Cervical spine problems, Vagus nerve compression, urinary incontinence

Ross A. Hauser, MD.

The evidence cervical neck problems can cause urinary incontinence

In this article, we will present the evidence that connects urinary incontinence with cervical spine and neck pain and instability and that when you treat the neck problems, often the bladder control problems are alleviated.

Many patients come to us with a myriad of symptoms related to their cervical neck instability. Some symptoms are clearly related to their neck problems. These would be, for example, the challenges of vertigo, vision problems, headaches, and swallowing difficulties. Some symptoms, which have no seemingly obvious connection as being related to cervical neck pain are usually categorized as “these other things that are wrong with me.”

This can be the case when it comes to urinary incontinence.

Here we may have a patient, whose cervical neck instability is causing pressure on their nervous symptom which can unsurprisingly to us, lead to the problems of urinary incontinence. For those who do not make a connection between cervical spine instability and urinary incontinence, this patient may be sent to a urology specialist who may find it challenging to help this patient, or, as we will see in the research be looking for a diagnosis that is not there.

Article summary:

“I’ll just have to urinate where I go in my pants”
Patients we are treating for cervical spine pain and instability will start revealing that they HAVE urinary challenges and their urinary challenges treatment as mostly or wholly unsuccessful.
Neurogenic Bladder Disorder is this only a problem of the lumbar spine? Is your cervical spine the cause?
People getting cervical spine surgery already have urinary and bladder problems.
Nearly half of all patients undergoing elective cervical spine surgery had moderate-to-severe LUTS (lower urinary tract symptoms).
Patients had urinary problems before their cervical neck surgeries – and – these patient’s urinary problems should not be mistaken for low back complications but should be traced back to the neck.
Degenerative cervical myelopathy.
There is a connection between the vagus nerve and renal failure and renal repair.
There is a connection between urinary problems and cervical neck pain, the Vagus Nerve and blood pressure.
The vagal nerves, blood pressure regulation, heartbeat regulation, urinary incontinence problems, could all trace a common source to the neck.
Vagus nerve compression
Treatments for urinary problems and cervical neck pain

“I’ll just have to urinate where I go in my pants”

The challenges of urinary incontinence and urinary urge can be seen in the same person. Here is an email that describes this condition as well as the characteristic multi-symptoms most patients we see suffer from. The email has been edited for clarity.

“I hear one thing from one doctor and another thing from another doctor. I suffered a neck and spine injury in July 2019 when an object fell on me. Since then I’ve been told there are bulging discs in my cervical spine ranging from c3-7 with post traumatic arthritis in my lumbar spine. I’ve had multiple cervical MRIs. I have been to physical therapy, they did injections, the Radiofrequency ablation (RFA) procedure, my last thing they did was the surgical epidural. Two weeks later the pain in my neck was back, the pain in my shoulder was back. I was in the hospital right before Thanksgiving last year because I’m forgetting how to swallow and gagging out of nowhere, and I don’t really urinate as much as I should a day, I’ll wake up and use the restroom then and that’s it or out of nowhere I’ll just have to urinate where I go in my pants.”

Patients we are treating for cervical spine pain and instability will start revealing that they HAVE urinary challenges and their urinary challenges treatment as mostly or wholly unsuccessful.

Typically, a patient we are treating for cervical spine pain and instability will start revealing that they HAVE urinary challenges and their urinary challenges treatment as mostly or wholly unsuccessful. They, in the past they admit, have been given the standard set of guidelines and urinary management suggestions: Dietary changes mostly, avoidance of caffeine (which many cervical neck patients cannot tolerate and do not take) as a primary lifestyle change along with healthier diet are recommended. There is usually nothing wrong with these recommendations but they are not working for this patient. Other recommendations were equally not helpful, such as “holding it in as long as you can,” to retrain your bladder to be able to hold it in. Of course, wearing some type of protective undergarments is always an option.

While these recommendations may be helpful to many, cervical spine and neck instability patients are dealing with multiple symptoms that they are not able to control. It is at this point the medications for urinary incontinence may be added to their treatments.

Neurogenic Bladder Disorder is this only a problem of the lumbar spine? Is your cervical spine the cause?

It is not easy to find research connecting cervical spine instability with urinary incontinence. We are going to see this below. The great weight of research centers on the problems of the lumbar spine and the neurological defects herniated lumbar discs may cause. But, as we will suggest and demonstrate, there is a connection between the cervical spine and urinary incontinence.

People getting cervical spine surgery already have urinary and bladder problems

In April 2019, doctors at the Department of Orthopaedics and Rehabilitation, Oregon Health & Science University published their research findings that made a connection between lower urinary tract symptoms and urinary bother in patients who underwent elective cervical spine surgery. The research was published in the journal Clinical Orthopaedics and Related Research. (1)

The researchers record that the purpose of this study was to:

Examine and determine the prevalence of moderate-to-severe lower urinary tract symptoms (LUTS) and clinically relevant urinary bother among patients undergoing elective cervical spine surgery
Does the presence of cervical myelopathy (spinal cord compression from cervical instability, herniated disc, or cervical stenosis) affect the frequency of moderate-to-severe lower urinary tract symptoms or clinically relevant urinary bother among patients undergoing elective cervical spine surgery?
Do MRI findings of spinal cord injury or compression correlate with the presence and severity of lower urinary tract symptoms?

The research:

242 patients (youngest 34 to oldest 83 years – average group age 58
There were 108 males (45%) and 134 females (55%).
Patients were grouped into a myelopathy group (spinal cord pressure) and a non-myelopathy group based on diagnosis as assigned by the operating surgeon.

Nearly half of all patients undergoing elective cervical spine surgery had moderate-to-severe LUTS (lower urinary tract symptoms)

Numbers:

The prevalence of moderate lower urinary tract symptoms in the patient sample was 40%
The prevalence of severe lower urinary tract symptoms in the patient sample was 8%
Clinically relevant urinary bother was reported in 18% of patients
The odds of moderate-to-severe lower urinary tract symptoms among patients with myelopathy were greater than that observed in patients without myelopathy
The prevalence of clinically relevant urinary bother was higher in patients with myelopathy (30% [26 of 88]) compared with those with no myelopathy (11% [15 of 140]).

Nearly half of all patients undergoing elective cervical spine surgery had moderate-to-severe lower urinary tract symptoms. This is more than double the prevalence that has been reported in a community-dwelling adult population. These symptoms can impair quality of life, lead to surgical complications (urinary retention or incontinence), and may be mistaken for cauda equina (lumbar nerve disorder), prompting potentially unnecessary imaging and studies.

In a commentary editorial on this article, Todd J Albert, MD, Surgeon-in-Chief and Medical Director, Hospital for Special Surgery wrote:(2) “These findings are extremely important, as preoperative identification of these symptoms is crucial for later differentiating between worsening spinal symptoms and emergent conditions such as cauda equina syndrome. When faced with a patient after spine surgery who has urinary difficulty, and in the absence of adequate baseline data about the risk of lower urinary tract symptoms and how they present, clinicians often feel the need to err on the side of evaluating such a patient using expensive tests, like MRIs. This study provides the basic background information to help tease out true clinical emergencies from baseline bladder bother, perhaps raising the threshold to perform unnecessary tests.

An important question to consider from this study is why the amount of cord compression, cord signal, and canal compromise did not affect the severity of lower urinary tract symptoms. This concept underscores how poorly spinal cord architecture and physiology are currently understood. We might expect bladder issues to increase generally linearly with apparent radiographic cord damage, yet this appears not to be the case. To predict accurately what functional pathways are affected by cord compromise, we need to be able to correlate radiographic findings with clinical findings to know exactly which patients are at risk for urinary dysfunction.

Dr. Albert also suggested:

Correlating imaging findings to objective measures such as post-void residual bladder volumes would help sharpen the connection between myelopathy and urinary bother.
More is still needed to learn more about how cervical and lumbar pathologies may interact when they present in tandem.
It is important to consider how the effects of surgical intervention affect bladder function in the days following surgery. . . Understanding how to better delineate true bladder dysfunction resulting from baseline cervical disease, medication and emergency syndromes such as cauda equina would be of great benefit to the clinician.

Patients had urinary problems before their cervical neck surgeries – and – these patient’s urinary problems should not be mistaken for low back complications but should be traced back to the neck

Here, we see that patients had urinary problems before their cervical neck surgeries and that these patients’ problems should not be mistaken for low back complications.

There have been previous studies to make a connection between urinary incontinence and cervical neck instability and in fact in some instances where a successful surgery did cure the patient if their urinary symptoms.

A 2005 study in the Journal of Spinal Disorders and Techniques (3) came from Japanese researchers at the Shinshu University School of Medicine. Here the researchers found that:

In 56 patients examined in this study, 29 (52%) had some urinary subjective complaints, whereas the remaining 27 (48%) had none.
Urologic examination indicated that 8 of these 29 (28%) patients with urinary complaints had urologic disorders other than neurogenic bladder (the urinary problems were not suspected of coming from the neck).
Of the remaining 21 patients, 6 (25%) were judged to have a neurogenic bladder in a urodynamic study. However Urodynamic study may be of limited value in diagnosing urinary disturbance in cervical myelopathy.
Patients with urinary complaints had significantly longer durations of myelopathy and delayed motor evoked potential latencies (neurologic complaints) than those without urinary complaints.
After surgery, 19 of the 21 (90%) patients with urinary complaints showed recovery from urinary disturbance. Operations in patients with cervical myelopathy were also effective against urinary disturbance. Urinary complaints may be an indication for surgical treatment despite the results of the urodynamic study.

What do we make of all this?

If you have been suffering from urinary problems that the urologist and the cervical surgeon disagree on what is causing it – the surgeon comes out on top here because 90% of cervical neck patients who had surgery and previous urinary dysfunction, were basically cured of that problem.

Degenerative cervical myelopathy

Degenerative cervical myelopathy is cervical spine degeneration that causes pressure or compression on the spinal cord. While typically classified as a wear and tear disorder caused by aging, the problems and symptoms can be much more complex.

Our website is filled with detailed articles on the problems of cervical spine instability. A list is provided below. In the many patients, we see, degenerative cervical myelopathy or cervical spine instability does not cause one problem in isolation. A patient will have neck pain, perhaps numbness, some will have headaches, some will have vision problems, some will have swallowing difficulties, some will have fainting spells or blackouts, some will have ringing in the ears, some will have 3 or 4 or 5 or more of these and other problems concurrently. Some will also have urinary incontinence and bladder problems and some of those people, as we have mentioned above, will be sent to a urologist and be given treatments that will be ineffective if the patient’s or your problem is coming from the cervical spine. A urologist does not work on neck pain.

Research led by doctors at the Academic neurosurgery unit, Department of Clinical Neurosurgery, University of Cambridge and published in the British Medical Journal (3) (February 2018) describes the problems of Degenerative cervical myelopathy in a category of articles titled: “Easily Missed.” What did the Cambridge doctors suggest was easily missed? Symptoms coming from the neck. This is quoted from the research:

“Consider degenerative cervical myelopathy in patients over 50 with progressive neurological symptoms, such as pain and stiffness in the neck or limbs, imbalance, numbness, loss of dexterity, frequent falls, and/or incontinence.”
Consider degenerative cervical myelopathy in “Autonomic symptoms such as bowel or bladder incontinence, erectile dysfunction, or difficulty passing urine.”

So patients with bladder problems and neck pain should be examined for neck pain.

We would also like to point out the guidelines the researchers gave their fellow physicians in regard to recommendations for surgery

“It is not possible to predict the long-term outcome of surgery. Maximal recovery occurs at around 6-12 months. Residual symptoms beyond this are likely to be permanent and should be managed appropriately. Functional deficits are common, and include falls and reduced mobility, incontinence, depression, sleep deficits, struggles with self-care, and often the most troublesome symptom is pain. Discuss with your patient that complete resolution of pain is unlikely. Neuropathic analgesia and anti-spasticity medication can be offered to manage the pain. Early referral to specialist pain clinics is often helpful.”

Surgery, as is generally recommended should be the last option.

In our practice, we continue to see a large number of patients with a myriad of symptoms related to cervical neck instability including seemingly unrelated problems of the bladder and urinary difficulties. As we have demonstrated in our own research, which we discuss below, and that of other researchers, problems of the neck can be far-reaching

There is a connection between the vagus nerve and renal failure and renal repair

The idea that cervical spine compression can cause urinary problems is both controversial and well understood.

A September 2021 paper from Dr. Tsuyoshi Inoue, MD, PhD. of the Nagasaki University Graduate School of Biomedical Sciences published in the journal Clinical and Experimental Nephrology (9) demonstrated the renal protection mechanisms of the vagus nerve. Here is what Dr. Inoue wrote, explanatory notes are added.

“The autonomic nervous system plays an important role in maintaining homeostasis in organisms. Recent studies have shown that it also controls inflammation by directly altering the function of the immune system. The cholinergic anti-inflammatory pathway (CAP) is one of the neural circuits operating through the vagus nerve. (Note: The modulation of systemic and local inflammation by the cholinergic anti-inflammatory pathway and its function as an interface between the brain and the immune system and a system under the control of the vagus nerve has been noted in many papers. (10))

Acetylcholine released from the terminal of the vagus nerve, which is a parasympathetic nerve, acts to reduce inflammation in the body. Previous animal studies demonstrated that vagus nerve stimulation reduced renal ischemia-reperfusion (Note: sudden loss of blood flow to the kidneys) injury.

Of note is the proper functioning of the vagus nerve in helping to prevent the development of kidney stones.

There is a connection between urinary problems and cervical neck pain, the Vagus Nerve, and blood pressure

The Vagus Nerve controls the muscle movement of the bladder during urination. If you look at the illustration above you will see where the Vagus nerve is closely related to the C1 – C2 – C3 vertebrae. While doctors usually discuss the vagus nerve in the singular sense, there are two vagus nerves, one on each side of the neck and in combination, they are referred to as the vagal nerves. This means that the degenerative damage in your neck can significantly impact the function of one or both vagus nerves.

There has been some degree of controversy as to whether or not the vagus nerves do provide nerve impulses and function to the bladder. It should not be far-fetched to think they do. The vagus helps regulate your heartbeat, the vagus helps regulate your breathing, and your vagus regulates the functions of your digestive tract. Wouldn’t it be within the realm of possibility that the vagus could also regulate the bladder? Let’s get to the science so we may be able to explain how treating your neck pain can, among other things, help regulate your bladder.

We are going to go back to a 1987 study performed on dogs, that makes a connection to neck area pain, the heart, and urinary bladder problems. If your neck pain includes problems of regulating your heartbeat, you may find a long-sought answer to some of your problems.

Let’s point out that this study is not coming from cervical spine specialists or urologists, it is coming from the Department of Cardiovascular Studies, the University of Leeds in the United Kingdom. It was published in the Quarterly Journal of Experimental Physiology. (4)

Here are the highlights:

The researchers anesthetized dogs and filled up their urinary bladders with saline. This began the experiment to see if the bladder and the vagal nerves talked to each other. How would the researchers know? By filling up the dog’s bladder they could measure the activity of the efferent (furthest from the bladder) vagal nerves. This would create changes in blood pressure and variation in heart activity. As we mention the Vagus nerves impact coronary function.

What did the researchers find?

It is concluded that distension of the urinary bladder results in the response of a decrease in activity in efferent cardiac vagal nerve fibres (the dog’s body has responded to a filled bladder by trying to reduce heart rate and blood pressure to calm the dog down. The vagal nerves also blocked the stimulating receptors in the carotid region (that part of the neck where the common left and right carotid arteries pass along with the carotid sinus, where they merge above the aorta, and the somatic nerves (the voluntary controls that help you control your bladder).

What does this mean to you?

Urinary problems, heart rate, and blood pressure, seemingly all have a common neck component.

The vagal nerves, blood pressure regulation, heartbeat regulation, and urinary incontinence problems, could all trace a common source to the neck.

Two years later a different set of researchers from the Department of Cardiovascular Studies, at the University of Leeds in the United Kingdom published a follow-up study in the Quarterly Journal of Experimental Physiology. (5) They found: that “inhibition of vagus nerve activity caused by bladder distension was affected by the level of carotid sinus pressure.” The filled bladder and the nerve impulses it was creating were being regulated by the carotid sinus in the neck. The vagal nerves, blood pressure regulation, heartbeat regulation, and urinary incontinence problems, could all trace a common source to the neck.

Now you would think research like this would get neurologists, urologists, and cardiologists talking. This was not the case. Let’s fast forward some 25 years later to 2012.

In a published study in Polish medical journal Folia Medica Cracoviensia, (6) doctors at the Department of Pathophysiology, Jagiellonian University Medical College, Kraków, Poland opened their study with this sentence:

“There is no evidence that vagal nerve innervates the urinary bladder.” They closed their research investigation with this sentence: “The modulation of vagal nerve activity affects the urinary bladder function in naive (normal) conditions, as well as in case of (damaged or degenerative tissue disease). These data imply the integrative action of visceral vagal nerve innervation in urinary bladder function.” There is a connection.

As you can there is controversy when it comes to urinary and bladder problems and cervical neck pain.

Vagus nerve compression

Vagus nerve compression has been implicated in many problems. See the list below. In the video below and the articles below, we will explain our ways of treating vagus nerve compression to help treat the long list of symptoms patients experience including urinary incontinence.

In our examination, we too are looking for compression.

In our clinical and research observations, we have documented that Prolotherapy can offer answers for sufferers of cervical instability, as it treats the problem at its source. Prolotherapy to the various structures of the neck eliminates the instability and the sympathetic symptoms such as urinary problems without many of the short-term and long-term risks of cervical fusion. We concluded that in many cases of chronic neck pain, the cause may be underlying joint instability and capsular ligament laxity. Furthermore, we contend that the use of comprehensive Prolotherapy appears to be an effective treatment for chronic neck pain and cervical instability, especially when due to ligament laxity. The technique is safe and relatively non-invasive as well as efficacious in relieving chronic neck pain and its associated symptoms.

Medical research validating the use of Comprehensive Prolotherapy, from simple dextrose injections to stem cell Prolotherapy injections is not new. There are 55 years of research supporting the use of Prolotherapy for problems of the neck and head. (7)

In this video, DMX displays Prolotherapy before and after treatments

In this video, we are using a Digital Motion X-Ray (DMX) to illustrate a complete resolution of a pinched nerve in the neck and accompanying symptoms of cervical radiculopathy.
A before digital motion x-ray at 0:11
At 0:18 the DMX reveals completely closed neural foramina and a partially closed neural foramina
At 0:34 DXM three months later after this patient had received two Prolotherapy treatments
At 0:46 the previously completely closed neural foramina are now opening more, releasing pressure on the nerve
At 1:00 another DMX two months later and after this patient had received four Prolotherapy treatments
At 1:14 the previously completely closed neural foramina are now opening normally during motion

Urinary incontinence is not a symptom in isolation of cervical neck instability patients. Please learn about how we can help you with these symptoms:

Questions about Cervical Neck Pain and Instability?
Get help and information from our Caring Medical Staff

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This article was updated June 26, 2022

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