Editing Neurogenic LUT Dysfunction (section)

=== Spinal cord injury ===
* '''See [[CUA: Neurogenic Lower Urinary Tract Dysfunction (2019)|2019 CUA NLUTD Guideline Notes]]'''
*'''The majority of SCIs occur at or above the T12 spinal column''' (vertebral) '''level, with injury to one of the 8 cervical segments accounting for the patients with tetraplegia and with patients with paraplegia having injury in the thoracic, lumbar, or sacral regions of the spinal cord.'''
* '''Urologic complications of SCI (8):'''
*# '''UTI'''
*# '''Sepsis'''
*# '''Upper urinary tract and LUT deterioration'''
*# '''Urolithiasis'''
*# '''Sexual and reproductive dysfunction'''
*# '''Autonomic hyperreflexia (dysreflexia)'''
*# '''Skin complications'''
*# '''Depression (which can complicate urologic management)'''
* '''Despite the strong correlation between neurologic and urodynamic findings, it is not perfect, and a neurologic examination is no substitute for a urodynamic evaluation in these patients''' when one is determining risk factors and treatment
* '''Spinal shock'''
** '''A temporary physiologic disorganization of spinal cord that may be expected after a significant SCI'''
** '''Defined as the loss of motor, sensory, reflex, and autonomic neurologic function below the level of SCI'''
** Classically starts within one hour after the neurologic injury.
** '''Bladder is acontractile and areflexic. The bladder neck is usually closed and competent'''
** '''The smooth sphincter mechanism appears to be functional. Some electromyographic activity may be recorded from the striated sphincter'''
** '''The normal guarding reflex (striated sphincter response during filling) is absent and there is no voluntary control'''
** '''Urinary retention is the rule, and catheterization is necessary to circumvent this problem'''
*** Once the patient is medically stable and can regulate fluid intake, the indwelling catheter can be removed and clean intermittent catheterization should be started.
** '''Spinal shock usually lasts 6-12 weeks in complete suprasacral spinal cord lesions''' '''but may last up to 1 or 2 years.'''
*** May last a shorter period of time in incomplete suprasacral lesions and only a few days in some.
**** The exception is sacral SCI which has persistent detrusor areflexia
*** '''Resolution of spinal cord shock classically begins with the initial return of the bulbocavernosus reflex followed by the eventual restoration of the deep tendon reflexes (DTR) below the level of spinal cord injury.'''
** '''Initial urodynamics should be performed within 3 months of SCI onset regardless of spinal shock resolution and then repeated after spinal shock has resolved.'''
*** '''The ideal time to perform initial urodynamics is after spinal shock has resolved,''' which can take up to 3 months in most cases.
**** Nearly two-thirds of patients had unfavorable urodynamic parameters (detrusor overactivity, vesicoureteral reflux and high detrusor filling pressures) within 40 days after SCI.
*** Videourodynamics with fluoroscopy is the gold standard for urodynamic investigation in patients with neurogenic bladder.
*** The Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction best practice policy on antibiotic prophylaxis during urodynamics recommends that patients with SCI receive a single antibiotic dose to avoid symptomatic UTI and bacteremia.
* '''Suprasacral spinal cord injury'''
** The characteristic pattern in a patient with a complete lesion above the sacral spinal cord is detrusor overactivity, smooth sphincter synergia (with lesions below the sympathetic outflow), striated sphincter dyssynergia, and absent sensation below the level of the lesion
*** Lesions at or above the spinal cord level of T7 or T8 (the spinal column level of T6) may result in smooth sphincter dyssynergia as well
*** The striated sphincter dyssynergia causes a functional obstruction with poor emptying and high detrusor pressure.
*** Occasionally, incomplete bladder emptying may result from what seems to be a poorly sustained or absent detrusor contraction.
** Neurologic examination shows spasticity of skeletal muscle distal to the lesion, hyperreflexic DTRs, and abnormal plantar responses. There is impairment of superficial and deep sensation
** The guarding reflex is absent or weak in most patients with a complete suprasacral SCI. In incomplete lesions the reflex is often preserved but quite variable
** From a functional standpoint, the voiding dysfunction most commonly seen in suprasacral SCI represents both a filling or storage and an emptying or voiding failure. Although the urodynamics are “safe” enough in some individuals to allow only periodic stimulation of bladder reflex activity, many will require some form of additional treatment.
* '''Sacral spinal cord injury'''
** Typically, a depression of DTRs below the level of a complete lesion with varying degrees of flaccid paralysis. Sensation is usually absent below the lesion level. Detrusor areflexia with high or normal compliance is the common initial result. However, decreased compliance may also develop
** '''The classic outlet findings are described as a competent but nonrelaxing smooth sphincter and a striated sphincter that retains some fixed tone but is not under voluntary control'''. Closure pressures are decreased in both areas

==== Management ====
* '''Although generally correct, the correlation between somatic neurologic findings and urodynamic findings in suprasacral and sacral SCI patients is not exact''', especially in patients with paraplegia resulting from spinal cord lesions at column level T10 to L2.
* '''If bladder pressures are suitably low or if they can be sufficiently and safely lowered with nonsurgical or surgical management, the problem can be treated primarily as an emptying failure. CIC''' can then be continued as a safe and effective way of satisfying many of the goals of treatment. The role of additive '''antimuscarinic''' administration is supported in this patient population.
** '''2019 AUA Update on SCI: For indwelling catheters a suprapubic catheter is preferred over a urethral catheter as there is less risk of urethral erosion and epididymo-orchitis in men. However, there is no difference between the 2 catheters regarding risk of UTI, bladder stones or urinary incontinence from NDO.'''
** In the absence of bladder outlet obstruction there is currently no role for medication in treating urinary retention in these patients.
* '''Alternatively, sphincterotomy, urethral stenting, or intrasphincteric injection of onabotulinumtoxinA can be used in males to lower the detrusor leak point to an acceptable level and render the patient incontinent, thus converting the dysfunction primarily to a storage failure (incontinence),''' which can be obviated either by timed stimulation or with an external collecting device. In the dexterous SCI patient, the former approach using CIC is becoming predominant.
* '''Electrical stimulation of the anterior sacral roots with some form of deafferentation''' is also now a distinct reality. Although used sparingly, as with all patients with neurologic impairment, a careful initial evaluation and periodic, routine follow-up evaluation must be performed to identify and correct the following risk factors and potential complications: bladder overdistention, high-pressure storage, high detrusor leak point pressure, vesicoureteral reflux (VUR), stone formation (lower and upper tracts), and complicating infection, especially in association with reflux.
* Potential risk factors and complications are those previously described, with particular emphasis on storage pressure, which can result in silent upper tract decompensation and deterioration in the absence of VUR. The treatment of such a patient is usually directed toward producing or maintaining low-pressure storage while circumventing emptying failure with CIC when possible.
* Bowel management
** Approximately 60% of patients will have fecal incontinence and 40% will have constipation.
** The goal of a neurogenic bowel regimen is to accomplish complete evacuation of the rectum on a regular basis, thereby reducing the risk of fecal impaction. This goal is achieved with adequate fluid intake, balanced diet, appropriate physical activity and a regular bowel routine.
** In a systematic review of non-pharmacological therapies for chronic constipation, a transanal irrigation system appeared promising in decreasing constipation and fecal incontinence.
** If further therapy is needed, patients with SCI should be started on medications such as cisapride, prucalopride or neostigmine.

==== Autonomic hyperreflexia (dysreflexia) ====
* '''See [[CUA: Neurogenic Lower Urinary Tract Dysfunction (2019)|2019 CUA NLUTD Guideline Notes]]'''
*'''Potentially fatal emergency unique to the SCI patient'''
* Onset after injury is variable—usually soon after spinal shock, but it may occur up to years after injury, and distal spinal cord viability is a prerequisite.
* '''Represents an acute massive disordered autonomic (primarily sympathetic) response in patients with SCI above the cord level of T6-T8 (the sympathetic outflow) to specific stimuli below the level of the lesion'''
* '''Symptoms (5):'''
*# '''Pounding headache'''
*# '''Hypertension'''
*# '''Flushing and sweating above the level of the lesion'''
*# '''Bradycardia'''
*#* Tachycardia or arrhythmia may be present
*# '''Hypertension'''
*#* May vary in severity from causing a mild headache before voiding to life-threatening cerebral hemorrhage or seizure
* The pathophysiology is that of nociceptive stimulation via afferent impulses that ascend through the cord and elicit reflex motor outflow, causing arteriolar, pilomotor, and pelvic visceral spasm and sweating. Normally, the reflexes would be inhibited by secondary output from the medulla, but because of the SCI this does not occur below the lesion level.
* '''The stimuli for this exaggerated response commonly arise from the bladder or rectum and typically involve distention.''' '''Precipitation may be the result of simple LUT instrumentation, tube change, catheter obstruction, or clot retention, and in such cases the symptoms resolve quickly if the stimulus is withdrawn.'''
* '''Ideally, any endoscopic procedure in susceptible patients should be done using spinal anesthesia or carefully monitored general anesthesia'''.
* '''Acutely, the hemodynamic effects of this syndrome may be managed with β- and/or α-adrenergic blocking agents.'''
** '''Sublingual nifedipine is capable of alleviating this syndrome when given during cystoscopy (10 to 20 mg) and of preventing it when given orally 30 minutes before cystoscopy (10 mg)'''
** No consensus on the acute pharmacologic management of autonomic dysreflexia when necessary;

==== Vesicoureteral reflux ====
* '''Incidence between 17-25% in SCI patients, more common in those with suprasacral SCI.'''
** Persistent reflux can lead to chronic renal damage and may be an important factor in the long-term survival of SCI patients.
* '''Contributing factors include:'''
*# '''Elevated intravesical pressure during filling and emptying'''
*# '''Infection'''
* '''Management'''
** '''The best initial treatment for VUR in a patient with voiding dysfunction secondary to neurologic disease or injury is to normalize LUT urodynamics (i.e., decrease storage pressures and decrease outlet resistance) as much and as quickly as possible.'''
*** Depending on the clinical circumstances, this may be achieved by pharmacotherapy, urethral dilatation (in the myelomeningocele patient), neuromodulation, deafferentation, augmentation cystoplasty, or sphincterotomy

==== Urinary tract infection ====
* Relatively common in patients with SCI.
* '''Bacteriuria should be treated only when the patient has signs or symptoms of a UTI'''
* Risk factors for symptomatic UTIs in patients with SCI:
** Bladder overdistention
** Increased bladder filling pressures
** Vesicoureteral reflux
** Bladder stones

==== Sexual dysfunction in males ====
* After SCI most men have erectile and ejaculatory dysfunction.
** Rates of successful intercourse after SCI in men range from 5% to 75%, and only 10% with SCI can ejaculate.
* Erectile dysfunction in men can be managed using the same options available to the general population.
* '''Only 10% of men with SCI are able to achieve natural conception.''' Infertile men with SCI can achieve fertility with medical intervention that restores ejaculatory function and normal semen quality.

==== Spinal cord injury in women ====
* Management complicated by lack of an appropriate external collecting device
* Surgical intervention for SUI in this population may be beneficial in well-selected patients
* Fertility is not impaired in most women with SCI

==== Spinal cord injury and bladder cancer ====
* Strong association between the development of bladder cancer (squamous cell carcinoma) and long-term indwelling catheterization
** Some patients have no obvious tumors visible at endoscopy, and the diagnosis is made by bladder biopsy

==== Follow-up ====
* '''See [[CUA: Neurogenic Lower Urinary Tract Dysfunction (2019)|2019 CUA NLUTD Guideline Notes]]'''