CUA: Neurogenic Lower Urinary Tract Dysfunction (2019): Difference between revisions
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'''See Original Guideline''' | '''See [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6570608/ Original Guideline]''' | ||
== Definitions == | == Definitions == | ||
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#'''<span style="color:#0000ff">U</span><span style="color:#ff0000">pper urinary tract deterioration (UUTD)''' | #'''<span style="color:#0000ff">U</span><span style="color:#ff0000">pper urinary tract deterioration (UUTD)''' | ||
=== | === Infection === | ||
* '''Sepsis''' | * '''Sepsis''' | ||
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**'''<span style="color:#ff0000">Diagnosis and Evaluation''' | **'''<span style="color:#ff0000">Diagnosis and Evaluation''' | ||
***'''The accepted definition of UTI in persons with NLUTD requires the presence of (3):''' | ***'''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''' | ***'''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''' | **'''<span style="color:#ff0000">Management''' | ||
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****'''<span style="color:#ff0000">Bladder management''' | ****'''<span style="color:#ff0000">Bladder management''' | ||
***** '''<span style="color:#ff0000">When possible, CIC should be used over other methods''' | ***** '''<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.''' | ****** '''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'''. | ******* '''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 | ***** <span style="color:#ff0000">'''Indwelling catheters should be changed every 2–4 weeks, with monthly being the most common interval''' | ||
**** '''Antimicrobial prophylaxis''' | **** '''Antimicrobial prophylaxis''' | ||
***** '''Routine antimicrobial prophylaxis for NLUTD UTI is not recommended for most patients''' | ***** '''Routine antimicrobial prophylaxis for NLUTD UTI is not recommended for most patients''' | ||
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=== Other === | === Other === | ||
==== | ==== PVR ==== | ||
* '''To address potential UTI risk and overflow incontinence; may prompt screening for upper tract deterioration''' | * '''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. | * 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.''' | *'''The need to treat PVR should be based on patient symptoms rather than an absolute number.''' | ||
==== | ==== Urodynamics ==== | ||
* '''<span style="color:#ff0000">Gold standard for evaluating NLUTD''' | * '''<span style="color:#ff0000">Gold standard for evaluating NLUTD''' | ||
*'''<span style="color:#ff0000">Necessary due to the absence of normal lower urinary tract sensation and the poor ability of symptoms to predict high-risk features.''' | *'''<span style="color:#ff0000">Necessary due to the absence of normal lower urinary tract sensation and the poor ability of symptoms to predict high-risk features.''' | ||
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*#** A low DLPP maintains low pressure drainage from the kidneys, however, this often results in urinary incontinence. | *#** A low DLPP maintains low pressure drainage from the kidneys, however, this often results in urinary incontinence. | ||
==== | ==== Voiding diaries ==== | ||
* '''Should be considered for all patients''' | * '''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. | * 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. | ||
==== | ==== Validated questionnaires ==== | ||
* '''Optional''' | * '''Optional''' | ||
*Generally used for research purposes in the NLUTD population | *Generally used for research purposes in the NLUTD population | ||
==== 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 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) | ||
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=== Oral therapy === | === Oral therapy === | ||
==== | ==== Options (2): ==== | ||
*'''<span style="color:#ff0000">Anticholinergics''' | *'''<span style="color:#ff0000">Anticholinergics''' | ||
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=== Surgical management of LUTD === | === 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 | *# 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 | *# 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) | *# Preventing the adverse effects of incontinence (e.g., dermatitis) | ||
*# Improving QoL by relieving bothersome symptoms of OAB and incontinence. | *# 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 | |||
== Surveillance studies for NLUTD patients in the community setting == | == Surveillance studies for NLUTD patients in the community setting == | ||