Spinal cord injury and neurogenic lower urinary tract dysfunction: what do we know and where are we going?

Abstract

One of the well reported but difficult to manage symptoms of spinal cord injury (SCI) is neurogenic lower urinary tract dysfunction (NLUTD). The type of NLUTD is variable based on location and extent of injury. SCI affects more males and NLUTD is especially debilitating for men with incomplete injury. This review summarizes the anatomical basis of NLUTD in SCI and discusses current diagnostic and management strategies that are being utilized clinically. The last two sections address new innovations and emerging discoveries with the goal of increasing scientific interest in improving treatment options for people with SCI. Areas warranting further investigation are pinpointed to address current gaps in knowledge and/or appropriate technology.

Neurogenic Bladder Physiology, Pathogenesis, and Management after Spinal Cord Injury

“…When a spinal cord injury is sustained, the location of the lesion can be described as suprasacral, mixed or sacral/infrasacral [ 8 ]. In a suprasacral SCI, the sacral reflex arc and PMC remain intact, but the SCI prevents communication between them, essentially disinhibiting the sacral micturition reflex arc, due to the upper motor neuron (UMN) lesion.…”

“…In a suprasacral SCI, the sacral reflex arc and PMC remain intact, but the SCI prevents communication between them, essentially disinhibiting the sacral micturition reflex arc, due to the upper motor neuron (UMN) lesion. The detrusor becomes hyperreflexic, as does the external urethral sphincter, leading to detrusor sphincter dyssynergia (DSD) and very high pressures within the detrusor, putting upper urinary tracts at risk [ 8 , 9 ]. In a mixed SCI, such as conus medullaris syndrome involving both cord and cauda equina, supraspinal disinhibition of the sacral micturition reflex may occur, or may be abolished due to damage to the sacral roots required for the micturition reflex; both conditions can lead to urinary incontinence [ 8 , 10 ].…”

“…The detrusor becomes hyperreflexic, as does the external urethral sphincter, leading to detrusor sphincter dyssynergia (DSD) and very high pressures within the detrusor, putting upper urinary tracts at risk [ 8 , 9 ]. In a mixed SCI, such as conus medullaris syndrome involving both cord and cauda equina, supraspinal disinhibition of the sacral micturition reflex may occur, or may be abolished due to damage to the sacral roots required for the micturition reflex; both conditions can lead to urinary incontinence [ 8 , 10 ]. In a sacral/infrasacral SCI, the lower motor neurons are damaged, and the voiding reflex arc is interrupted while the PMC remains intact, leading to an areflexic detrusor muscle and flaccid external urethral sphincter.…”

“…Urodynamic studies allow the assessment of lower tract function, including evaluation of detrusor compliance and voiding pressures [ 8 , 15 , 23 ]. This study involves the placement of a urethral catheter, as well as an abdominal catheter (placed either in the rectum or the vagina) that allows for the interpretation of detrusor pressures during filling and voiding.…”

“…This study involves the placement of a urethral catheter, as well as an abdominal catheter (placed either in the rectum or the vagina) that allows for the interpretation of detrusor pressures during filling and voiding. This can be combined with fluoroscopic images to provide anatomic details, such as bladder diverticuli, vesicoureteral reflux, bladder outlet obstruction, and stones [ 8 , 15 , 23 ]. Urodynamic testing is critically important to diagnose conditions that predispose the patient to upper tract damage, such as poor bladder compliance, DSD, and bladder outlet obstruction.…”