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Neurogenic bladder

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Updated 2024 EAU guidelines for the diagnosis and management of neurogenic bladder.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of neurogenic bladder are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2024), the European Association of Urology (EAU/ESPU 2023), the American Urological Association (AUA/SUFU 2021), and the International Society of Urology (SIU/ICUD 2018).
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Classification and risk stratification

Risk assessment
As per AUA/SUFU 2021 guidelines:
Classify patients at initial evaluation as low-risk or unknown risk requiring further evaluation to allow for complete risk stratification.
B
Obtain risk stratification in patients with an acute neurological event resulting in neurogenic lower urinary tract dysfunction once the neurological condition has stabilized.
B
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Diagnostic investigations

Initial evaluation: as per EAU 2024 guidelines, elicit an extensive general history, concentrating on past and present symptoms.
A
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  • Urinalysis and culture

  • Urinary tract imaging

  • Urodynamic studies

  • Blood tests

Diagnostic procedures

Cystoscopy: as per AUA/SUFU 2021 guidelines, do not perform routine cystoscopy in the initial evaluation of patients with neurogenic lower urinary tract dysfunction.
D
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Medical management

General principles
As per ICUD/SIU 2018 guidelines:
Prescribe medications, particularly combination therapy, with care due to the risk of polypharmacy and cognitive impairment in patients with spinal cord injury.
B
Avoid offering drug "cycling" in patients with spinal cord injury if oral medical therapy fails. Consider offering alternative treatment such as botulinum neurotoxin or surgical reconstruction.
D
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  • Anticholinergics

  • Alpha-blockers

  • Beta-3 agonists

  • Parasympathomimetics

  • TCAs

  • Antibiotic prophylaxis

  • Management of autonomic dysreflexia

  • Management of erectile dysfunction

  • Management of infertility (male)

  • Management of infertility (female)

  • Management of recurrent UTIs

Nonpharmacologic interventions

Bladder expression: as per ICUD/SIU 2018 guidelines, do not offer bladder expression or triggered bladder voiding in patients with spinal cord injury if any of the following video-urodynamic findings are present:
small bladder capacity
high leak point pressure
low compliance
vesicoureteral reflux at any point of the study
closed bladder neck during voiding or high voiding pressure.
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Therapeutic procedures

Intermittent catheterization
As per EAU 2024 guidelines:
Offer intermittent catheterization as a standard treatment for patients unable to empty their bladder.
A
Instruct patients thoroughly in the technique and risks of intermittent catheterization.
A
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  • Indwelling catheterization

  • Condom catheterization

  • Botulinum toxin injections

  • Intravesical oxybutynin

  • Sacral neuromodulation

Surgical interventions

Bladder augmentation: as per EAU 2024 guidelines, offer bladder augmentation in patients with low bladder compliance and/or refractory neurogenic detrusor overactivity.
A
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  • Urethral slings

  • Artificial urinary sphincter

Specific circumstances

Pediatric patients, evaluation: as per EAU/ESPU 2023 guidelines, obtain urodynamic testing in all patients with spina bifida, and with a high suspicion of neurogenic bladder to estimate the risk for the upper urinary tract and to evaluate the function of the detrusor and the sphincter.
B
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  • Pediatric patients (intermittent catheterization)

  • Pediatric patients (medical management)

  • Pediatric patients (botulinum toxin injections)

  • Pediatric patients (surgical management)

  • Pediatric patients (follow-up)

Patient education

Patient education: as per AUA/SUFU 2021 guidelines, educate patients with neurogenic lower urinary tract dysfunction about the symptoms and signs warranting additional assessment.
B
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Follow-up and surveillance

Follow-up, general principles: as per EAU 2024 guidelines, assess the upper urinary tract at regular intervals in high-risk patients.
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  • Follow-up (patients with indwelling catheter)

  • Follow-up (patients with condom catheter)

  • Re-evaluation of patients with new symptoms