Neurogenic bladder: understanding loss of control and its causes

Two months after a lumbar slipped disc, Ganesh Naik noticed unusual bladder issues. “I suffered through days of lower urinary tract symptoms like increased frequency of urination, urgency, and inconsistency while urinating. I also had voiding problems [difficulty in emptying the bladder] like poor stream and dribbling,” says the 27-year-old from Mangaluru. After a sonography and Magnetic Resonance Imaging of his lower back, his nephrologist diagnosed him with a neurogenic bladder.

“Neurogenic bladder is a condition where nerves of the brain lose effective communication with the muscles of the bladder, making an individual lose control over urination,” says Dr Narendra Pai, associate professor, department of urology, KS Hegde Medical Academy, Mangaluru.

Brain-bladder interplay 

The bladder is a balloon-shaped organ that collects the urine that the kidneys produce. When the bladder is full, it sends a message to the brain, prompting neurons to instruct the bladder muscles to contract and empty its contents.

“Disruptions in this communication can lead to bladder control issues such as incontinence or urinary retention,” says Dr Pai.

The root of neurogenic bladder 

Damage to any nerve involved in the brain-bladder signal relay can cause bladder innervation, that is, disrupt communication between nerves and bladder muscles. “This damage can occur from neurological conditions such as Parkinson’s, multiple sclerosis or stroke. Other reasons could be diabetes, brain or spinal cord infections, trauma, injury, cerebral palsy or even spina bifida,” says Dr Shailesh Mohan Badole, consultant neuro physician at Russh Super Speciality Hospital, Telangana.

In Naik’s case, the slipped disc caused a skewed innervation leading to a neurogenic bladder.

Faulty communication can arise in two ways: failed messages from the bladder to the brain and vice versa. “For example, in conditions such as Parkinson’s disease, the upper motor neurons are affected; therefore, the brain fails to send effective signals to the bladder,” explains Dr Pai.

On the contrary, when lower motor neurons are affected in conditions such as spinal cord injury, brain signals are not relayed to the bladder due to nerve damage.

In such cases, the person may lose bladder control. “This means that even if the bladder is full, the person may not be able to empty it due to the lack of sensation,” says Dr Pai.

Dr Badole notes that the symptoms vary depending on the type of nerve damage. People with a neurogenic bladder are prone to urinary tract infections, which is also an initial symptom of the condition. Other symptoms may include pain while urinating or in the lower back, low urine volume, kidney stones, and blood in the urine.

Affected in both ways

A neurogenic bladder can either be overactive or underactive, says Dr Pai. Those with an overactive bladder experience sudden and urgent spasms in the bladder muscles. They feel the need to urinate frequently, even when the bladder is not full, leading to involuntary urine loss.

On the flip side, those with an underactive bladder may find difficulty in emptying it. The urine is passed in a dribble, causing urinary retention because the brain fails to signal the bladder muscles to contract and empty its entire contents.

Dr Pai cites the example of a 20-year-old boy with a spinal cord fracture from a road accident. “Initially, he did not have any bladder sensation; therefore, urine had to be drained using an external tube (catheter). However, even after removing the catheter, he could not void on his own. Finally, an ultrasound revealed that although his bladder had a good amount of urine, he could not void it.”

Some people may experience both overactive and underactive bladder. “This is most commonly seen in people with stroke or multiple sclerosis,” says Dr Badole. He explains the case of a 23-year-woman who had developed an abnormal build-up of fluid in the brain. This excessive fluid build-up prevented her from feeling a full bladder or the passage of urine.

Road to diagnostic clarity

A basic ultrasound scan, which clarifies how nerve activity affects the bladder and its filling up, is typically used to diagnose neurogenic bladder.  “Sometimes, when the bladder pressure rises, it is transferred to the kidney and the ureter. As such, determining the pressure on the kidneys and ureter is another way to diagnose this condition,” says Dr Pai.

Dr Badole suggests renal function tests and urine analysis as the most effective tools to detect a neurogenic bladder condition in those with repeated urinary tract infections. He adds that, depending on the severity of the damage, a urodynamic study and an MRI of the brain or spine could help in an early diagnosis.

Effective therapy

Neurogenic bladder occurs due to damage to the nerve covering, reduced plasticity and growth of neurons or nerve breakage. The chances of recovery and the duration depend on the type of nerve damage that has occurred.

“It is easier for the bladder to recover if the damage is caused by reduced plasticity or neuron growth. Sometimes we cannot expect a good recovery, but can keep the condition under check,” explains Dr Pai.

After being diagnosed, Naik was prescribed intermittent catheterisation, and advised muscle training exercises and yoga, plus abstinence from alcohol. “I have been able to live a normal life ever since,” says Naik.

Dr Badole throws light on bladder training, an effective strategy that helps schedule voiding, reducing the urge to urinate. It combines educative modules on setting a voiding schedule every 2-4 hrs and pelvic muscle exercises. “Scheduled voiding is especially useful in people with weak sphincter muscles or hyperactive bladder,” he adds.