CUA: Neurogenic Lower Urinary Tract Dysfunction (2019): Difference between revisions

'''See Original Guideline'''

* '''Neurological conditions commonly associated with LUT dysfunction (3):'''

*# '''Multiple sclerosis (MS)'''

*# '''Spina bifida (SB)/myelomeningocele'''

*# '''Spinal cord injury (SCI)'''

* '''Other causes include:'''

** '''Parkinson’s disease, cerebrovascular accidents, traumatic brain injury, brain or spinal cord tumour, cauda equina syndrome, transverse myelitis, multisystem atrophy, pelvic nerve injury, and diabetes'''

* '''Classified based on whether the primary lesion is (3):'''

*# '''Suprapontine'''

*# '''Spinal (infrapontine-suprasacral)'''

*# '''Sacral/infrasacral'''

|'''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'''

* '''Detrusor sphincter dyssynergia (DSD)'''

* '''Lesions between brainstem and T6 may have autonomic dysreflexia and smooth sphincter dyssynergia'''

|'''Overactive'''

|'''Sacral/infrasacral (below S2)'''

|'''Predominantly voiding symptoms'''

|'''Usually elevated PVR'''

* '''Underactive''' (hypocontractile or acontractile) '''detrusor'''

|'''Normal or underactive'''

|'''Risk group'''

|'''Description'''

|'''High-risk'''

* '''Underlying high-risk disease (SCI, spina bifida, advanced MS) OR select other neurogenic diseases with evidence of significant urological complications or morbidity'''

* '''With any high-risk feature(4):'''

*# '''Bladder management technique: Valsalva/crede/reflexive voiding; or'''

*# '''UDS: Known high-risk features on UDS without confirmation of appropriate attenuation after treatment (DSD, NDO, impaired compliance [<20 ml/cm H2O], DLPP >40 cm H2O, vesico-ureteral reflex); or'''

*# '''Imaging: new/worsening renal imaging (hydronephrosis, atrophy, scarring); or'''

*# '''Renal function: new/worsening renal insufficiency'''

|'''Moderate-risk'''

|'''Low-risk'''

* '''Other indicators of potentially higher risk of urological morbidity in NLUTD patients (3):'''

** '''Imaging demonstrating'''

*** '''Stone disease'''

*** '''Abnormal bladder morphology'''

** '''SCI patients with autonomic dysreflexia associated with bladder dysfunction'''

* '''Patients with SCI, spina bifida, or advanced MS without high-risk features are considered moderate-risk'''

== Genitourinary sequelae of NLUTD ==

* '''SUSU VIU'''

# '''Sepsis'''

#** '''This is a lower than non-neurogenic UTIs, partly explained by the increased incidence of Pseudomonas, Acinetobacter, Enterococcus, and fungi such as Candida'''

#* '''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:'''

##** '''>102 cfu/ml (clean catheterized sample)'''

##** '''>104 cfu/ml (clean voided)'''

## '''Clinical symptoms'''

##* '''Signs and symptoms of UTI in SCI include fever, cloudy urine, malodorous urine, dysuria, urinary incontinence/failure of control or leaking around catheter, increased spasticity, malaise, lethargy or sense of unease, back pain, bladder pain, and autonomic dysreflexia'''

#* '''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

#* '''Urine cultures should always be obtained prior to antimicrobial therapy due to the increased risk of nosocomial and multidrug-resistant microorganisms'''

#* '''A 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'''

#** '''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.'''

#** '''Risk of stones: CIC and condom catheter lower risk than indwelling transurethral or suprapubic'''

#** Indwelling catheters should be changed every 2–4 weeks, with monthly being the most common interval.

# '''Incontinence and urethral damage'''

#* '''Urinary incontinence is commonly observed in patients with neurogenic bladder'''

#* '''Freedom from indwelling catheters is a priority in the management of neurogenic bladder'''

#* '''Complications related to an indwelling catheter include:'''

#** '''Men: urethral strictures, false passages, diverticuli, periurethral abscesses, urethrocutaneous fistula, and iatrogenic traumatic hypospadias'''

#** '''Women: urethral dilation, erosion, and potentially destruction'''

#** '''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'''

# '''Upper urinary tract deterioration (UUTD)'''

== Autonomic dysreflexia ==

* '''Typically occurs in patients with an injury at level T6 or above'''

* '''Caused by an exaggerated sympathetic nervous system response triggered by either a noxious or non-noxious stimulus originating below the level of the SCI'''

* '''Manifests with:'''

*# '''Acute onset hypertension'''

*# '''Reflex bradycardia'''

*# '''Sweating'''

*# '''Headache'''

*# '''Flushing above the level of the spinal cord lesion'''

** '''The normal BP in para and quadriplegics is low, usually 90-110 mmHg systolic. Elevation with autonomic dysreflexia symptoms classically begin with a 20 mmHg rise above baseline, well within normal range for a neurologic intact individual. If BP is > 120 mmHg and patient is symptomatic, presumed autonomic dysreflexia is present'''

* '''Management'''

** '''An emergency in subjects who have had an SCI'''

** '''Initial therapy should focus on the removal of inciting factors (e.g. emptying of the bladder and removal of all urodynamic catheters in an SCI patient experiencing autonomic dysreflexia during UDS)'''

** '''If symptoms persist and systolic pressure remains elevated but < 150 mmHg, then evaluation for and treatment of fecal impaction, the second most common cause of AD after the bladder, is recommended.'''

** '''However, if the systolic pressure remains > 150 mmHg after bladder emptying and catheter removal, then use of a rapid-onset, short-acting antihypertensive is recommended while the cause of AD is investigated.'''

*** '''Nitropaste 2%, applied 0.5-1 inch above the level of the lesion (vasoconstriction occurs below the level of the lesion and may interfere with the drugs absorption) is preferred due to its ability to be wiped free if rebound hypotension occurs. Alternatively, Nitroglycerin 0.4 mg sublingually, are the two first line drugs of choice in the outpatient setting'''

**** '''Must make sure the patient has not used a PDE-5 inhibitor for erectile dysfunction in the past 24 hours,''' due to concern for rebound hypotension.

***** If a sildenafil agent has been used within 24 hours, Captopril 25 mg chewed or given sublingually becomes the drug of choice.

*** Nifedipine used to be recommended as primary treatment or prophylactic agent for AD, however, because of several adverse, rebound hypotensive crisis resulting in stroke or MI after its use, the Joint commission for treatment of High Blood Pressure and National Spinal Cord Injury committees have discouraged its use and it has been banned for treatment or prevention of autonomic dysreflexia in some hospitals.

** If the blood pressure remains elevated and does not respond to oral therapy, I.V. hydralazine is an option; however, BP may be quite labile after its use with both hypotension and/or rebound hypertension and therefore the patient will require hospital admission with further monitoring.

** '''In the outpatient setting, when autonomic dysreflexia is triggered and successfully treated, it is recommended that the patient should be monitored for resumption of hypertension for a minimum of two hours'''. If AD recurs, hospitalization with monitoring for 24 hours is recommended, if not, the patient can be discharged from the outpatient setting.

** Recommendations to prevent autonomic dysreflexia preceding cystoscopy or urodynamic evaluations are to use: terazosin 5 mg, prazosin 1 mg, or tamsulosin 0.8 mg the night before the exam, or alternatively at the time of the exam place Nitropaste 2% .5 inch (if not on sildenafil) or Captopril 25 mg sublingually 10-15 minutes prior to exam.

** Recent data suggests that intravesical injection of onabotulintoxinA decreases the frequency and severity of AD episodes.

* '''Mandatory in all patients (3): history and physical exam, urinalysis, PVR'''

** '''Due to a higher risk of serious sequela from bladder dysfunction, patients with SCI, SB, or advanced MS with specific features should also have (3):'''

**# '''Baseline UDS'''

**# '''Renal ultrasound'''

**# '''Measurement of renal function'''

**#* '''Selected patients with NLUTD due to other diagnoses may undergo these investigations when referred for specific urological concerns such as:'''

**#*# '''Clinically significant PVR'''

**#*# '''Frequent UTI'''

**#*# '''Bothersome incontinence'''

**#*# '''Use of catheters for bladder management'''

**#*# '''Known high-risk features'''

**#*# '''Considering more invasive treatment options'''

* '''History and physical exam'''

** '''History'''

*** '''History of the neurological disease'''

**** SCI: Year and level/completeness of lesion (ASIA level), frequency of autonomic dysreflexia, level of spasticity, mobility/transfers

**** MS: Year and type of MS (primary progressive, secondary progressive, relapsing remitting), mobility level (or Expanded Disability Status Scale)

**** Spina bifida: Type (i.e., ambulatory lipomyelomeningocele), caregiver, VP shunt, latex allergy, prior reconstructive surgery

*** '''Bladder management history'''

**** Use of catheters (CIC, indwelling [size and frequency of changes], condom), crede/straining/reflexive bladder emptying, bladder medications, and prior urological surgery history

*** '''Storage & voiding symptoms'''

**** Storage: frequency, urgency, nocturia, incontinence

**** Voiding: weak stream, intermittency, straining, incomplete emptying

*** '''NLUTD complications'''

**** UTIs (symptoms, culture status, associated sepsis/fever, response to antibiotics/antibiotic resistance, triggers, hospital admissions)

**** Sequela of incontinence (skin breakdown, ulcers, pad usage, bother)

**** Bladder or renal stone disease

**** Catheter complications (urethral loss in women; urethral erosion, false passages, strictures in men, encrustation/sediment)

**** Renal function deterioration (imaging results, renal function)

*** '''Review of relevant systems'''

**** Bowel function

**** Coexisting non-NLUTD dysfunction (prostatic enlargement, stress incontinence)

**** Gross hematuria

**** Gynecological/pregnancy history

**** Genitourinary/pelvic pain

**** Motor abilities (hand function, ability to transfer)

**** Cognitive function

**** Support systems/caregivers

*** '''General components'''

**** Allergies, medications, alcohol/drug use/smoking

** '''Physical exam'''

*** '''Assessment of body habitus, abdominal, genital, and rectal exam'''

*** May include a '''focused screening neurological exam''' (such as lower limb sensory, motor, and reflex function), especially when there is a suspicion of NLUTD without a confirmed neurological disease.

* '''Urinalysis'''

** Rule out infection, microscopic hematuria, and unexpected pyuria or proteinuria

* '''PVR'''

** To address potential UTI risk and overflow incontinence; may prompt screening for upper tract deterioration

** In the non-NLUTD population, a value >300 mL is used to define chronic urinary retention. The need to treat PVR should be based on patient symptoms rather than an absolute number.

* '''Urodynamics'''

** '''Gold standard for evaluating NLUTD and are necessary due to the absence of normal lower urinary tract sensation and the poor ability of symptoms to predict high-risk features.'''

** '''VideoUDS are preferred, as the additional correlation with imaging allows assessment of (3):'''

**# '''VUR'''

**# '''Abnormal bladder morphology'''

**# '''Behaviour of the urinary sphincters during voiding'''

*** The availability of videoUDS is not universal; a voiding cystogram is an acceptable alternative in some cases

** Urodynamic diagnoses, such as neurogenic detrusor overactivity (NDO), impaired compliance, reduced bladder capacity, or a high detrusor leak point pressure (DLPP, defined as the lowest detrusor pressure at which urine leaks from the bladder in the absence of a detrusor contraction or increased abdominal straining) can identify a patient with potentially higher risk of urological complications (such as renal dysfunction, urinary infections, and incontinence).

*** A DLPP of >40 cm H2O has traditionally been cited as the cutoff above which a patient has a high risk of renal deterioration; however, this is based on a historical study of children with SB, and may not be applicable to adult NLUTD.

*** As DLPP increases, so too does the risk of renal dysfunction due to an increased resting pressure in the bladder being transmitted to the kidneys.

*** '''If a high DLPP only occurs at a volume greater than the usual capacity during the normal daily voiding pattern, then this DLPP may not be physiologically relevant.'''

*** A low DLPP maintains low pressure drainage from the kidneys, however, this often results in urinary incontinence.

** '''Other potential UDS findings, such as the duration of the NDO contraction, may also predict renal deterioration.'''

* '''Imaging'''

** Renal and bladder imaging is necessary to identify hydronephrosis (a late but potentially reversible sign of bladder dysfunction in NLUTD), renal/bladder stone disease, abnormal bladder morphology (for example, thickened bladder wall, diverticula), and both renal atrophy and degree of scarring

* '''Renal function'''

** '''Serum creatinine can be used to assess renal function; however, serum creatinine has been criticized as a reliable early marker of renal function in patients with NLUTD, as patients often have muscle atrophy from disuse and denervation.'''

** '''Renography and 24-hour urine creatinine clearance may be preferred to sequentially assess renal function in neurogenic bladder patients'''.

* '''Cystoscopy'''

** Should be reserved for situations where there is a clinical indication to assess either the urethra or bladder (such as suspicion of urethral strictures or false passages, bladder stones, or bladder cancer)

** '''Should be considered for all patients'''

** Allows the patient to self-reflect on their urinary habits and the physician to measure changes over time in a non-invasive manner and interpret urodynamic findings in the context of the patient’s day-to-day urinary patterns.

* '''The timing of this initial evaluation is variable and dependent on the severity of symptoms, underlying risk of serious urological complications, and the etiology of the neurogenic bladder.'''

===== '''Summary: initial investigations and risk stratification for neurogenic lower urinary tract dysfunction (NLUTD) patients''' =====

* '''See Figure 2 from Original Guideline'''

== Management of NLUTD ==

 

* '''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: CIC or condom-catheter preferred'''

*# '''Non-catheter mechanisms'''

*# '''Catheter mechanisms'''

*#* '''Options (3): CIC (preferred), indwelling urethral and suprapubic catheter'''

*#** '''CIC associated with reduced risk of infection, reduced risk of stones, and preservation of bladder compliance compared with indwelling urethral or SP catheter'''

* '''Oral therapy (2): anticholinergics and beta-3 agonists'''

*# '''Anticholinergics''' (with dose-escalation)

*#* '''First-line pharmacological treatment for patients with NLUTD'''

*#* Should be offered to people with urodynamic findings of NDO or those with SCI and symptoms of overactive bladder (OAB)

*#** 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'''

*#* '''Use improves OAB symptoms and NDO, decreases urgency urinary incontinence, and lowers detrusor pressures'''

*#* '''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 therapy'''

*#* '''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 (2): botox and oxybutynin'''

*# '''Botox'''

*#* '''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'''

** '''Indicated 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): bladder augmentation, catherizable channel, external urethral sphincterotomy, bladder neck closure with continent or incontinent channel, incontinent diversion'''

**# '''Bladder augmentation'''

**#* '''Indications (2):'''

**#*# '''Reduced compliance or NDO refractory to all other non-surgical treatments'''

**#*# '''Reduced bladder capacity necessitating an indwelling catheter or CIC to be done too frequently'''

**# '''Catheterizable channels and continent cutaneous urinary diversion'''

**#* '''In cases where urethral catheterization is precluded, a catheterizable channel may be offered''' 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

##* 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