What are the possible causes of neurogenic bladder in a 17-year-old female patient?

Causes of Neurogenic Bladder in a 17-Year-Old Girl

In a 17-year-old female, the most common causes of neurogenic bladder are spinal dysraphism (particularly spina bifida/myelomeningocele), tethered cord syndrome, spinal cord injury, and central nervous system disorders such as multiple sclerosis or cerebral palsy. 1, 2

Congenital/Developmental Causes

Spinal Dysraphism

• Spina bifida/myelomeningocele is the most common congenital cause of neurogenic bladder in adolescents, with approximately 80% of patients requiring long-term clean intermittent catheterization and 26% developing renal failure over time. 3, 1
• Myelomeningocele causes sacral and lower spinal cord malformations with universal bowel and bladder dysfunction. 4
• These patients typically present with secondary urinary incontinence, often accompanied by fecal incontinence and/or constipation in toilet-trained children and adolescents. 3, 1

Tethered Cord Syndrome

• Tethered cord presents with progressive urologic dysfunction, with up to 75% of patients showing lower extremity neurologic and orthopedic abnormalities. 3
• Key clinical clue: onset of secondary urinary incontinence in a previously continent adolescent, especially with concurrent fecal incontinence, constipation, or progressive lower extremity weakness. 3, 1
• Associated cutaneous markers include midline lumbosacral hemangiomas, dimples, hairy patches, lipomas, or skin tags overlying the spine. 3, 1

Anorectal Malformations

• Between 10-52% of children with anorectal malformations have associated dysraphic malformations, with higher rates (43%) in complex versus simple (11%) malformations. 3, 1

Acquired Neurologic Causes

Spinal Cord Injury

• Nearly all patients with spinal cord injury historically develop renal dysfunction, making this a critical cause to identify. 3, 1
• Suprasacral spinal lesions typically disrupt both motor and sensory pathways, resulting in impaired bladder sensation. 4
• These patients have a 7% risk of stone development within 10 years, contributing to renal insufficiency. 3

Central Nervous System Disorders

• Multiple sclerosis is an important cause in adolescents and young adults, presenting with detrusor overactivity and typically preserved bladder sensation. 4, 5
• Cerebrovascular accidents (though less common in this age group) cause suprapontine lesions with detrusor overactivity but intact sensation—patients feel urgency but cannot inhibit contractions. 4
• Cerebral palsy is associated with neurogenic bladder dysfunction. 1

Peripheral Nerve Lesions

• Cauda equina syndrome produces lower motor neuron dysfunction with characteristically impaired perineal sensation and often progresses to a "paralyzed, insensate bladder." 4
• Cauda equina syndrome with retention (CESR) specifically involves neurogenic retention with an insensate bladder. 4

Other Causes to Consider

Inflammatory/Infectious

• Spinal cord inflammation (transverse myelitis) can cause neurogenic bladder. 2
• Urodynamic studies should be performed as soon as there is suspicion of neurogenic bladder from inflammatory causes. 2

Neoplastic

• Spinal cord or brain tumors can disrupt neurologic control of bladder function. 2, 6

Traumatic

• Spinal trauma beyond acute spinal cord injury, including vertebral fractures affecting nerve roots. 2

Clinical Presentation Patterns by Age

In this 17-year-old patient, expect:

• Urgency, urge incontinence, sudden or stress incontinence, new-onset enuresis, urinary frequency, and nocturia, often accompanied by fecal soiling. 3, 1
• Recurrent urinary tract infections remain common at this age. 3, 1
• Progressive symptoms suggest tethered cord syndrome requiring urgent evaluation. 3

Critical Physical Examination Findings

Look specifically for:

• Midline cutaneous lesions overlying the spine (hemangiomas, dimples, hairy patches, lipomas, skin tags). 3, 1
• Lower extremity sensorimotor deficits, progressive weakness, leg pain, or gait disturbances. 3, 1
• Scoliosis or other orthopedic deformities. 3, 1
• Anorectal abnormalities. 3, 1

Diagnostic Approach

Initial evaluation must include:

• Detailed neurologic history and physical examination focusing on cognitive ability, extremity function, spasticity, mobility, and any known neurological conditions. 3
• Post-void residual measurement in patients who spontaneously void. 3
• Urinalysis to assess for infection. 3
• Renal ultrasound to identify hydronephrosis, hydroureter, bladder wall thickening, or abnormal bladder configuration. 3, 1

Definitive diagnosis requires:

• Urodynamic studies, preferably videourodynamics, are essential for definitive diagnosis and characterization of neurogenic bladder. 1, 2
• Urodynamics should be performed as soon as there is suspicion of neurogenic bladder from any cause. 2