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

== Answers ==

# List conditions associated with neurogenic lower urinary tract dysfunction.
## Multiple sclerosis (MS)
## Spina bifida (SB)/myelomeningocele
## Spinal cord injury (SCI)
## Parkinson’s disease
## Cerebrovascular accidents
## Traumatic brain injury
## Brain or spinal cord tumour
## Cauda equina syndrome
## Transverse myelitis
## Multisystem atrophy
## Pelvic nerve injury
## Diabetes
# What is the expected history, urodynamic findings, PVR, and sphincter activity based on the location of the spinal cord lesion?
##

{| class="wikitable"
|Location of lesion
|History
|Ultrasound
|Urodynamics
|Sphincter
|-
|Suprapontine
|Predominantly storage symptoms
|Insignificant PVR
|Detrusor overactivity
|Normal
|-
|Spinal (infrapontine-suprasacral)
|Storage and voiding symptoms
|Usually elevated PVR
|Detrusor overactivity, DSD, (lesions between brainstem and T6 may have smooth sphincter dyssynergia and autonaumic dysreflexia)
|Overactive
|-
|Sacral/infrasacral
|Predominantly voiding symptoms
|Usually elevated PVR
|Hypocontractile or acontractile detrusor
|Normal or underactive
|}

##
# What are considered high-risk features related to NLUTD?
## Bladder management technique: Valsalva/crede/reflexive voiding
## Known high-risk features on UDS without confirmation of appropriate attenuation after treatment (DSD, NDO, impaired compliance [<20 ml/cmH2O], DLPP >40 cmH2O, vesico-ureteral reflex)
## New/worsening renal imaging (hydronephrosis, atrophy, scarring)
## New/worsening renal insufficiency
# What are potential risk factors for upper urinary tract deterioration in patients with NLUTD?
## High bladder storage pressures
## Bladder outlet obstruction
## Ureteral obstruction
## UTI
## Stones
# What are potential imaging findings associated with high bladder pressures in neurogenic bladder?
## VUR
## Hydronephrosis
## Thick-walled bladder
## Abnormal contour bladder
# What are potential complications of long-term indwelling catheterization?
#* Men: urethral strictures, false passages, diverticuli, periurethral abscesses, urethrocutaneous fistula, and iatrogenic traumatic hypospadias
#* Women: urethral dilation, erosion, and potentially destruction
# What is the most common pathogen responsible for UTI in NLUTD?
#* E. Coli
# What is signs and symptoms are required for a diagnosis of UTI in patients with NLUTD?
## Leukocytosis
## Bacteruria
## Presence of symptoms
# What are signs and symptoms of UTI in a patient with SCI?
#* Fever, urinary incontinence/failure of control or leaking around catheter, increased spasticity, malaise, lethargy or sense of unease, cloudy urine, malodorous urine, back pain, bladder pain, dysuria, and autonomic dysreflexia
# What are potential complications of NLUTD?
## UUTD
## UTI
## Stones
## Sepsis
## Ureteric obstruction
## Vesicoureteric reflux
## Sequela of incontinence (skin breakdown, ulcers, pad usage, bother)
## Catheter complications
# What spinal cord injury level is associated with autonomic dysreflexia?
#* Above T6
# What are the mandatory investigations in patients with NLUTD?
#* History, physical exam, PVR, urinalysis in all patients
#* In patients with MS, SB, or SCI, all should have baseline UDS, renal imaging, renal function assessment
#* In patients with other neurological conditions but specific features should also have baseline UDS, renal imaging, and renal function assessment. These features include:
#*# Clinically significant PVR
#*# Frequent UTI
#*# Bothersome incontinence
#*# Use of catheters for bladder management
#*# Known high-risk features
#*# Considering more invasive treatment options
# When should the urological evaluation of a patient with newly acquired SCI take place?
#* Within 3-6 months of injury
# What is the first-line pharmacological treatment for patients with NLUTD?
#* Oral anti-cholinergics or beta-3-agonists
# What is the second-line pharmacological treatment for patients with NLUTD?
#* Intradetrusor botox
# What is a potential treatment option to treat NDO in NLUTD patients who are doing CIC?
#* Intravesical oxybutynin
# What are the objectives of treatment of NLUTD?
## Prevent UUTD
## 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.
# What are the surgical options in the treatment of NLUTD?
## Bladder augmentation
## Catheterizable channel and continent cutaneous diversion
## Incontinent urinary diversion
## External urinary sphincterotoy
## Bladder neck closure
# What is the recommended surveillance in patients with NLUTD?
## High/moderate risk:
### Yearly urological evaluation (history and physical examination)
### Yearly renal-bladder imaging
### Yearly renal function assessment
### UDS
###* High-risk: yearly
###* Moderate-risk: every 2-5 years
## Low risk:
### Yearly evaluation with GP, physiatrist, neurologist, or urologist (history and physical examination with attention to general neuro-urological assessment outlined previously)
### Yearly renal imaging in select cases
### Re-referral for urological evaluation as suggested by:
#### New-onset/worsening incontinence; or
#### New frequent urinary infections; or
#### New-onset catheter issues (for example, penile/urethral erosions, encrustation, bypassing)
#### Renal-bladder imaging changes suggestive of upper or lower UT deterioration (hydronephrosis, new clinically significant PVR, or significant increase in PVR) or new stone disease