The severity of bladder dysfunction after traumatic spinal cord injury (SCI) is a strong predictor of long-term morbidity and upper urinary tract damage. Early detection of patients who are at risk of developing high-risk neurogenic bladder is therefore crucial. 
 for high-pressure storage pathophysiology is crucial. Our objective was to assess whether the severity of neurological impairment and the level of injury independently may lead to high-risk bladder conditions upon initial urodynamic assessment.

This study was a retrospective observational cohort study examining predictors of high-risk neurogenic bladder features focused on urodynamic findings and clinical characteristics at the first urodynamic evaluation (T1) following spinal cord injury (SCI). We included only patient with a clearly traumatic mechanism of injury were retained. Non-traumatic etiologies (e.g., tumors, degenerative disease, vascular events/infarcts, infection such as epidural abscess/discitis, inflammatory etiologies such as transverse myelitis, congenital conditions such as spina bifida, cauda equina/conus conditions, and iatrogenic/post-surgical etiologies) were excluded from the primary analytic cohort to ensure etiologic homogeneity and interpretability of injury-related predictors. In addition. participants were required to have sufficient data available to define the urodynamic outcomes at T1 High-risk bladder criteria were poor compliance, vesicoureteral reflux, or maximum detrusor pressure >40 cmH₂O. Multivariable logistic regression evaluated associations between injury level (cervical/thoracic/lumbar), neurological severity (ASIA A–B vs C–D), age, sex, and time from injury to T1. Model performance was examined using Nagelkerke R² and area under the receiver operating characteristic curve (AUC). The local Ethics Committee has approved this study.

The source database included 608 individuals with SCI-related records, of whom 446 had traumatic SCI. Complete urodynamic data were available for 297 patients, and these patients constituted the study cohort. The median age of this cohort was  33.6 years and 76% were males. The median interval between SCI and first urodynamic assessement was 16 months.  65.7% of patients demonstrated high-risk bladder at T1.
Cross-tabulation analysis demonstrated a significant association between ASIA severity and high-risk bladder status (χ²(1) = 14.20, p < .001). Among patients without high-risk features, 54.1% were classified as ASIA A–B and 45.9% as ASIA C–D. In contrast, among patients with high-risk bladder, 75.8% were ASIA A–B and only 24.2% were ASIA C–D. Thus, severe neurological impairment (ASIA A–B) was substantially more prevalent among patients classified as having high-risk bladder at T1. Figure. 
After adjustment, ASIA A–B injuries were independently associated with high-risk bladder (OR 2.57, 95% CI 1.32–5.00, p=0.005) while, injury level was not independently associated with marked bladder dysfunction. Model discrimination was moderate (AUC 0.67). In secondary analyses, ASIA A–B strongly associated with poor compliance (OR 4.68, p<0.001) and vesicoureteral reflux (OR 3.42, p=0.031). Cervical injury was independently related poor compliance (OR 2.08, p=0.029). Age, sex, and time from injury were not significant independent factors.

High-risk bladder pathophysiology is common at the first urodynamic evaluation after traumatic SCI, suggesting that significant lower urinary tract dysfunction is already present in many patients early after injury. Our findings indicate that neurological completeness, rather than anatomical injury level, is the main determinant of adverse storage dysfunction, highlighting the greater relevance of functional disruption of spinal pathways over lesion location itself. Patients with complete or near-complete injuries therefore represent a particularly vulnerable subgroup. These results support early and targeted urological surveillance following traumatic SCI, especially in those with severe neurological deficits, to enable prompt detection and management of potentially harmful bladder dysfunction.

Neurological completeness appears to be a more important determinant of adverse bladder abnormalities than anatomical level of injury. These findings support early urodynamic assessment and closer urological surveillance, particularly in patients with complete or near-complete injuries.

Continence 19S (2026) 102549
DOI: 10.1016/j.cont.2026.102549