Editing CUA: Neurogenic Lower Urinary Tract Dysfunction (2019) (section)

== Diagnosis and Evaluation ==

* '''<span style="color:#ff0000">Mandatory in all patients (3):'''
*#'''<span style="color:#ff0000">History and physical exam'''
*#'''<span style="color:#ff0000">Urinalysis'''
*#'''<span style="color:#ff0000">PVR'''
* '''<span style="color:#ff0000">If SCI, SB, or advanced MS with specific features, should also have (3)'''
*# '''<span style="color:#ff0000">Baseline UDS'''
*# '''<span style="color:#ff0000">Renal ultrasound'''
*# '''<span style="color:#ff0000">Measurement of renal function'''
*#* '''SCI, SB, or advanced MS patients are at higher risk of serious sequela from bladder dysfunction'''
*#*'''<span style="color:#ff0000">Selected patients with NLUTD due to other diagnoses may undergo these investigations when referred for specific urological concerns such as:'''
*#*# '''<span style="color:#ff0000">Clinically significant PVR'''
*#*# '''<span style="color:#ff0000">Frequent UTI'''
*#*# '''<span style="color:#ff0000">Bothersome incontinence'''
*#*# '''<span style="color:#ff0000">Use of catheters for bladder management'''
*#*# '''<span style="color:#ff0000">Known high-risk features'''
*#*# '''<span style="color:#ff0000">Considering more invasive treatment options'''
*'''See [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6570608/figure/f2-cuaj-6-e157/ Figure 2] (Initial investigations and risk stratification for neurogenic lower urinary tract dysfunction (NLUTD) patients) from Original Guideline'''

=== History and Physical Exam ===
* '''<span style="color:#ff0000">History'''
** '''<span style="color:#ff0000">History of the neurological disease'''
*** SCI: Year and level/completeness of lesion (ASIA level), frequency of autonomic dysreflexia, level of spasticity, mobility/transfers
*** MS: Year and type of MS (primary progressive, secondary progressive, relapsing remitting), mobility level (or Expanded Disability Status Scale)
*** Spina bifida: Type (i.e., ambulatory lipomyelomeningocele), caregiver, VP shunt, latex allergy, prior reconstructive surgery
** '''<span style="color:#ff0000">Bladder management history'''
*** Use of catheters (CIC, indwelling [size and frequency of changes], condom), crede/straining/reflexive bladder emptying, bladder medications, and prior urological surgery history
** '''<span style="color:#ff0000">Storage & voiding symptoms'''
*** Storage: frequency, urgency, nocturia, incontinence
*** Voiding: weak stream, intermittency, straining, incomplete emptying
** '''<span style="color:#ff0000">NLUTD complications'''
*** UTIs (symptoms, culture status, associated sepsis/fever, response to antibiotics/antibiotic resistance, triggers, hospital admissions)
*** Sequela of incontinence (skin breakdown, ulcers, pad usage, bother)
*** Bladder or renal stone disease
*** Catheter complications (urethral loss in women; urethral erosion, false passages, strictures in men, encrustation/sediment)
*** Renal function deterioration (imaging results, renal function)
** '''<span style="color:#ff0000">Review of relevant systems'''
*** Bowel function
*** Sexual function
*** Coexisting non-NLUTD dysfunction (prostatic enlargement, stress incontinence)
*** Gross hematuria
*** Gynecological/pregnancy history
*** Genitourinary/pelvic pain
*** Motor abilities (hand function, ability to transfer)
*** Cognitive function
*** Support systems/caregivers
** '''<span style="color:#ff0000">General components'''
*** Allergies, medications, alcohol/drug use/smoking
* '''<span style="color:#ff0000">Physical Exam'''
** '''General'''
***Body habitus
**'''Abdomen'''
**'''Genitals'''
**'''Rectal exam'''
** May include a '''focused screening neurological exam''' (such as lower limb sensory, motor, and reflex function), especially when there is a suspicion of NLUTD without a confirmed neurological disease.

=== Labs ===
*'''<span style="color:#ff0000">Urinalysis'''
** '''Rule out infection, microscopic hematuria, and unexpected pyuria or proteinuria'''
***Proteinuria is a marker of renal damage which can be screened for and warrants a nephrology referral
*'''<span style="color:#ff0000">Renal function'''
** '''<span style="color:#ff0000">Serum creatinine'''
***'''can be used to assess renal function'''
***'''Has been criticized as a reliable early marker of renal function in patients with NLUTD, as patients often have muscle atrophy from disuse and denervation.'''
** '''<span style="color:#ff0000">Renography and 24-hour urine creatinine clearance may be preferred to sequentially assess renal function in neurogenic bladder patients'''.

=== Imaging ===

* '''<span style="color:#ff0000">Renal and bladder imaging'''
**'''<span style="color:#ff0000">Necessary to identify (4):'''
**#'''<span style="color:#ff0000">Hydronephrosis (a late but potentially reversible sign of bladder dysfunction in NLUTD)'''
**#'''<span style="color:#ff0000">Renal/bladder stone disease'''
**#'''<span style="color:#ff0000">Abnormal bladder morphology (for example, thickened bladder wall, diverticula)'''
**#'''<span style="color:#ff0000">Renal atrophy and degree of scarring'''

=== Other ===

==== PVR ====
* '''To address potential UTI risk and overflow incontinence; may prompt screening for upper tract deterioration'''
* In the non-NLUTD population, a value >300 mL is used to define chronic urinary retention.
*'''The need to treat PVR should be based on patient symptoms rather than an absolute number.'''

==== Urodynamics ====
* '''<span style="color:#ff0000">Gold standard for evaluating NLUTD''' 
*'''<span style="color:#ff0000">Necessary due to the absence of normal lower urinary tract sensation and the poor ability of symptoms to predict high-risk features.'''
* '''<span style="color:#ff0000">VideoUDS are preferred, as the additional correlation with imaging allows assessment of (3):'''
*# '''<span style="color:#ff0000">VUR'''
*# '''<span style="color:#ff0000">Abnormal bladder morphology'''
*# '''<span style="color:#ff0000">Behaviour of the urinary sphincters during voiding'''
** The availability of videoUDS is not universal; a voiding cystogram is an acceptable alternative in some cases
* '''<span style="color:#ff0000">Urodynamic findings associated with increased risk of urological complications (such as renal dysfunction, urinary infections, and incontinence) (4):'''
*#'''<span style="color:#ff0000">Neurogenic detrusor overactivity (NDO)'''
*#*'''Duration of the NDO contraction''' may predict renal deterioration
*#'''<span style="color:#ff0000">Impaired compliance'''
*#'''<span style="color:#ff0000">Reduced bladder capacity'''
*#'''<span style="color:#ff0000">High detrusor leak point pressure (DLPP)'''
*#*DLPP: defined as the lowest detrusor pressure at which urine leaks from the bladder in the absence of a detrusor contraction or increased abdominal straining
*#** A DLPP of >40 cm H2O has traditionally been cited as the cutoff above which a patient has a high risk of renal deterioration; however, this is based on a historical study of children with SB, and may not be applicable to adult NLUTD.
*#** As DLPP increases, so too does the risk of renal dysfunction due to an increased resting pressure in the bladder being transmitted to the kidneys.
*#** '''If a high DLPP only occurs at a volume greater than the usual capacity during the normal daily voiding pattern, then this DLPP may not be physiologically relevant.'''
*#** A low DLPP maintains low pressure drainage from the kidneys, however, this often results in urinary incontinence.

==== Voiding diaries ====
* '''Should be considered for all patients'''
* Allows the patient to self-reflect on their urinary habits and the physician to measure changes over time in a non-invasive manner and interpret urodynamic findings in the context of the patient’s day-to-day urinary patterns.

==== Validated questionnaires ====
* '''Optional'''
*Generally used for research purposes in the NLUTD population

==== Cystoscopy ====
* Should be reserved for situations where there is a clinical indication to assess either the urethra or bladder (such as suspicion of urethral strictures or false passages, bladder stones, or bladder cancer)

=== Timing ===
*'''Depends on the severity of symptoms, underlying risk of serious urological complications, and the etiology of the neurogenic bladder.'''
** '''SB and SCI have a significant risk of renal dysfunction and are acquired at birth (SB) or often as young adults (SCI); this makes patients particularly susceptible to renal dysfunction in their lifetime. This contrasts with slowly progressive diseases, such as relapsing-remitting MS, or the predominately elderly population with Parkinson’s disease or dementia.'''
** '''The urological evaluation of a patient with a newly acquired SCI should occur within 3–6 months of the SCI.'''
*** Significant bladder dysfunction can appear early after SCI. Efforts should made to assess patients with urological complications or concerns as soon as possible after the acute SCI.