Current Bladder Dysfunction Reports

, Volume 13, Issue 2, pp 75–83 | Cite as

Stress Urinary Incontinence in Women with Neurogenic Lower Urinary Tract Dysfunction

  • Elizabeth V. DrayEmail author
  • Anne P. Cameron
  • Rachel Bergman
Stress Incontinence and Prolapse (S Reynolds, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Stress Incontinence and Prolapse


Purpose of Review

The purpose of this review is to discuss the pathophysiology of neurogenic SUI in the female patient, examine the evidence supporting surgical and non-surgical treatment options, and outline our recommendations for the care of this population.

Recent Findings

AFPVS appears to be more efficacious than MUS for this group; however, almost all patients will require self-catheterization after surgery. MUS have a higher probability of maintaining spontaneous voiding but also care the risk mesh complications and higher failure rates. Bladder neck AUS placement may also be considered, but most studies show high reoperation rates and have only a few female subjects. In severe refractory cases of SUI or in the setting of urethral erosion, bladder neck closure has been shown to have good continence outcomes.


SUI in the setting of neurogenic lower urinary tract dysfunction is often more severe and harder to address than non-neurogenic SUI, due in part to the high rates of ISD in this population. Patients should be screened for other causes of urinary incontinence with UDS prior to any invasive interventions. AFPVS is an appropriate first-line therapy for these patients, particularly in individuals who already perform self-catheterization. Finally, in the setting of moderate to severe urethral erosion, bladder neck closure or urinary diversion should be strongly considered.


Neurogenic lower urinary tract dysfunction Stress incontinence 


Compliance with Ethical Standards

Conflict of Interest

Elizabeth V. Dray, Anne P. Cameron, and Rachel Bergman declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: •Of importance ••Of major importance

  1. 1.
    •• Gajewski JB, Schurch B, Hamid R, et al. An International Continence Society (ICS) report on the terminology for adult neurogenic lower urinary tract dysfunction (ANLUTD). Neurourol Urodyn. 2017;(July):1–10. doi: Recent standardization of terminology for ANLUTD .
  2. 2.
    Minassian VA, Stewart WF, Wood GC. Urinary incontinence in women: variation in prevalence estimates and risk factors. Obstet Gynecol. 2008;111(2 Pt 1):324–31. CrossRefPubMedGoogle Scholar
  3. 3.
    Peyrat L, Haillot O, Bruyere F, Boutin JM, Bertrand P, Lanson Y. Prevalence and risk factors of urinary incontinence in young and middle-aged women. BJU Int. 2002;89(1):61–6. CrossRefPubMedGoogle Scholar
  4. 4.
    • Schimpf MO, Rahn DD, Wheeler TL, Patel M, White AB, Orejuela FJ, et al. Sling surgery for stress urinary incontinence in women: a systematic review and metaanalysis. Am J Obstet Gynecol. 2014;211(1). doi:10.1016/j.ajog.2014.01.030) Excellent meta-analysis of sling outcomes:71.e1–71.e27.Google Scholar
  5. 5.
    DeLancey JO. Anatomy and physiology of urinary continence. Clin Obstet Gynecol. 1990;33(2):298–307. CrossRefPubMedGoogle Scholar
  6. 6.
    Fowler CJ, Griffiths D, de Groat WC. The neural control of micturition. Nat Rev Neurosci. 2008;9(6):453–66. Scholar
  7. 7.
    DeLancey JO. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol. 1994;170(6):1713-20-3.–1723.CrossRefGoogle Scholar
  8. 8.
    DeLancey JO. Stress urinary incontinence: where are we now, where should we go? Am J Obstet Gynecol. 1996;175(2):311–9. CrossRefPubMedGoogle Scholar
  9. 9.
    • El-Azab AS, El-Nashar SA. Midurethral slings versus the standard pubovaginal slings for women with neurogenic stress urinary incontinence. Int Urogynecol J. 2015;26(3):427–32. Prospective pilot study of select women with SCI at S2 or below showing equivalent outcomes between TVT and AFPVS
  10. 10.
    Chancellor MB, Erhard MJ, Kiilholma PJ, Karasick S, Rivas DA. Functional urethral closure with pubovaginal sling for destroyed female urethra after long-term urethral catheterization. Urology. 1994;43(4):499–505. Scholar
  11. 11.
    Panicker JN, Fowler CJ, Kessler TM. Lower urinary tract dysfunction in the neurological patient: clinical assessment and management. Lancet Neurol. 2015;14(7):720–32. Scholar
  12. 12.
    Nager CW, Brubaker L, Litman HJ, Zyczynski HM, Varner RE, Amundsen C, et al. A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med. 2012;366(21):1987–97.
  13. 13.
    Winters JC, Dmochowski RR, Goldman HB, et al. Adult Urodynamics: AUA/SUFU Guideline. Am Urol Assoc. 2012:1–30.Google Scholar
  14. 14.
    Pajoncini C, Costantini E, Guercini F, Porena M. Intrinsic sphincter deficiency: do the maximum urethral closure pressure and the Valsalva leak-point pressure identify different pathogenic mechanisms? Int Urogynecol J Pelvic Floor Dysfunct. 2002;13(1):30–5. CrossRefPubMedGoogle Scholar
  15. 15.
    Dumoulin C, Hay-Smith EJC, Mac Habée-Séguin G. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2014;5:CD005654. Scholar
  16. 16.
    Kobashi KC, Albo ME, Roger R, Ginsberg DA, Goldman HB. American Urological Association ( AUA )/SURGICAL TREATMENT OF FEMALE STRESS URINARY INCONTINENCE: AUA/SUFU GUIDELINE American Urological Association ( AUA )/Society of Urodynamics , Female Pelvic Medicine & Urogenital Reconstruction ( SUFU ) Stress. 2017;(March):1–33.Google Scholar
  17. 17.
    Khanna OP, Elkouss G, Heber D, Gonick P. Imipramine hydrochloride: pharmacodynamic effects on lower urinary tract of female dogs. Urology. 1975;6(1):49–51. CrossRefPubMedGoogle Scholar
  18. 18.
    Lin HH, Sheu BC, Lo MC, Huang SC. Comparison of treatment outcomes for imipramine for female genuine stress incontinence. Br J Obstet Gynaecol. 1999;106(10):1089–92. CrossRefPubMedGoogle Scholar
  19. 19.
    Cameron AP, Clemens JQ, Latini JM, McGuire EJ. Combination drug therapy improves compliance of the neurogenic bladder. J Urol. 2009;182(3):1062–7. Scholar
  20. 20.
    Bennett JK, Green BG, Foote JE, Gray M. Collagen injections for intrinsic sphincter deficiency in the neuropathic urethra. Paraplegia. 1995;33(12):697–700. Scholar
  21. 21.
    Kassouf W, Capolicchio G, Berardinucci G, Corcos J. Collagen injection for treatment of urinary incontinence in children. J Urol. 2001;165(5):1666–8. CrossRefPubMedGoogle Scholar
  22. 22.
    Chernoff A, Horowitz M, Combs A, Libretti D, Nitti V, Glassberg KI. Periurethral collagen injection for the treatment of urinary incontinence in children. J Urol. 1997;157(6):2303–5. CrossRefPubMedGoogle Scholar
  23. 23.
    Monga AK, Robinson D, Stanton SL. Periurethral collagen injections for genuine stress incontinence: a 2-year follow-up. Br J Urol. 1995;76(2):156–60. CrossRefPubMedGoogle Scholar
  24. 24.
    Gorton E, Stanton S, Monga A, Wiskind AK, Lentz GM, Bland DR. Periurethral collagen injection: a long-term follow-up study. BJU Int. 1999;84(9):966–71. CrossRefPubMedGoogle Scholar
  25. 25.
    Kirchin V, Page T, Keegan PE, Atiemo KOM, Cody JD, McClinton S, et al. Urethral injection therapy for urinary incontinence in women. Cochrane Database Syst Rev. 2017;7:CD003881.
  26. 26.
    Dray E, Cameron A, Hall M, Clemens JQ, Stoffel J. MP40-10 CAN URETHRAL BULKING AGENTS SALVAGE FAILED SLINGS? J Urol. 2017;197(4):e526–7. Scholar
  27. 27.
    Kobashi KC, Albo ME, Dmochowski RR, Ginsberg DA, Goldman HB, Gomelsky A, et al. Surgical treatment of female stress urinary incontinence: AUA/SUFU Guideline. J Urol. 2017;198(4):875–83.
  28. 28.
    Schierlitz L, Dwyer PL, Rosamilia A, Murray C, Thomas E, de Souza A, et al. Effectiveness of tension-free vaginal tape compared with transobturator tape in women with stress urinary incontinence and intrinsic sphincter deficiency: a randomized controlled trial. Obstet Gynecol. 2008;112(6):1253–61.
  29. 29.
    Pannek J, Bartel P, Gocking K. Clinical usefulness of the transobturator sub-urethral tape in the treatment of stress urinary incontinence in female patients with spinal cord lesion. J Spinal Cord Med. 2012;35(2):102–6. Scholar
  30. 30.
    Reuvers SHM, Groen J, Scheepe JR, et al. Heterogeneity in reporting on urinary outcome and cure after surgical interventions for stress urinary incontinence in adult neuro-urological patients: a systematic review. Neurourol Urodyn. 2017;(May). doi:
  31. 31.
    Abdul-Rahman A, Attar KH, Hamid R, Shah PJR. Long-term outcome of tension-free vaginal tape for treating stress incontinence in women with neuropathic bladders. BJU Int. 2010;106(6):827–30. Scholar
  32. 32.
    Hamid R, Khastgir J, Arya M, Patel HRH, Shah PJR. Experience of tension-free vaginal tape for the treatment of stress incontinence in females with neuropathic bladders. Spinal cord Off J Int Med Soc Paraplegia. 2003;41(2):118–21. CrossRefGoogle Scholar
  33. 33.
    Patki P, Woodhouse JB, Patil K, Hamid R, Shah J. An effective day case treatment combination for refractory neurophatic mixed incontinence. Int Braz J Urol. 2008;34(1):63–72.CrossRefPubMedGoogle Scholar
  34. 34.
    Losco GS, Burki JR, Omar YAI, Shah PJR, Hamid R. Long-term outcome of transobturator tape (TOT) for treatment of stress urinary incontinence in females with neuropathic bladders. Spinal Cord. 2015;53(7):544–6. Scholar
  35. 35.
    Lombardi G, Musco S, Celso M, Ierardi A, Nelli F, del Corso F, et al. A retrospective study on female urological surgeries over the 10 years following spinal cord lesion. Spinal Cord. 2013;51(9):688–93. Scholar
  36. 36.
    Jack C, Hou GEL. The role of fascial slings in the treatment of stress urinary incontinence in women: a 2013 update. Curr Urol Rep. 2013;14(3):247–52.CrossRefGoogle Scholar
  37. 37.
    Bang SBM. Autologous pubovaginal slings: back to the future or a lost art? Res Reports Urol. 2016;8:11–20.CrossRefGoogle Scholar
  38. 38.
    Gregory G, Bailly KVC. The pubovaginal sling: reintroducing an old friend. Can Urol Assoc J. 2017;11(6):S147+.Google Scholar
  39. 39.
    Arthi Satyanarayan Gary E, Lemack LG. Diagnosis and management of stress urinary incontinence in females with neurogenic disease. Curr Bl Dysfunct Rep. 2015;10:52–6.CrossRefGoogle Scholar
  40. 40.
    Anne Pelletier Cameron Edward J. McGuire CL-G. Pubovaginal Fascial Slings. In: Sam D. Graham MD Thomas E. Keane MD J, ed. GLENN’S UROLOGIC SURGERY. Philadelphia, PA: LIPPIN COTT WILLIAMS & WILKIN S; 2010:271–277.Google Scholar
  41. 41.
    Karram MD, Zoorob Dani MD, Reynolds W, Stuart MD, Kaufman Melissa RMD, Dmochowski Roger MDM. Biologic bladder neck pubovaginal slings. In: Surgery for urinary incontinence. Philadelphia: Saunders, an imprint of Elsevier Inc. p. 2013.Google Scholar
  42. 42.
    •• Morgan TO Jr, McGuire EJWOL. Pubovaginal sling: 4-year out-come analysis and quality of life assessment. J Urol. 2000;163:1845–8. Large prospective cohort study of patients undergoing AFPVS showing high efficacy and durability with low complication rates Google Scholar
  43. 43.
    Chaikin DC Blaivas JGRJ. Pubovaginal fascial sling for all types of stress urinary incontinence: long term analysis. J Urol. 1998;160:1312–6.CrossRefPubMedGoogle Scholar
  44. 44.
    Athanasopoulos A, Gyftopoulos K, McGuire EJ. Treating stress urinary incontinence in female patients with neuropathic bladder: the value of the autologous fascia rectus sling. Int Urol Nephrol. 2012;44(5):1363–7. Scholar
  45. 45.
    Crystal D, Sadik Ngoc-Bich P, Le DA. Evaluation and management of neurogenic stress urinary incontinence. Curr Bladder Dysfunct Rep. 2014;9(2):108–13.CrossRefGoogle Scholar
  46. 46.
    Scott FB, Bradley WE, Timm GW. Treatment of urinary incontinence by an implantable prosthetic urinary sphincter. J Urol. 1974;112(1):75–80. CrossRefPubMedGoogle Scholar
  47. 47.
    Kim SP, Sarmast Z, Daignault S, Faerber GJ, McGuire EJ, Latini JM. Long-term durability and functional outcomes among patients with artificial urinary sphincters: a 10-year retrospective review from the University of Michigan. J Urol. 2008;179(5):1912–6. Scholar
  48. 48.
    Myers JB, Mayer EN, Lenherr S, Neurogenic Bladder Research Group ( Management options for sphincteric deficiency in adults with neurogenic bladder. Transl Androl Urol. 2016;5(1):145–57. PubMedPubMedCentralCrossRefGoogle Scholar
  49. 49.
    López Pereira P, Somoza Ariba I, Martínez Urrutia MJ, Lobato Romero R, Jaureguizar Monroe E. Artificial urinary sphincter: 11-year experience in adolescents with congenital neuropathic bladder. Eur Urol. 2006;50(5):1096–101; discussion 1101. Scholar
  50. 50.
    Herndon CDA, Rink RC, Shaw MBK, et al. The Indiana experience with artificial urinary sphincters in children and young adults. J Urol. 2003;169(2):650–4; discussion 654. Scholar
  51. 51.
    Hafez AT, McLorie G, Bägli D, Khoury A. A single-centre long-term outcome analysis of artificial urinary sphincter placement in children. BJU Int. 2002;89(1):82–5. CrossRefPubMedGoogle Scholar
  52. 52.
    •• Farag F, Koens M, Sievert K-D, De Ridder D, Feitz W, Heesakkers J. Surgical treatment of neurogenic stress urinary incontinence: a systematic review of quality assessment and surgical outcomes. Neurourol Urodyn. 2016;35(1):21–5. Well-designed meta-analysis of existing data regarding neurogenic stress urinary incontinence
  53. 53.
    Kropp KA, Angwafo FF. Urethral lengthening and reimplantation for neurogenic incontinence in children. J Urol. 1986;135(3):533–6. CrossRefPubMedGoogle Scholar
  54. 54.
    Hohenfellner R. The Kropp-onlay procedure (Pippe Salle procedure). Br J Urol. 1995;76(4):525–6. CrossRefPubMedGoogle Scholar
  55. 55.
    Donnahoo KK, Rink RC, Cain MP, Casale AJ. The Young-Dees-Leadbetter bladder neck repair for neurogenic incontinence. J Urol. 1999;161(6):1946–9. CrossRefPubMedGoogle Scholar
  56. 56.
    • Willis H, Safiano NA, Lloyd LK. Comparison of transvaginal and retropubic bladder neck closure with suprapubic catheter in women. J Urol. 2015;193(1):196–202. Large retrospective review of bladder neck closure techniques, showing no difference in efficacy and reduced short-term complications with vaginal approach
  57. 57.
    Zimmern PE, Hadley HR, Leach GE, Raz S. Transvaginal closure of the bladder neck and placement of a suprapubic catheter for destroyed urethra after long-term indwelling catheterization. J Urol. 1985;134(3):554–7. CrossRefPubMedGoogle Scholar
  58. 58.
    Grimsby GM, Menon V, Schlomer BJ, Baker LA, Adams R, Gargollo PC, et al. Long-term outcomes of bladder neck reconstruction without augmentation cystoplasty in children. J Urol. 2016;195(1):155–61. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Elizabeth V. Dray
    • 1
    Email author
  • Anne P. Cameron
    • 1
  • Rachel Bergman
    • 2
  1. 1.Department of UrologyUniversity of MichiganAnn ArborUSA
  2. 2.University of Michigan Medical SchoolAnn ArborUSA

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