Practice Uncertainties Page

What is the most effective management of neurogenic bladder dysfunction?

BMJ 2009; 338 doi: (Published 12 March 2009) Cite this as: BMJ 2009;338:b659
  1. Brian Buckley, Cochrane research fellow1,
  2. Adrian M Grant, professor of health services research2
  1. 1Department of General Practice, National University of Ireland, Galway
  2. 2Institute of Applied Health Sciences, College of Life Sciences and Medicine, University of Aberdeen, Health Sciences Building, Aberdeen AB25 2ZD
  1. Correspondence to: B Buckley bsbuckley{at}

    What is the uncertainty?

    Neural damage from injury to the spinal cord or neurological conditions, such as multiple sclerosis or spina bifida, may cause neurogenic bladder dysfunction; this affects the ability to retain or to void urine, or both. Considerable uncertainty exists regarding the most effective management of neurogenic bladder dysfunction, which aims to prevent urinary tract infection and preserve upper urinary tract health, continence, and quality of life.1 2 The effect of incontinence on quality of life can hardly be overestimated.3

    Management is usually long term, complex, and determined by the underlying neurological abnormality. It is often guided by urodynamic evaluation of lower urinary tract function. The patient’s preferences and availability of help from carers also affect management choices and must be carefully assessed.

    Management options depend on the patient’s characteristics but include indwelling urethral or suprapubic catheterisation; intermittent catheterisation; urine collection by an external device; sacral nerve stimulation; and surgical techniques such as urinary diversion, bladder augmentation or substitution, sphincterotomy, and artificial sphincter implantation. But which technique is the most effective? For instance, which catheter policy results in fewest urinary tract infections?

    Intermittent catheterisation has several advantages over other techniques—fewer infections, reduced equipment needs, and greater independence.4 However, the patient or carer must be able and willing to perform the procedure so it may not always be practicable. Indwelling catheters have become a …

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