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

== Urologic Complications of NLUTD ==

* '''<span style="color:#0000ff">SIRI OU'''
# '''<span style="color:#0000ff">S</span><span style="color:#ff0000">tones'''
#'''<span style="color:#0000ff">I</span><span style="color:#ff0000">nfection</span>'''
# '''<span style="color:#ff0000">Vesicoureteral </span><span style="color:#0000ff">R</span><span style="color:#ff0000">eflux'''
# '''<span style="color:#0000ff">I</span><span style="color:#ff0000">ncontinence and urethral damage'''
#'''<span style="color:#ff0000">Ureteric <span style="color:#0000ff">O</span><span style="color:#ff0000">bstruction'''
#'''<span style="color:#0000ff">U</span><span style="color:#ff0000">pper urinary tract deterioration (UUTD)'''

=== Infection ===

* '''Sepsis'''
* '''<span style="color:#ff0000">Urinary Tract Infections'''
** '''Pathogens'''
***'''The Enterobacteriaceae family represents the most commonly isolated organism in the NLUTD population, with E.coli comprising 50% of all strains.'''
**** '''This is a lower than non-neurogenic UTIs, partly explained by the increased incidence of Pseudomonas, Acinetobacter, Enterococcus, and fungi such as Candida'''
**'''<span style="color:#ff0000">Diagnosis and Evaluation'''
***'''The accepted definition of UTI in persons with NLUTD requires the presence of (3):'''
***#'''Leukocyturia'''
***#*Consensus cut-off for leukocyturia is 100 leukocytes/mL or any leukocyte esterase activity on dipstick
***#'''Bacteriuria'''
***#*No evidence-based cut-off values for bacteriuria; '''generally accepted guidelines:'''
***#**'''Any detectable concentration for suprapubic aspirate'''
***#**'''>102 cfu/ml (clean catheterized sample)'''
***#**'''>104 cfu/ml (clean voided)'''
***#'''Clinical symptoms'''
***#*'''<span style="color:#ff0000">Signs and symptoms of UTI in SCI''' 
***#*#'''<span style="color:#ff0000">Fever'''
***#*#'''<span style="color:#ff0000">Cloudy urine'''
***#*#'''<span style="color:#ff0000">Malodorous urine'''
***#*#'''<span style="color:#ff0000">Dysuria'''
***#*#'''<span style="color:#ff0000">Urinary incontinence/failure of control or leaking around catheter'''
***#*#'''<span style="color:#ff0000">Increased spasticity'''
***#*#'''<span style="color:#ff0000">Malaise'''
***#*#'''<span style="color:#ff0000">Lethargy or sense of unease'''
***#*#'''<span style="color:#ff0000">Back pain'''
***#*#'''<span style="color:#ff0000">Bladder pain'''
***#*#'''<span style="color:#ff0000">Autonomic dysreflexia'''
***'''Urine cultures should always be obtained prior to antimicrobial therapy due to the increased risk of nosocomial and multidrug-resistant microorganisms'''
**'''<span style="color:#ff0000">Management'''
***'''7-day course of antimicrobials is recommended for patients with prompt clinical response and 10–14 days for those with significant infection or a delayed response'''
***'''<span style="color:#ff0000">Prevention of UTI''' 
****'''<span style="color:#ff0000">Bladder management'''
***** '''<span style="color:#ff0000">When possible, CIC should be used over other methods'''
****** '''Risk of UTI: Transurethral indwelling catheterization carries >5x risk of recurrent UTIs when compared to suprapubic catheterization and CIC'''. '''Risk of UTI comparable between suprapubic, condom catheter, and CIC.'''
******* '''Condom catheters are effective and safe in select NLUTD patients''' (low PVRs and bladder storage pressures) '''but are significantly associated with Pseudomonas and Klebsiella bacteriuria and an incidence of UTI comparable to CIC'''.
****** Risk of stones: CIC and condom catheter lower risk than indwelling transurethral or suprapubic
***** <span style="color:#ff0000">'''Indwelling catheters should be changed every 2–4 weeks, with monthly being the most common interval'''
**** '''Antimicrobial prophylaxis'''
***** '''Routine antimicrobial prophylaxis for NLUTD UTI is not recommended for most patients'''
***'''<span style="color:#ff0000">Screening and treatment of asymptomatic bacteriuria in persons with NLUTD should be avoided''' as it promotes microbe resistance and can increase the likelihood of symptomatic UTI
****Exceptions to treat asymptomatic bacteriuria include pregnancy and prior to urological interventions where mucosal bleeding is expected

=== Ureteric obstruction ===
* In some cases, high storage pressure results in prolonged compression of the ureteric orifices, leading to obstructed urine outlet during a prolonged period and, consequently, renal damage.

=== Incontinence and urethral damage ===
* '''<span style="color:#ff0000">Urinary incontinence is commonly observed in patients with neurogenic bladder'''
* '''<span style="color:#ff0000">Freedom from indwelling catheters is a priority in the management of neurogenic bladder'''
* Reports on urethral complications from indwelling catheters are scarce, but more common than for patients on CIC
* '''<span style="color:#ff0000">Complications related to an indwelling catheter include:'''
** '''<span style="color:#ff0000">Males:''' 
***'''<span style="color:#ff0000">Urethral strictures'''
***'''<span style="color:#ff0000">False passages'''
***'''<span style="color:#ff0000">Diverticuli'''
***'''<span style="color:#ff0000">Periurethral abscesses'''
***'''<span style="color:#ff0000">Urethrocutaneous fistula'''
***'''<span style="color:#ff0000">Iatrogenic traumatic hypospadias'''
** '''<span style="color:#ff0000">Females:''' 
***'''<span style="color:#ff0000">Urethral dilation'''
***'''<span style="color:#ff0000">Urethral erosion'''
***'''<span style="color:#ff0000">Urethral destruction'''
** '''<span style="color:#ff0000">Potentially serious secondary consequences, such osteitis pubis or non-healing decubiti ulcers can occur from continued urinary leakage'''
* '''Urethral urinary leakage (catheter bypassing) should be addressed by (3):'''
# '''Ruling out bladder stones and infection'''
# '''Avoiding increasing the catheter size'''
# '''Aggressively treating with oral medications or onabotulinumtoxinA injections'''
* '''Patients with indwelling urethral catheters should be offered conversion to a suprapubic catheter in the setting of significant urethral damage and ideally before the urethra has been irreversibly damaged and there is a risk of stress incontinence.'''
* '''Sexuality is adversely affected'''. Side effects from medications and surgeries to treat urinary incontinence may also secondarily cause sexual dysfunction

=== Upper urinary tract deterioration (UUTD) ===
* CKD rates vary from 0.6–3.3% for MS, 1.3–5.6% for SCI, and up to 8% for SB patients, which is higher than that of the general population
* The pathophysiology of CKD in neurogenic bladder is not well-understood
* '''<span style="color:#ff0000">Potential risk factors for UUTD in NLUTD (5):'''
*# '''<span style="color:#ff0000">Bladder outlet obstruction'''
*# '''<span style="color:#ff0000">Ureteric obstruction'''
*# '''<span style="color:#ff0000">UTIs'''
*# '''<span style="color:#ff0000">Stones'''
*# '''<span style="color:#ff0000">Persistent high intravesical pressures (most important)'''
*#* '''High pressures could be from NDO, poor bladder compliance, DSD, ureteric obstruction,''' or a combination, and can '''cause subsequent VUR and UUTD'''.
*#** VUR may appear as hydroureteronephrosis on imaging.
*#* '''Symptoms of high intravesical pressure''' (e.g., leakage between CIC) '''are rarely present and UDS are required to properly identify it'''
*#* '''<span style="color:#ff0000">Since VUR and hydroureteronephrosis may be manifestations of high bladder pressures in neurogenic bladder, treatment should focus first on ensuring low storage pressure.'''
*#** '''<span style="color:#ff0000">Anti-reflux surgery or double-J ureteral stenting should be avoided in these cases.'''
* '''<span style="color:#ff0000">CIC is superior to chronic suprapubic or urethral catheterization for preserving bladder compliance'''
** Despite the fact that patients with a chronic indwelling catheter have an empty bladder most the time, they still warrant follow-up for urological complications and hydronephrosis
* Overall, patients at higher risk of UUTD are SB, suprasacral SCI, and men with MS. Clinically stable MS patients have lower rates of UUTD
* '''Lifelong upper tract surveillance of UUTD is recommended'''
** Renal function decline can occur up to 45 years after injury