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

== Management ==

* '''The treating clinician should identify patients as either being high-, moderate-, or low-risk, offer the patient appropriate initial therapy, and consider a urological surveillance program as outlined below'''

=== Assisted bladder drainage ===
*'''<span style="color:#ff0000">CIC or condom-catheter preferred'''
*# '''<span style="color:#ff0000">Non-catheter mechanisms'''
*#* Rely on involuntary emptying that is either induced or spontaneous
*#* '''Some bladder methods (reflex triggering and Valsalva or Credé manoeuvres) should be strongly discouraged due their associated risk of upper tract injury.'''
*#** The '''Crede manoeuvre''' (external pressure on the bladder) '''and Valsalva''' voiding induces bladder drainage via an increase in abdominal pressure that can overcome the external urethral sphincter. It can be '''inefficient and risk high pressures and cause hemorrhoids, hernias, and VUR.'''
*#* '''Condom catheter drainage''' is often used to collect urine in these non-catheter methods
*# '''<span style="color:#ff0000">Catheter mechanisms'''
*#* '''<span style="color:#ff0000">Options (3): CIC (preferred), indwelling urethral and suprapubic catheter'''
*#** '''<span style="color:#ff0000">CIC associated with reduced risk of infection, reduced risk of stones, and preservation of bladder compliance compared with indwelling urethral or SP catheter'''
*#* Until evidence can confidently demonstrate that multiple use is as safe as single-use catheters, healthcare providers should advocate a single use of catheters in individuals with SCI.

=== Oral therapy ===

==== Options (2): ====

*'''<span style="color:#ff0000">Anticholinergics''' 
*'''<span style="color:#ff0000">Beta-3 agonists'''

==== Anticholinergics ====
* '''<span style="color:#ff0000">First-line pharmacological treatment for patients with NLUTD'''
* '''<span style="color:#ff0000">Indications'''
**'''<span style="color:#ff0000">Should be offered to people with urodynamic findings of NDO or those with SCI and symptoms of overactive bladder (OAB)'''
** '''<span style="color:#ff0000">Should be considered whether or not patients are using assisted bladder drainage.'''
*** '''Absence of its usage has been shown to be a risk factor for upper tract deterioration'''
* '''<span style="color:#ff0000">Use improves OAB symptoms and NDO, decreases urgency urinary incontinence, and lowers detrusor pressures'''
* '''<span style="color:#ff0000">Do not alter the detrusor or abdominal leak point pressures since they do not act on the external urethral sphincter'''
* '''Studies that compared one medication to another''' (usually oxybutynin IR) '''did not reveal statistically significant differences.''' The optimal drug dosage was not identified.
* '''Supratherapeutic dosages may be considered according to tolerability''' but should be used cautiously.
* '''Combining antimuscarinics may be beneficial for patients who are refractory to dose escalation antimuscarinic monotherapy'''
* '''There is very limited data supporting the use of transdermal oxybutynin in NLUTD'''

==== Beta-3 adrenergic agonist ====
* '''<span style="color:#ff0000">Mirabegron may be a useful alternative to anticholinergics for patients with symptoms of OAB and NLUTD, but further evidence of urodynamic changes are needed in this population'''
** There is very limited data supporting the use of mirabegron in NLUTD

=== Intravesical therapy ===

==== Options (2): ====

*'''<span style="color:#ff0000">Botox'''
*'''<span style="color:#ff0000">Oxybutynin'''

==== Botox ====
* '''<span style="color:#ff0000">Ona-botulinum toxin A injection (200 units) in the detrusor is an effective, minimally invasive treatment that can achieve continence, improve bladder function, and diminish NDO in individuals with SCI or MS who have an inadequate response to or are intolerant of an anticholinergic medication'''
* '''Abo-botulinum toxin A is also effective in NLUTD, with the optimal dose of 750 units'''
* Sustained efficacy in terms of reduced incontinence episodes, enhanced bladder function, as well as substantial improvements in key urodynamic parameters and QoL
* UTIs and large urine residual or urinary retention are the most frequent adverse events. Therefore, the likelihood of future need of CIC is increased

==== Oxybutynin by CIC ====
* '''A safe alternative approach to managing NDO and NLUTD in patients who are doing CIC;''' safe and effective short-term therapy in patients suffering from NDO who remain incontinent or are intolerant of oral anticholinergic medication
* '''Results in significant increase in bladder capacity'''
* '''This approach avoids systemic side effects compared to oral oxybutynin'''

=== Neural stimulation and neuromodulation therapy ===
* '''Current data supporting the use of sacral neuromodulation (SNM) and peripheral tibial nerve stimulation (PTNS) are limited'''; remains unclear which subgroups of neurogenic voiding dysfunction and which underlying neurological disease will respond best to these different therapies.
*# '''SNM could be considered for the treatment of NDO or non-obstructive urinary retention in carefully selected individuals with NLUTD, as it can be a safe and effective option'''. It should be preceded by an adequate testing phase and may not be a good alternative to decrease detrusor pressures or improve bladder compliance.
*# '''PTNS can be effective in NLUTD resulting from MS, but requires initial frequent weekly visits.''' PTNS appears to be well-tolerated and effective in small studies, with minimal reported adverse events, mainly mild to moderate pain at the puncture site
* '''Dorsal rhizotomy (sacral deafferentation S2-S4/5) and sacral anterior root stimulation by an implantable device can achieve safe storage detrusor pressure and voluntary emptying of bladder and bowel in patients with complete SCI.''' '''Furthermore, it diminishes autonomic dysreflexia.''' This technique has good variable success rates in specialized centres, but comes with long-term complications and a very high rate of surgical revisions

=== Surgical management of LUTD ===

==== Indications ====

*'''When conservative measures, medical therapy, and minimally invasive interventions alone fail to achieve the objectives of:'''
*# Protecting kidney function and mitigating autonomic dysreflexia by maintaining bladder storage at safely low pressures
*# Ensuring adequate and timely bladder emptying to mitigate the risks of overflow incontinence, recurrent UTIs, bladder stones, and kidney damage
*# Preventing the adverse effects of incontinence (e.g., dermatitis)
*# Improving QoL by relieving bothersome symptoms of OAB and incontinence.

==== Options (5): ====

#'''<span style="color:#ff0000">Bladder augmentation'''
#'''<span style="color:#ff0000">Catherizable channel'''
#'''<span style="color:#ff0000">External urethral sphincterotomy'''
#'''<span style="color:#ff0000">Bladder neck closure with continent or incontinent channel'''
#'''<span style="color:#ff0000">Incontinent diversion'''

===== Bladder augmentation =====
* '''<span style="color:#ff0000">Indications (2):'''
*# '''<span style="color:#ff0000">Reduced compliance or NDO refractory to all other non-surgical treatments'''
*# '''<span style="color:#ff0000">Reduced bladder capacity necessitating an indwelling catheter or CIC to be done too frequently'''

===== Catheterizable channels and continent cutaneous urinary diversion =====
* '''<span style="color:#ff0000">In cases where urethral catheterization is precluded, a catheterizable channel may be offered</span>''' after careful consideration and multidisciplinary evaluation.
* '''The most commonly used tube is the appendix (Mitrofanoff appendicovesicostomy). Where the appendix is unavailable or unsatisfactory''' (must be 8–10 cm in length for adult patients), '''a segment of terminal ileum can be employed''' (Yang-Monti or Casale technique), albeit with slightly poorer outcomes.

===== External urethral sphincterotomy =====
* '''Contraindications (4):'''
*# '''Female'''
*# '''Unable to wear condom catheter'''
*# '''Detrusor underactivity'''
*# '''Patient wants to maintain fertility'''

===== Bladder neck closure combined with a continent or incontinent channel =====
* '''Indicated in cases of severe outlet damage'''

===== Incontinent urinary diversion (ileovesicostomy and ileal conduit) =====
* '''Last resort in managing the complications of NLUTD'''
* The bladder should be removed at the time of surgery to reduce the risks of pyocystis, chronic symptomatic cystitis, and malignancy