Neurogenic lower urinary tract dysfunction (NLUTD) is nearly universal after spinal cord injury (SCI) and is a major driver of morbidity. Urodynamic studies (UDS) are the gold standard for evaluating NLUTD; however, in the United States, UDS are not routinely performed in early SCI because of concerns regarding limited clinical utility. We hypothesized that early UDS would identify clinically actionable bladder dysfunction and meaningfully alter bladder management.

This cohort study included patients screened for a tibial nerve stimulation trial in early SCI (CT.gov: NCT04350359). Patients who consented underwent baseline UDS, while eligible patients who declined participation comprised the no UDS group. Both groups were similar, with inclusion criteria of: 18–75 years, admission to rehabilitation inpatient facility within 6 weeks of SCI, neurologic level of injury at or above thoracic level 9, and need for catheter-based bladder management. This study was approved by the institutional IRB (HSC-MS-24-1097).

UDS were independently reviewed by two blinded investigators, with discrepancies resolved by consensus. Neurogenic detrusor overactivity (NDO) and detrusor sphincter dyssynergia (DSD) were classified as present or absent; low bladder compliance was defined as ≤15 mL/cm H2O; low maximum cystometric capacity (lowMCC) as <300 mL; and elevated detrusor pressure (highPdet) as ≥40 cm H2O. High-risk bladder was defined as a composite of any of these abnormalities. Between-group comparisons were performed using Fisher’s exact test. Multivariable Firth logistic regression evaluated associations with overactive bladder (OAB) medication use and urinary tract infection (UTI).

The cohort included 149 patients (70 with no UDS, 79 with UDS). Baseline characteristics were similar except for age, which was lower in the UDS group (median 41 years [IQR 24–55] vs 51 years [36–63]; p=0.006). Time from injury to admission was similar between groups (median 12 [IQR 9-20] vs 14 days [11-21]).

UDS identified urodynamic abnormalities in 45/79 (57.0%) patients. NDO was present in 43/79 (54.4%), DSD in 18/79 (22.8%), low compliance in 14/79 (17.7%), lowMCC in 18/79 (22.8%), and highPdet in 23/79 (29.1%).

High-risk bladder guided bladder management, strongly associated with OAB medication prescription at discharge (11/45 [24.4%] vs 2/34 [5.9%]; OR 4.33, 95% CI 1.01–18.48), and this association remained significant after adjustment for bladder emptying method (OR 4.58, 95% CI 1.07–19.72) at the time of discharge from rehabilitation facility. Patients with high-risk UDS findings were also more likely to be discharged on OAB medications than patients who did not undergo UDS (24.4% vs 8.6%; OR 3.31, 95% CI 1.16–9.42).

UTI occurred in 33/70 (47.1%) patients without UDS and 45/79 (57.0%) with UDS (p=0.253). 19/45 (42.2%) UTIs in the UDS group occurred after UDS. In adjusted analyses, UDS was not associated with UTI (OR 1.26, 95% CI 0.66–2.41).

UDS identified clinically actionable NLUTD in most patients with early SCI. The strong association between high-risk urodynamic findings and OAB pharmacotherapy, both within the UDS cohort and compared with patients managed without UDS, indicates that UDS informs treatment decisions and identifies patients who would otherwise remain undertreated. Importantly, this clinical impact was achieved without evidence of increased UTI risk. These findings should be interpreted in the context of a modest sample size, requiring a larger confirmatory trial.

UDS identifies clinically important bladder dysfunction that is otherwise undetected and drives targeted treatment during early SCI. These findings directly challenge the longstanding assumption of “spinal shock” as a barrier to early evaluation and provide compelling evidence against delaying assessment. Our findings support a paradigm shift in current practice, establishing early urodynamics as a central component of initial bladder management following SCI.

Continence 19S (2026) 102570
DOI: 10.1016/j.cont.2026.102570