Neurogenic Bladder Management and Nursing Care

What is Neurogenic Bladder?

Neurogenic bladder is the overlying term for a variety of urinary dysfunctions caused by a disease or an injury that has disrupted normal neurological functioning (Shenot 2020).

Depending on the nerve damage experienced by the individual, their bladder may become overactive (spastic) or underactive (flaccid) (Cleveland Clinic 2016).

Normal bladder function relies on information travelling through neural pathways from the cerebral cortex, through the spinal cord, and on to the bladder to coordinate normal micturition and urinary continence. When this pathway is damaged, it can result in loss of bladder sensation and also the loss of the coordination between the urethral sphincter and its muscles. This means that these muscles may not contract even when the bladder fills or the person has the urge to void, leading to bladder dysfunctions such as urinary incontinence and retention (Mauk 2012).

Depending on the aetiology and classification of the neurogenic bladder, the individual may experience a variety of symptoms, including:

• Urinary urgency and frequency;
• Urinary retention;
• Urinary incontinence;
• Overflow incontinence;
• Urge incontinence;
• Erectile dysfunction;
• Nocturia; and
• Spastic paralysis.

(Shenot 2020)

Causes of Neurogenic Bladder

Neurogenic bladder can be caused by any condition that affects the bladder or bladder outlet nerves, including:

• Stroke;
• Amyotrophic lateral sclerosis;
• Herniated disks;
• Parkinson’s disease;
• Multiple sclerosis;
• Syphilis;
• Diabetes;
• Infection;
• Nerve damage from pelvic surgery;
• Trauma or injury to the brain or spinal cord;
• Genetic nerve issues;
• Heavy metal poisoning;
• Birth defects affecting the spinal cord;
• Tumours in the brain or spinal cord;

(Shenot 2020; Johns Hopkins Medicine 2015)

Classifications of a Neurogenic Bladder

A neurogenic bladder can be classified in many ways, typically depending on the location of the neurologic lesion:

• Lesions above the pontine micturition centre: These are seen commonly in patients with strokes and brain tumours and produce an uninhibited bladder. A patient with an uninhibited neurogenic bladder will experience sensation but lack voluntary control, so they may have urgency, frequent bladder contractions and nocturia.
• Lesions between the pontine micturition centre and sacral spinal cord: This is commonly seen in people with traumatic spinal cord injuries or MS, and produces an upper motor neuron bladder in which there is a reduced bladder capacity. Consequently, the potential high pressures within the bladder have the capacity to produce renal damage. These patients will often lack the sensation to void, which can also result in urinary retention.
• Sacral cord lesions that damage the detrusor nucleus but spare the pudendal nucleus produce a mixed, type A bladder in which patients may experience urinary retention without incontinence.
• Sacral cord lesions that spare the detrusor nucleus but damage the pudendal nucleus produce a mixed, type B bladder in which the patient may experience episodes of incontinence.
• Lower motor neuron bladder from sacral cord or sacral nerve root injuries in which the patient will experience an areflexic bladder.

(Dorsher & McIntosh 2012; Mauk 2012)

Investigations and Bladder Assessment

Diagnosis of neurogenic bladder is essential to ensure effective management strategies are implemented. There are a variety of investigations and assessments that need to be completed in order to diagnose a neurogenic bladder and exclude other possible causes. Some of these investigations include:

• Analysis of the urine;
• Measurement of residual urine;
• Urine flow test;
• Filling and voiding cystometry;
• Ureteroscopy;
• Radiological investigations;
• Neurophysiological examination of the pelvic floor; and
• Micturition cystourethrography.

(Greenwood et al. 2013)

Potential Complications of Neurogenic Bladder Dysfunction

In addition to physical complications caused by neurogenic bladder, there may also be negative psychosocial effects including decreased quality of life and feelings of embarrassment and depression, which can lead to further social isolation. This may be devastating in the case of someone with a progressive neurological condition (Ginsberg 2013a).

Potential physical complications of neurogenic bladder include:

• Urinary tract infections;
• Urinary calculi;
• Autonomic dysreflexia, a medical emergency in which the message that the bladder is full cannot reach the brain. Because the message is blocked, it leads to arteriole vasoconstriction and hypertension, which causes vasodilation of the heart and brain, leading to bradycardia and dilation of smaller blood vessels to compensate. If left untreated, the patient can have severe hypertension with systolic BP as high as 300 mmHg and stroke, coma or death can occur. The most common cause is a distended bladder; and
• Hydronephrosis, which is when an over-distended bladder causes a reflux of urine into the kidneys.

(Shenot 2020; Mauk 2012)

Management of Neurogenic Bladder

Management of neurogenic bladder needs to be individualised according to the patient, the classification of their bladder dysfunction, the cause of their dysfunction and their symptoms. Nurses will often be involved in supporting the patient to learn techniques and strategies for managing the condition.

The main focus of management is patient education. The goal of all bladder management programs is to develop predictable and effective patterns of elimination by emptying the bladder and preventing potential complications. The patient needs to be involved in their own bladder management program to ensure it works for them and fits in with their lifestyle. This may mean a combination of bladder training, behaviour modification and medications, and as a last resort, surgery may be required (Dorsher & McIntosh 2012; Mauk 2012).

Bladder training is an essential component of neurogenic bladder management. It ensures regular and adequate emptying of the bladder and may be through the means of a voiding schedule or self-catheterisation (Ginsberg 2013).

Intermittent catheterisation can be used for patients who have complete or partial urinary retention. Self-administered intermittent catheterisation has many benefits over indwelling catheters, including enhanced independence and confidence, and a reduction of potential barriers to sexual function. If the patient has some ability to void, intermittent catheterisation can be used as part of their bladder retraining program. Patient education is critical for patients who are self-administering intermittent catheterisation, with one of the most frequent complications being urinary tract infections (Ginsberg 2013b).

An indwelling catheter or suprapubic catheter can also be used, but once again, patient education is essential for catheter care on discharge. While this is not the preferred method of long-term bladder management, it may be the most effective and practical solution for people with poor hand function, high fluid intake, lack of support or lack of success with other management strategies (Mauk 2012).

Pharmacological therapies can also be used for bladder management; antimuscarinics are commonly used and not only result in an increased bladder capacity, but also delay the urge to void (Ginsberg 2013b).

Surgical interventions are generally implemented as a last resort and include procedures such as transurethral sphincterotomy and enterocystoplasty (Ginsberg 2013b).

References

• Cleveland Clinic 2016, Neurogenic Bladder, Cleveland Clinic, viewed 8 December 2020, https://my.clevelandclinic.org/health/diseases/15133-neurogenic-bladder
• Dorsher, P T & McIntosh, P M 2012, ‘Neurogenic bladder’, Advances in Urology, vol. 2012, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3287034/
• Ginsberg, D 2013a, ‘The Epidemiology and Pathophysiology of Neurogenic Bladder’, The American Journal of Managed Care, vol. 19, no. 10, pp. 191–6, https://www.ajmc.com/view/ace012_jul13_ngb_ginsberg1_s191
• Ginsberg, D 2013b, ‘Optimizing Therapy and Management of Neurogenic Bladder’, The American Journal of Managed Care, vol. 19, no. 10, pp. 197-204, https://www.ajmc.com/view/ace012_jul13_ngb_ginsberg2_s197
• Greenwood, RJ, Barnes, MP, McMillan, TM & Ward, C (eds.) 2013, Handbook of Neurological Rehabilitation, 2nd edn, Routledge, New York.
• Johns Hopkins Medicine 2015, Neurogenic Bladder, Johns Hopkins Medicine, viewed 8 December 2020, https://www.hopkinsmedicine.org/health/conditions-and-diseases/neurogenic-bladder
• Mauk, KL 2012, Rehabilitation Nursing: A Contemporary Approach to Practice, Jones & Bartlett Learning, Sudbury.
• Shenot, P J 2020, Neurogenic Bladder, MSD Manual, viewed 8 December 2020, https://www.msdmanuals.com/en-au/professional/genitourinary-disorders/voiding-disorders/neurogenic-bladder