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Treatment options for neurogenic detrusor overactivity (NDO)

The goals of NDO treatment are to protect the upper urinary tract, achieve (or maintain) urinary continence, improve patients’ quality of life and restore lower urinary tract function.5,6 Additional considerations are the potential for future complications, the patient’s condition, and the ease and cost-effectiveness of treatment.5

Treatment options for NDO include:6,7

  • Lifestyle advice/behavioural approaches
  • Assisted emptying
  • Containment
  • Pharmacotherapy
  • Botulinum toxin type A*
  • Neurostimulation
  • Surgery

Lifestyle/behavioural interventions for NDO include the use of regular voiding schedules and pelvic floor muscle exercises.5

Patients can be taught how to void by abdominal stimulation (triggered reflex voiding) or abdominal straining.5

Containment approaches for NDO include temporary urinary containment products (such as absorbent pads, waterproof pants and external sheaths) and intermittent self- or third-party catheterisation.5

Anticholinergics are widely used treatment for urgency urinary incontinence, but there is limited evidence supporting their use in NDO. Higher doses of anticholinergics can be related to a higher rate of side effects, while other potential limitations include drug-drug interactions, low rates of patient adherence and cognitive effects in the elderly.8–13 For patients in whom oral therapy is not effective, options include botulinum toxin type A, sacral anterior root stimulation, sacral nerve stimulation and surgery.

Sacral anterior root stimulation involves implantation of a device that enables patients with a spinal cord lesion to empty their bladders via stimulation of the sacral anterior roots.13

Sacral nerve stimulation aims to rebalance micturition via electrical stimulation of the sacral nerve roots.14,15 

Enterocystoplasty involves enlargement of the bladder by grafting to it a detached segment of intestine.16

Urinary diversion involves the creation of a new bladder outlet with a valve for urinary continence, which is catheterised to empty.17,18

An autologous urethral sling made from the patient’s own body tissue and placed under the urethra to hold it closed when the bladder is pushed downwards, preventing urine leakage is an option for female patients.5

NICE recommends bladder wall injection with botulinum toxin type A as an option for adults:17

  • With spinal cord disease (e.g. spinal cord injury or multiple sclerosis) and
  • With symptoms of an overactive bladder and
  • In whom antimuscarinic drugs have proved to be ineffective or poorly tolerated

The EAU guidelines recommend botulinum toxin injection in the detrusor as an option to reduce neurogenic detrusor overactivity in patients with multiple sclerosis or spinal cord injury if antimuscarinic therapy is ineffective.6

BOTOX® is the only botulinum toxin type A currently indicated for the management of bladder dysfunctions in adult patients who are not adequately managed with anticholinergics: overactive bladder with symptoms of urinary incontinence, urgency and frequency; neurogenic detrusor overactivity with urinary incontinence due to sub cervical spinal cord injury (traumatic or non-traumatic) or multiple sclerosis.7

The goals of NDO treatment are to protect the upper urinary tract, achieve (or maintain) urinary continence, improve patients' quality of life and restore lower urinary tract function5,6

NDO: neurogenic detrusor overactivity.

*BOTOX® is indicated for the management of bladder dysfunctions in adult patients who are not adequately managed with anticholinergics: neurogenic detrusor overactivity with urinary incontinence due to subcervical spinal cord injury (traumatic or non-traumatic), or multiple sclerosis.7

© NICE [2012] Urinary incontinence in neurological disease. Available from All rights reserved. Subject to Notice of rights

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.


  1. Allergan. Data on file. INT/0423/2016
  2. Aurora S K, Winner P et al. OnabotulinumtoxinA for treatment of chronic migraine: pooled analyses of the 56-week PREEMPT clinical program. Headache 2011;51(9):1358-1373
  3. Blumenfeld A M, Stark R J et al. Long-term study of the efficacy and safety of OnabotulinumtoxinA for the prevention of chronic migraine: COMPEL study. J Headache Pain 2018;19(1):13
  4. Allergan. Data on file. 014
  5. Stöhrer M, Blok B et al. EAU guidelines on neurogenic lower urinary tract dysfunction. Eur Urol 2009;56:81–8
  6. European Association of Urology Guidelines on Neuro-Urology. 2019. Available at: Accessed April 2022
  7. BOTOX® Summary of Product Characteristics. Available at: Accessed April 2022
  8. Chapple C R, Yamanishi T and Chess-Williams R. Muscarinic receptor subtypes and management of the overactive bladder. Urology 2002;60(5):82-88
  9. Chapple C R, Khullar V et al. The effects of antimuscarinic treatments in overactive bladder: an update of a systematic review and meta-analysis. Eur Urol 2008;54:543–62
  10. Andersson KE et al. Pharmacological treatment of urinary incontinence. 3rd International Consultation on Incontinence 2004
  11. Wagg A, Compion G et al. Persistence with prescribed antimuscarinic therapy for overactive bladder: a UK experience. BJU Int 2012;110:1767–74
  12. Gray S L, Anderson M L et al. Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study. JAMA Intern Med 2015;175:401–7
  13. Guiho T, Azevedo-Coste C et al. Sacral Anterior Root Stimulation and Visceral Function Outcomes in Spinal Cord Injury–A Systematic Review of the Literature Over Four Decades. World Neurosurg 2022;157:218-232.e14
  14. Oerlemans DJAJ, van Kerrebrock PEV. Sacral nerve stimulation for neuromodulation of the lower urinary tract. Neururol Urodyn 2008;27:28–33
  15. Sanford M T and Suskind A M. Neuromodulation in neurogenic bladder. Transl Abdrol Urol 2016;5:117–126 
  16. Abrams P et al. Incontinence: 6th Edition 2017;50
  17. National Institute for Health and Care Excellence (NICE). CG148: Urinary incontinence in neurological disease. Available at: Accessed April 2022
  18. de Jong TPVM, Chrzan R et al. Treatment of the neurogenic bladder in spina bifida. Pediatr Nephrol 2008;23:889–96

Please refer to the BOTOX® Summary of Product Characteristics for further information on adverse events, contraindications and special warnings and precautions for use.


Adverse events should be reported. Reporting forms and information can be found at

Adverse events should also be reported to AbbVie on [email protected] 


Date of preparation: April 2022. UK-BUO-220022.