Management of neurogenic lower urinary tract dysfunction in individuals with spinal cord injury (SCI) involves consideration of patient-specific and bladder-specific factors. Although individuals with SCI prioritize treatment of their symptoms, providers should pay equal, if not more, attention to addressing urodynamic (UDS) parameters such as neurogenic detrusor overactivity (NDO) and impaired compliance due to the associated risk for upper tract deterioration. Anticholinergics, β-3 agonists, and onabotulinumtoxin A (BTX-A) are guideline-supported pharmacotherapies. Though each therapy variably improves NDO, changes in compliance are not well demonstrated.
Tailoring treatment to individual patients is now a central topic in clinical practice, yet in patients with neurologically based bladder dysfunction, symptom relief is not the only factor that must be taken into account. Alongside this, the issue of deterioration of the upper urinary tract is, if possible, even more important. However, even within this group, for a long time the focus has been more on relieving symptoms, rather than on assessing or preventing deterioration of the upper urinary tract.
In addition to analysing the treatments currently available and their efficacy and safety, this review raises a fundamental and troubling question: are we really measuring outcomes that truly matter? [1] The difference between symptoms and urodynamic safety is not merely semantic: particularly in patients with spinal cord injury (SCI), increased detrusor pressures and poor compliance can compromise the upper urinary tract even if symptoms are well controlled by treatment. In this regard, the review underlines the importance of the urodynamic aspect, which must be a primary consideration in patients with SCI in the therapeutic decision making, not a secondary endpoint only related to symptom burden.
The authors evaluate the response to anticholinergic drugs in this patient population and emphasise that these medications do not substantially alter the risk of upper urinary tract damage when compared to placebo [2]. This finding is of critical importance when dealing with such patients, in whom persistently poor bladder compliance, inadequately improved by anticholinergic therapy, remains a primary driver of upper tract deterioration. Therefore, in these patients, anticholinergic therapy should be used with this caveat in mind, in addition to the well-known potential impact on cognitive function, which is now increasingly recognised as a key variable in the shared decision-making process [3].
The authors also highlight the efficacy and safety profile of beta-3 agonists in patients with neurogenic detrusor overactivity (NDO). This is particularly noteworthy today because we essentially have two molecules that act by sharing the same pathway but with different outcomes; currently, vibegron appears more promising, not only in terms of efficacy but also in terms of safety (lower cardiovascular risk) in this patient group [4,5].
Intradetrusor botulinum toxin injections may seem like the definitive solution for NDO, despite requiring periodic re-injection. However, although the DIGNITY trials demonstrated excellent results in terms of symptom relief and improved compliance [6], further studies in neurological patients have shown that symptomatic improvement following botulinum toxin treatment is not correlated with an actual improvement in compliance [7]. This underscores the importance of follow-up with urodynamic testing in these patients, regardless of their symptoms.
This study, in a very simple and straightforward manner, highlights how, also in the field of neurogenic bladder, there is inconsistency among studies in the literature. This is primarily due to the heterogeneity of neurological conditions and the related urinary symptoms, which vary depending on the specific neurological disorder being treated, the type of patient, and the nature of the lesion.
It is also important to note the wide variety of outcomes and tools used to measure bladder dysfunction and post-treatment outcomes. This brings into focus what may be the evolution currently happening in functional urology and in neurourology: the move away from population-level treatment algorithms toward a phenotype-driven, individualised approach. The pharmacological approach must be tailored to the individual patient and reflect and account for the heterogeneity of bladder dysfunction.
Looking ahead, these aspects require not only more trials but also randomised, well-designed trials specific to a particular neurological aetiology, with standardised and predefined urodynamic parameters, as well as follow-up protocols designed to rapidly detect changes that may lead to damage to the upper urinary tract. This review does not fill that gap, nor does it set out to do so. Its value is that it renders the gaps visible and it reminds the practitioner that doing our best in treating neurogenic lower urinary tract dysfunction (NLUTD) after SCI requires not just choosing the right pharmacotherapy, but addressing what is truly important for our patient’s well-being, not just in terms of symptoms.
References
[1] Findlay BL, Anderson KT. Making the most of pharmacologic interventions: urodynamic effects of different therapies for neurogenic lower urinary tract dysfunction following spinal cord injury. Eur Urol Focus 2026. https://doi.org/10.1016/j.euf.2026.03.011
[2] Madhuvrata P, Singh M, Hasafa Z, Abdel-Fattah M. Anticholinergic drugs for adult neurogenic detrusor overactivity: a systematic review and meta-analysis. Eur Urol 2012;62:816–30.
[3] Welk B. The impact of anticholinergics on cognitive function in patients with neurogenic lower urinary tract dysfunction: a narrative review. Indian J Urol 2024;40:82–7.
[4] Takahashi R, Imada K, Maki T. Comparison of the efficacy of vibegron and fesoterodine for neurogenic detrusor overactivity in individuals with spinal cord lesion: a single-center prospective randomized crossover trial. Neurourol Urodyn 2025;44:1545–52.
[5] Akkoc Y. Efficacy and safety of mirabegron for treatment of neurogenic detrusor overactivity in adults with spinal cord injury or multiple sclerosis: a systematic review. Spinal Cord 2022;60:854–61.
[6] Rovner E, Dmochowski R, Chapple C, Thompson C, Lam W, Haag-Molkenteller C. OnabotulinumtoxinA improves urodynamic outcomes in patients with neurogenic detrusor overactivity. Neurourol Urodyn 2013;32:1109–15.
[7] Koschorke M, Leitner L, Sadri H, Knüpfer SC, Mehnert U, Kessler TM. Intradetrusor onabotulinumtoxinA injections for refractory neurogenic detrusor overactivity incontinence: do we need urodynamic investigation for outcome assessment? BJU Int 2017;120:848–54.