Editing Neurogenic LUT Dysfunction (section)

=== Neurospinal dysraphism ===

* See Pediatrics: Neuromuscular Disorders of the Lower Urinary Tract Chapter Notes
* '''LUT dysfunction occurs in 90% of patients.'''
* '''LUT dysfunction secondary to occult spinal dysraphism may not manifest in childhood,''' and such patients may be referred as adults for symptoms as commonplace as urinary incontinence or recurrent UTIs.
* '''The level(s) of the lesion correlate(s) poorly with urodynamic findings.'''
* '''The “typical” myelodysplastic patient shows an areflexic bladder with an open bladder neck.'''
** The bladder usually fills until the resting residual fixed external sphincter pressure is reached, and then leakage occurs.
** Stress incontinence may also occur owing to changes in intra-abdominal pressure.
** A small percentage (10-15%) of patients demonstrate DSD, but these individuals show normal bladder neck function that, if detrusor reflex activity is controlled, may be associated with urinary continence.
* The neurologic exam does not predict urodynamic behaviour
* '''Management'''
** Regardless of the pattern of LUT dysfunction in the adult, the main goal of therapy is the avoidance of high storage pressures
** The urologic rehabilitation of patients with spinal dysraphism relies primarily on medical management and intravesical injection of onabotulinumtoxinA, with the selective use of augmentation enterocystoplasty or urinary diversion if failure occurs.
** '''The treatment strategy in women is to increase urethral sphincter efficiency without causing an increase in urethral closing pressure significant enough to result in a change in bladder compliance.'''
*** Periurethral injection therapy may be a safer option than the pubovaginal sling and artificial urethral sphincter in this case.
** SUI in men with myelodysplasia may follow similar general rules as in women, and bulking agents may give good results in this group as well.
*** When the urethra is very widely dilated and somewhat rigid, and neither procedure alone will provide sufficient coaptation, it may be possible to combine a “prostatic sling” with periurethral bulking.
*** Continent individuals will remain on CIC.
* '''Tethered cord syndrome'''
** Defined as a stretch-induced functional disorder of the spinal cord with its caudal part anchored by inelastic structures and restricting vertical movement.
** Children often develop symptoms of tethered cord after growth spurts; in adults the presenting symptoms often follow activities that stretch the spine, such as sports or motor vehicle accidents
** '''Cord tethering can affect both bowel and leg function, as well as bladder function. Usually, there is no bladder dysfunction, and treatment must be based on urodynamic evaluation.'''
*** Despite efforts at improved radiographic visualization of the spinal cord, imaging does not correlate with physical findings or connote overall responsiveness to surgical intervention because detethering remains a critical aspect of management and control of tethered cord.
*** Urodynamics is improved by detethering, and this parallels functional improvement in those individuals who have undergone the surgical procedure
* Follow-up
** Includes annual surveillance for early identification of urinary tract deterioration.
*** These assessments should include renal and bladder ultrasonography and urodynamics when indicated (by symptomatic change or clinical physical examination finding).
*** In addition, serum creatinine and renal scintigraphy may be performed when upper tract changes are suspected.