Neurogenic Bladder

Detrusor Hyperreflexia Without Outlet Obstuction. In patients with detrusor hyperreflexia without outlet obstruction, the treatment most frequently given is an anticholinergic drug such as oxybutynin, propantheline, or dyclomine. Timed voiding and moderate fluid restriction are helpful in reducing frequency, urgency, and urge incontinence. DDAVP may also be useful in patients with significant incontinence and nocturia. In patients with severe spasticity, both intrathecal baclofen infusion and dorsal rhizotomy may be effective. Augmentation cystoplasty has a place in the treatment of patients with MS and refractory detrusor hyperreflexia.

Detrusor Hyperreflexia with Outlet Obstruction. Treatment of patients with detrusor hyperreflexia and detrusor-sphincter dyssynergia is more difficult, and these patients are at higher risk of sustaining upper urinary tract damage. Alpha-1 antagonists such as phenoxybenzamine or prazosin may decrease bladder-outlet sphincter tone. Dantrolene, baclofen, or benzodiazepines may reduce the tone of the striated external sphincter. The most useful method is the combined use of anticholinergics and intermittent self-catheterization. Surgical external sphincter-otomy or diversion procedures are treatments of last resort.

Detrusor Areflexia or Poor Bladder Contractility. Bethanechol hydrochloride is a muscarinic agonist that has a relatively selective action on the urinary bladder and may be effective in treating patients with chronic detrusor atony or hypotonia. Other options include the use of adrenergic antagonists, prostaglandins, and narcotic antagonists, but their efficacy is unproved. The simplest and most effective form of management in patients with hypotonic bladder and detrusor areflexia is intermittent self-catheterization. Patients who are unable to perform intermittent self-catheterization because of motor difficulties may require an indwelling catheter or suprapubic diversion. Women may benefit from using the Crede(c) maneuver. In patients with conus or cauda equina lesions, alpha-adrenergic agonists (e.g., ephedrine or phenylpropanolamine) may be used to increase bladder outlet resistance.

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