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Neurogenic Bladder Disorders and Their Management

Our understanding of the neurologic control of micturition has progressed since the description of the pontine micturition center by Barrington (see Brain 1921; 44:23). Recent PET studies in humans have shown activity in the medio-posterior pons during voiding. Likewise, a SPECT study has reported enhancement of periaqueduct gray matter during micturition.

This review describes how cortical lesions and strokes cause voiding dysfunction. It reminds us that multiple system atrophy (MSA) should be suspected if urinary symptoms and erectile dysfunction precede parkinsonism and that bladder outflow surgery should be avoided in these patients, as results are disappointing. MS and other spinal cord disease remain the most common cause of detrusor hyperreflexia with detrusor sphincter dyssynergia. Most patients can be treated using oral anticholinergics, with intermittent self-catheterization for those with incomplete bladder emptying. Desmopressin decreases nocturia, and intravesical capsaicin or resiniferatoxin can reduce intractable detrusor hyperreflexia. With progressive disability, suprapubic catheterization may become necessary. The Brindley nerve root stimulator can achieve good results in patients with complete spinal cord transection. Some young women with urinary retention and "whale noises" on sphincter EMG experience improved voiding with S3 sacral nerve stimulation.

Comment: This article reminds us that much can be done to manage neurogenic incontinence. A good starting point is examination of the legs of any patient with suspected neurogenic bladder because neurologically the bladder lies "below the legs." Postvoid residual measurements are recommended and further urodynamic studies give useful information in selected patients. Treatment is largely medical with surgery reserved for a few selected patients.

— P Dasgupta

Prokar Dasgupta, MSc Urol, FRCS, is Honorary Lecturer in Uro-Neurology, National Hospital for Neurology and Neurosurgery, London; Senior Registrar in Urology, Colchester General Hospital, Essex, UK.

Published in Journal Watch Neurology November 1, 1999

Citation(s):

Fowler CJ. Neurological disorders of micturition and their treatment. Brain 1999 Jul 122 1213 -1231.

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