When brain meets bladder: Neurogenic lower urinary tract dysfunction: Explained and managed

Lower urinary tract symptoms are common in neurological conditions, having a significant impact on a person’s quality of life, independence and rehabilitation outcomes.

In this webinar, consultant urological surgeon Dr Sheilagh Reid, MS specialist nurse Liam Rice, and consultant neurologist Professor Siva Nair, all from Sheffield Teaching Hospitals NHS Foundation Trust, explored this highly impactful issue and shared their advice on management.

Neurogenic lower tract dysfunction explained

Sheilagh explained that bladder, bowel, and sexual function are innervated from the sacral spinal cord segments S2–S4, and bladder control is based on two main spinal reflexes.

The first is the sacral micturition reflex, mediated through the S3 sacral micturition centre. When the bladder fills, stretch signals activate parasympathetic nerves that cause detrusor contraction. The second is the guarding reflex, which runs through Onuf’s nucleus and uses somatic nerves to contract the rhabdosphincter, the main portion of the urethral sphincter responsible for continence. These reflexes are coordinated by the pontine micturition centre (PMC), which ensures the bladder remains relaxed and the sphincter contracted during storage, and vice versa during voiding.

NICE guidelines on urinary incontinence group brain conditions into three categories: brain conditions (above the PMC), suprasacral spinal cord conditions, and sacral or peripheral nerve lesions. In suprasacral cord conditions, there can be detrusor sphincter dyssynergia. “The bladder and the sphincter are contracting at the same time, and that causes high pressures,” said Sheilagh. People with sacral cord or peripheral nerve conditions can experience loss of bladder/sphincter innervation, in which the S3 “is not working”, she added.

The primary goal of management, she went on is to protect the kidneys. “An unsafe bladder is one that threatens the kidneys through sustained high pressure… if the pressure in the kidney is lower than the pressure in the bladder, it can't drain.” This can cause hydronephrosis and, ultimately, renal failure. High-risk groups include spinal cord injury, spina bifida, and anorectal abnormalities, and such patients require lifelong renal surveillance.

Key red flags requiring referral to urology include haematuria, recurrent infections, catheter complications, and high-risk patterns, such as spinal cord injury, advanced MS, or cauda equina injury . In addition, men with potential bladder outflow obstruction should be referred for prostate assessment. Investigations can include renal and post-void ultrasound, and some patients may require CT, cystoscopy, or video urodynamics, depending on their presentation and risk factors.

Neurogenic lower tract dysfunction management: A nurse’s perspective

Liam shared a nurse’s perspective on urinary assessment, outlining key lower urinary tract symptoms (LUTS) such as urgency, frequency, nocturia, hesitancy, incontinence, and post-micturition dribble. Taking a comprehensive history, including disease progression, co-morbidities, medications, sexual function, bowel habits, substance use, and fluid intake is essential, he added.

Asking the patient to keep a diary, detailing fluid intake, voiding patterns, and symptom severity, can be “really helpful”, Liam went on. He explained he send a diary template out before appointments in order to get as “much information as possible” for the assessment. “It gets the patient involved and gets them thinking about what they are drinking,” he added. Liam described bladder scanning as a vital, easy-to-use tool for measuring post-void residual (PVR) urine and guiding treatment decisions.

Lifestyle and conservative management, including reducing caffeine, fizzy drinks, bladder-irritating foods, and maintaining adequate hydration, are the first step to management. Bowel health is equally critical, as constipation can worsen bladder dysfunction, Liam explained.

Urinary tract infections (UTIs) are a major concern, he went on, explaining that neuropathic patients, particularly those with multiple sclerosis “do not do well with UTIs”, which can lead to pseudo relapse. He advocated for careful diagnosis and reducing antibiotic use where possible with preventative measures.

Liam also presented a stepwise clinical pathway for overactive bladder management. It focuses on assessment, bladder scanning, urinalysis, bowel review, and conservative measures, followed by medications such as anticholinergics and beta-3 agonists, intermittent self-catheterisation, and, if needed, botulinum toxin injections into the bladder or urological referral.

Overall, his emphasised the importance of holistic assessment, conservative management, and multidisciplinary working to improve bladder and bowel outcomes.

Neurogenic lower tract dysfunction management: A neurologist’s perspective

Neurological disease and bladder dysfunction have a two-way relationship, with each able to influence, mimic, or worsen the other, said Siva. “We need to consider neurology and urology not as two separate specialties, but holistically,” he said, adding that the priorities were to identify the underlying cause of symptoms, practical management, and timely intervention.

Bladder dysfunction may be an early manifestation of neurological disease, and urological problems such as infection, stones, retention, or incontinence can significantly worsen neurological symptoms. In people with conditions such as MS or spinal cord injury, bladder problems may trigger spasticity, mobility decline, delirium, recurrent hospital admissions, and pseudo-relapses, Siva explained.

The treatments used for bladder dysfunction can also affect neurological health. Anticholinergic medications, commonly prescribed for overactive bladder, interfere with acetylcholine, a neurotransmitter essential for memory and cognition. Long-term use is associated with cognitive decline, increased dementia risk, and acute delirium. Siva encouraged healthcare professionals to calculate anticholinergic burden and consider alternative therapies, such as beta-3 agonists, when appropriate.

Neurological impairments themselves can compromise continence, “even if the disease isn’t causing neurological problems”, he went on. There may be, for example, absent or delayed recognition of bladder sensations, or mobility problems could impede the person’s ability to access the toilet. Ataxia, weakness, and poor hand function may prevent timely toileting or self-catheterisation. In addition, some medications for neurological symptoms, such as baclofen, gabapentin, diazepam, and dantrolene, can weaken pelvic floor muscles, thereby contributing to incontinence.

Depending on the patient, approaches might include bladder training, with timed voiding and fluid regulation, pelvic floor muscle exercises, or accessible toilets and mobility aids. Pharmaceutical options include botulinum toxin, which is used for both spasticity and overactive bladder. Said Siva: “If the person is receiving both treatments, we need good communication between neurology and urology teams regarding dates and dose of injections, and the type of toxin used.”

He also highlighted scan-negative cauda equina syndrome, where no structural cause is found. In such cases, symptoms may be functional and associated with psychological distress. Management should include validating the symptoms, and providing a clear explanation. Bowel optimisation, cautious intermittent self-catheter use, and psychological support can be helpful

Overall, bladder and neurological symptoms must be considered together within a holistic, multidisciplinary framework, he concluded.