functions of the spinal cord. Increased activity of the deep tendon reflex (Babinski reflex) indicates damage to the nerve pathways from the brain to the anterior horns of the spinal cord above the S1-S2 level (upper motor neuron) and is usually associated with neurogenic detrusor overactivity. Decreased activity of this reflex indicates damage to the nerve pathways from the anterior horns of the spinal cord at the S1-S2 level to the peripheral organs (lower motor neuron).

Determination of the anal and bulbocavernous (or clitoral) reflexes helps to assess the integrity of the sacral spinal cord. When these reflexes are reproduced, irritation along the afferent fibers of the pudendal and/or pelvic nerve enters the sacral spinal cord and returns along the efferent fibers of the pudendal nerve.

The anal reflex is determined by lightly touching the mucocutaneous junction of the anus, which normally causes a reflex, visible to the eye, contraction of the anal sphincter. The absence of contraction usually indicates damage to the sacral nerve (the exception is the elderly, for whom its absence does not always serve as a pathological sign).

The bulbocavernous (or clitoral) reflex is determined by recording the contraction of the anal sphincter and pelvic floor muscle in response to squeezing the clitoris or the head of the penis with fingers. The absence of the bulbocavernous reflex is considered a consequence of damage to the sacral nerves or S2-S4 segments of the spinal cord. However, it should be taken into account that approximately 20% of people may normally have no bulbocavernous reflex.

It is important to assess the tone of the anal sphincter and its ability to contract voluntarily. The presence of tone in the absence of voluntary contractions of the anus indicates a suprasacral lesion of the nerve pathways, in which neurogenic distrusor hyperactivity can be suspected.

Neurological examination often includes evoked potentials from the posterior tibial nerve to determine the patency of the nerve fibers.

Urological examination begins with an assessment of symptoms characteristic of lower urinary tract diseases. The time of their appearance and dynamics are analyzed, which is important in determining the causes of urination disorders.

Symptoms of neurogenic bladder may occur immediately after the onset of a neurological disease (stroke and others) or damage to the nervous system (spinal cord injury), or at a later stage. It is noteworthy that in approximately 12% of patients with multiple sclerosis, the first symptom of the disease is a violation of the act of urination.

A voiding diary and the international questionnaire on the IPSS scoring system are used to assess the symptoms of lower urinary tract diseases. Keeping a voiding diary involves recording the number of urinations and episodes of urgent urges, the volume of each urination and episodes of urgent urinary incontinence for at least 72 hours. A voiding diary is important in assessing complaints of patients with impaired bladder storage function.

Initially, the IPSS questionnaire was proposed to assess urination disorders in prostate diseases, but at present it is successfully used to assess the symptoms of lower urinary tract diseases caused by other diseases, including neurological ones. The IPSS questionnaire includes 7 questions concerning symptoms of bladder storage and emptying disorders.

Symptoms characteristic of lower urinary tract diseases may be a consequence of not only neurological diseases and disorders, but also various urological nosologies, so it is important to conduct a complete urological examination, especially in men.

Laboratory diagnostics of neurogenic bladder includes biochemical and clinical blood tests, urine sediment analysis, and bacteriological urine analysis. The results of biochemical blood tests may reveal increased creatinine and urea levels due to impaired nitrogen-excreting function of the kidneys. This is often caused by vesicoureteral reflux and ureterohydronephrosis in neurological patients with impaired bladder emptying function. When examining urine sediment, the main focus is on the presence of bacteria and the number of leukocytes. Bacteriological urine analysis allows one to determine the type of microorganisms and their sensitivity to antibiotics.

Ultrasound scanning of the kidneys, bladder, prostate in men and determination of residual urine is a mandatory method of examination of all patients with neurogenic dysfunction of the lower urinary tract. Attention is paid to the anatomical condition of the upper urinary tract (reduction in the size of the kidneys, thinning of the parenchyma, expansion of the renal pelvis and ureters), the volume of the bladder and residual urine is determined. When prostate adenoma is detected in neurological patients, it is important to determine the dominant cause of the symptoms of bladder emptying disorders.

X-ray diagnostics of neurogenic bladder in the form of excretory urography and retrograde urethrocystography are used according to indications. Retrograde urethrocystography is most often used to exclude urethral stricture.

The main modern method for diagnosing neurogenic dysfunction of the lower urinary tract is UDI. Researchers believe that treatment of this category of patients is possible only after determining the form of dysfunction of the lower urinary tract using urodynamic examination. 48 hours before UDI, it is necessary to cancel (if possible) medications that can affect the function of the lower urinary tract. All patients with damage to the cervical and thoracic spine should have their blood pressure monitored during the study, since they have an increased risk of autonomic dysreflexia (sympathetic reflex) in response to filling the bladder in the form of headache, increased blood pressure, flushing of the face and sweating.

UFM is a non-invasive urodynamic method for determining urine flow parameters. UFM, along with ultrasound determination of residual urine volume, are the main instrumental methods for assessing lower urinary tract dysfunction. To correctly determine urine flow parameters and residual urine volume, it is recommended to repeat them several times at different times of the day and always before performing invasive research methods. Impaired bladder emptying function is characterized by a decrease in the maximum and average urine flow rate, interruption of urine flow, an increase in urination time and urine flow time.

Cystometry is a recording of the relationship between the volume of the bladder and the pressure in it during filling and emptying. Cystometry is usually performed with simultaneous EMG of the pelvic floor muscles. The ability of the detrusor to stretch in response to fluid entering the bladder and maintain pressure in it at a sufficiently low level (no more than 15 cm H2O), which does not cause contraction of the detrusor, is called the adaptive capacity of the detrusor. Impairment of this ability occurs with suprasacral injuries and leads to phasic or terminal detrusor hyperactivity (increase in pressure by more than 5 cm H2O).

Filling cystometry determines the sensitivity of the bladder in response to the introduction of fluid. Normally, the patient, in response to filling the bladder, notes an increase in the urge to urinate up to a pronounced and irresistible urge, but there are no involuntary contractions of the detrusor. Increased sensitivity of the bladder is characterized by the appearance of the first sensation of its filling, as well as the first and strong urge to urinate in response to a reduced volume of fluid introduced into the bladder. With decreased sensitivity of the bladder, a weakening of the urge to urinate when the bladder is filled up to its complete absence is observed.

The most important parameter of filling cystometry is the detrusor leak point pressure. This is the lowest detrusor pressure at which urine leaks through the urethra in the absence of abdominal straining or detrusor contraction. If the detrusor leak point pressure is greater than 40 cm H2O, there is a high risk of vesicoureteral reflux and upper urinary tract injury.

The absence of an increase in the electromyographic activity of the pelvic floor muscles during filling cystometry, especially with high volumes of injected fluid, as well as with an increase in abdominal pressure, indicates the absence of contractile activity of the striated sphincter of the urethra.

The pressure/flow study involves the simultaneous recording of intravesical and abdominal pressures (with automatic calculation of their difference, detrusor pressure), as well as urine flow parameters. In neurological patients, the electromyographic activity of the striated sphincter of the urethra is always recorded simultaneously. The pressure-flow study allows one to evaluate the coordination between detrusor contraction and relaxation of the striated sphincter of the urethra and pelvic floor muscles during urination. The results of the pressure-flow study are used to determine the function of the detrusor and the striated sphincter of the urethra. Normally, with voluntary contraction of the detrusor, the striated sphincter of the urethra and pelvic floor muscles relax, followed by emptying of the bladder without residual urine. Decreased detrusor activity is characterized by a contraction of the detrusor of reduced strength or length during emptying of the bladder. Lack of detrusor activity is manifested by a failure to contract the detrusor during an attempt to empty the bladder. Dysfunction of the striated sphincter of the urethra consists in the absence of adequate relaxation of the latter during urination (electromyographic activity is recorded). Only during the "pressure/flow" study can such a urodynamic condition as external detrusor-sphincter dyssynergia be detected, i.e. involuntary contraction of the striated sphincter of the urethra and pelvic floor muscles during detrusor contraction. External detrusor-sphincter dyssynergia is manifested by increased electromyographic activity during emptying of the bladder.

Video urodynamic examination allows recording the above parameters of the filling (cystometry) and emptying phases ("pressure-flow" and EMG of the striated sphincter of the urethra and pelvic floor muscles) of the bladder with simultaneous radiographic imaging of the upper urinary tract and lower urinary tract. During video urodynamic examination, in contrast to standard UDI, it is possible to detect impaired relaxation of the smooth muscle structures of the bladder neck (internal detrusor-sphincter dyssynergia) and vesicoureteral reflux.

According to indications, special tests are performed during UDI: cold water test. The cold water test consists of measuring detrusor pressure by rapidly introducing cooled distilled water into the bladder. In patients with upper motor neuron damage, a sharp contraction of the detrusor occurs in response to the rapid introduction of cooled liquid, often accompanied by urgent urinary incontinence.

A positive test result indicates damage to the lower segments of the spinal cord or bladder nerves.

Thus, urodynamic methods of examination allow to reveal all existing forms of neurogenic dysfunction of the lower urinary tract. Filling cystometry allows to evaluate the accumulation phase of the bladder and to determine a decrease or increase in bladder sensitivity, a decrease in the adaptive capacity (compliance) of the detrusor, an increase in the volume of the bladder, detrusor hyperactivity and sphincter acontractility.

"Pressure-flow" with simultaneous EMG of the pelvic floor muscles helps to assess the phase of emptying the bladder and identify a decrease or absence of contractile activity of the detrusor, external detrusor-sphincter dyssynergia, and a violation of adequate relaxation of the striated sphincter of the urethra.

Videourodynamic examination allows diagnosing internal detrusor-sphincter dyssynergia and impaired adequate relaxation of the bladder neck.

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