12. Monitoring of Neurogenic Bladder

Bladder function should be reviewed annually by the family physician, and periodically by a urologist.

The Problem

Neurogenic bladder (dysfunction of the ability to store and void urine) is a common complication of spinal cord injury (SCI), affecting 80-85% of individuals. Spinal cord injury often causes decreased bladder compliance, detrusor-sphincter dysynergia, or increased detrusor pressure. These conditions can result in significant renal damage if not properly managed. Neurogenic bladder may also be accompanied by complications such as bladder or kidney stones, recurrent infections, or autonomic dysreflexia (see Nugget #4).

Methods of managing a neurogenic bladder include clean intermittent catheterization, specific voiding techniques, indwelling or condom collection devices. The method(s) used depend on the patient’s anatomy, functional abilities, medical co-morbidities, and social life. An optimal bladder management routine is typically determined by a physiatrist or urologist. The goals of managing neurogenic bladder are continence, regular emptying, avoiding increased bladder pressure, and preventing complications. Bladder function may change as patient’s age and acquire secondary conditions, or their circumstances change.

Evidence-based Best Practice

Success of bladder management is measured in terms of social continence, bladder capacity >360 ml, detrusor pressure <40 cm H2O, and absence of autonomic dysreflexia (AD).

Although there is no consensus on the frequency of neurogenic bladder surveillance, annual review in primary care is a reasonable approach for those without additional risk factors, such as recurrent urinary tract infections, altered continence, increased post-void residuals, hydronephrosis, raised creatinine or cystatin C, or lowered GFR. For patients with any of those factors, follow-up should be as needed.

Annual review should include:

  1. Medical history and clinical exam;
  2. Renal laboratory bloodwork – recommend estimated GFR based on serum cystatin C, rather than serum creatinine;
  3. Imaging surveillance — ultrasound of the upper and lower urinary tract; X-rays for kidney or bladder stones not recommended;
  4. Urodynamics — as dictated by symptoms;
  5. Cystoscopy/cytology – screening for bladder cancer (see Nugget #15).

Routine urinalysis is not recommended (see Nugget #13)

Key Reference

Przydacz, M., Chlosta, P., & Corcos, J. (2018). Recommendations for urological follow-up of patients with neurogenic bladder secondary to spinal cord injury. International urology and nephrology, 50(6), 1005-1016.

Actionable Nuggets (4th ed., 2019)

Additional References (since 2016)

Bragge, P., Guy, S., Boulet, M., Ghafoori, E., Goodwin, D., & Wright, B. (2019). A systematic review of the content and quality of clinical practice guidelines for management of the neurogenic bladder following spinal cord injury.Spinal Cord, 57(7), 540-549. doi:10.1038/s41393-019-0278-0

Dray, E. V., & Cameron, A. P. (2017). Identifying patients with high-risk neurogenic bladder: Beyond detrusor leak point pressure.The Urologic Clinics of North America, 44(3), 441.

Gomelsky, A., Lemack, G. E., Castano Botero, J. C., Lee, R. K., Myers, J. B., Granitsiotis, P., & Dmochowski, R. R. (2018). Current and future international patterns of care of neurogenic bladder after spinal cord injury.World Journal of Urology, 36(10), 1613-1619. doi:10.1007/s00345-018-2277-8

Harris, C. J., & Lemack, G. E. (2016). Neurourologic dysfunction: Evaluation, surveillance and therapy.Current Opinion in Urology, 26(4), 290-294. doi:10.1097/MOU.0000000000000290

Kreydin, E., Welk, B., Chung, D., Clemens, Q., Yang, C., Danforth, T., . . . Ginsberg, D. A. (2018). Surveillance and management of urologic complications after spinal cord injury.World Journal of Urology, 36(10), 1545-1553. doi:10.1007/s00345-018-2345-0

Romo, P. G. B., Smith, C. P., Cox, A., Averbeck, M. A., Dowling, C., Beckford, C., . . . Cameron, A. P. (2018). Non-surgical urologic management of neurogenic bladder after spinal cord injury.World Journal of Urology, 36(10), 1555-1568. doi:10.1007/s00345-018-2419-z

Welk, B., Lenherr, S., Elliott, S., Stoffel, J., Presson, A. P., Zhang, C., & Myers, J. B. (2018). The neurogenic bladder symptom score (NBSS): A secondary assessment of its validity, reliability among people with a spinal cord injury.Spinal Cord, 56(3), 259-264. doi:10.1038/s41393-017-0028-0

Wheeler, T. L., de Groat, W., Eisner, K., Emmanuel, A., French, J., Grill, W., . . . Bowel and Bladder Workshop Participants. (2018). Translating promising strategies for bowel and bladder management in spinal cord injury.Experimental Neurology, 306, 169-176. doi:10.1016/j.expneurol.2018.05