Clare Juliet Fowler

This chapter reviews bladder disturbances in non-traumatic neurological conditions and provides an approach to its evaluation and management. The pattern of bladder dysfunction depends upon the level of neurological localisation and accordingly, lesions can be suprapontine, infrapontine/suprasacral (spinal), or infrasacral. The importance of the frontal lobes for bladder control has been confirmed and vascular disease or tumour can result in incontinence. There is better understanding about the very different urological profile of the two sometimes confused conditions, multiple system atrophy and Parkinson’s disease. Guidelines for the management of lower urinary tract dysfunction in multiple sclerosis are reviewed. Lower urinary tract (LUT) dysfunction is common in neurological disease and its importance to patient health and quality of life is now widely recognized.

If a young woman in complete urinary retention is investigated and all urological and neurological investigations are found to be normal, the commonest diagnosis then made is Fowler’s syndrome (FS). Described by Fowler et al. in 1987, the original syndrome comprised of complete urinary retention with the finding of a particular pattern of electromyographic (EMG) activity recorded with a concentric needle electrode from the striated urethral sphincter, in a young woman with clinical features of polycystic ovaries. Prior to that, description medical opinion was that urinary retention in young women was due to ‘hysteria’; more had been written about ‘psychogenic urinary retention in women’ than any other possible causes. Twenty-five years on, the situation now seems to be that if neither the urologist or urologist can discover an underlying abnormality, the woman may be told she has FS without any positive identification of that condition.

CUAJ is the only indexed, peer-reviewed journal endorsed and supported by the Canadian Urological Association.

Bladder symptoms in multiple sclerosis (MS) are common and distressing but also highly amenable to treatment. A meeting of stakeholders involved in patients’ continence care, including neurologists, urologists, primary care, MS nurses and nursing groups was recently convened to formulate a UK consensus for management. National Institute for Health and Clinical Excellence (NICE) criteria were used for producing recommendations based on a review of the literature and expert opinion. It was agreed that in the majority of cases, successful management could be based on a simple algorithm which includes using reagent sticks to test for urine infection and measurement of the post micturition residual urine volume. This is in contrast with published guidelines from other countries which recommend cystometry. Throughout the course of their disease, patients should be offered appropriate management options for treatment of incontinence, the mainstay of which is antimuscarinic medications, in combination, if necessary, with clean intermittent self-catheterisation. The evidence for other measures, including physiotherapy, alternative strategies aimed at improving bladder emptying, other medications and detrusor injections of botulinum toxin A was reviewed. The management of urinary tract infections as well as the bladder problems as part of severe disability were discussed and recommendations agreed.

Over the last 10 years functional brain imaging has emerged as the most powerful technique for studying human brain function. Although the literature is now vast, including studies of every imaginable aspect of cortical function, the number of studies that have been carried out examining brain control of bladder function is relatively limited. Nevertheless those that have been reported have transformed our thinking. This article reviews that development in the context of emerging ideas of interoception and a working model of brain activity during bladder filling and emptying is proposed. Some studies have also been carried out using functional imaging methods to examine pathophysiological bladder conditions or the effect of treatments and these are reviewed and future work anticipated. Neurourol. Urodynam. 29: 49–55, 2010.