Adult Neurogenic Lower Urinary Tract Dysfunction Flashcards
What does the term neurogenic lower urinary tract dysfunction (NLUTD) refer to?
Abnormal function of either the bladder, bladder neck, and/or its sphincters related to a neurologic disorder
What patient factors may influence decision making for options for neurogenic lower urinary tract dysfunction?
Patient’s urologic symptoms and urodynamic findings (if applicable)
Cognition (which can be impacted by the neurologic disorder)
Hand function
Type of neurologic disease (progressive versus stable)
Mobility
Bowel function/management
Social and caregiver support (if needed)
What should one do at initial evaluation of a patient with neurogenic lower urinary tract dysfunction?
Identify the patient as (1) low risk or (2) unknown risk – will require further evaluation to allow for complete risk stratification.
Perform detailed history, physical exam, and urinalysis.
Obtain PVR – if the patient can void.
Optional studies: voiding/catheterization diary, pad test, non-invasive uroflow.
Imaging:
–Low risk: NO routine upper tract imaging, renal functional assessment, or urodynamics
–Unknown risk: upper tract imaging, renal function assessment, and multichannel urodynamics
DO NOT perform routine cystoscopy
What imaging should be obtained in patients with NLUTD?
Imaging:
- -Low risk: NO routine upper tract imaging, renal functional assessment, or urodynamics
- -Unknown risk: upper tract imaging, renal function assessment, and multichannel urodynamics
Should clinicians do a cystoscopy in the initial evaluation of NLUTD patients?
No
Risk Category: Patients with suprapontine lesions (CVA, brain tumor, CVA)
Tend to have detrusor overactivity (DO) with synergistic voiding and low PVRs
They would be placed in the low-risk category
However, elevated PVRs could be seen in certain patients after CVA or in patients with cerebral palsy and pseudodyssynergia; placing them in the moderate-risk category.
Risk Category: Lesions distal to the spinal cord
Tend to have low bladder storage pressures - which would make them low risk
However – poor contractility could result in elevated PVRs and over time loss of bladder compliance can be seen in this patient population as well, another example of how lesion location can cross over into several risk stratification categories.
Risk Category: Suprasacral Spinal Cord Lesion (SCI, MS, Transverse Myelitis)
Greatest risk for detrusor overactivity (DO) and detrusor-external sphincter dyssyneria (DESD)
Unknown risk category until UDS, upper tract imaging, assessment of renal function
Risk Category: Low Risk NLUTD
Suprapontine lesions * (CVA, Parkinson’s, brain tumor, traumatic brain injury, cerebral palsy) without identified potentially related NLUTD complications
Lesions distal to the spinal cord * (Disc disease, pelvic surgery, diabetes) without identified potentially related NLUTD complications
Spontaneously void (no indwelling catheter or CIC)
Low PVR
No other identified potentially related complications such as hydro, bladder stones, elevated PVR, recurrent UTIs
Renal function normal / stable
UDS (if assessed): synergistic voiding
Upper tract imaging (if assessed): normal/stable
Stable LUTS
* Can see elevated PVRs / poor emptying with lesions in these locations if so - place in unknown risk category and continue with risk stratification
Surveillance: Low Risk NLUTD
Not indicated
Re-evaluate and repeat risk stratification if new complications (eg AD, UTIs, stones, and/or upper tract or renal function deteriorating) or change in symptoms
Risk Category: Unknown-Risk NLUTD
Suprasacral spinal cord lesions (SCI, multiple sclerosis, transverse myelitis, spinal dysraphism)
Other neurologic lesions with identified GU complications potentially related to NLUTD such as hydro, bladder stones, elevated PVR, recurrent UTI
Change in LUTS
Risk Category: Moderate Risk NLUTD
Urodynamics demonstrating urinary retention, BOO, or DO with incomplete bladder emptying
PVR: Elevated
Upper tract imaging: normal
Renal function: normal / stable
Surveillance: Moderate Risk NLUTD
Annual history, examination, symptom assessment
Annual renal function assessment
Upper tract imaging q1-2 years
UDS: ONLY repeat if change in signs and symptoms (eg AD, UTIs, Stones) and or upper tract or renal function deterioration
Risk Category: High Risk NLUTD
ANY of these makes the patient high risk!!!
Urodynamics:
- Poor bladder compliance
- Elevated detrusor storage pressures with DO
- DSD
- VUR (if done with fluoroscopy)
Upper tract imaging:
- Hydronephrosis
- New renal scarring
- Parenchymal loss
- Staghorn
- Large or increased stone burden
Renal function: abnormal/unstable
Surveillance: High Risk NLUTD
Annual history, examination, symptom assessment
Annual renal function assessment
Upper tract imaging EVERY year (remember moderate was 1-2 years)
UDS: Repeat if change in signs and symptoms (eg AD, UTIs, Stones) and or upper tract or renal function deterioration
NLUTD Risk Stratification Flow Chart
When should you perform workup for acute neurological event resulting in NLUTD?
Once the neurological condition has stabilized
What is the spinal cord level associated with autonomic dysreflexia?
AD is caused by an aberrant spinal reflex related to the SCI AT OR ABOVE T6.
Cervical and upper thoracic level SCI are at greater risk for AD.
What happens in autonomic dysreflexia?
AD is caused by an aberrant spinal reflex related to the SCI at or above T6.
Bladder distention during cystoscopy and/or UDS enters the spinal cord below the level of injury, this afferent stimulus generates sympathetic overactivity leading to vasoconstriction below the neurologic lesion along with involvement of splanchnic circulation causing vasoconstriction and hypertension.
The excessive *compensatory parasympathetic activity* leads to vasodilation above the level of the lesion and is thought to be responsible for headache, visual disturbances flushing, sweating, and nasal congestion.
The reflex bradycardia is secondary to baroreceptor mediated vagal stimulation.
Bladder distension is the most common trigger factor for AD.
–The distension that can result from urinary retention, catheter blockage, or lower urinary tract procedures accounts for up to 85% of cases of AD.
It is important to note that the second most common trigger factor for AD is bowel distension due to fecal impaction. This can be noticed during placement of the rectal catheter at the time of multichannel UDS. Other potential factors include hemorrhoids, anal fissures, and/or pressure ulcers.
Education of patients, clinicians, caregivers, and family members regarding AD is vital to prevent its occurrence, facilitate its recog- nition, and proceed with treatment in a timely fashion.
Autonomic Dysreflexia - when should you monitor, how do you treat?
During urodynamic testing and/or cystoscopic procedures, clinicians must hemodynamically monitor NLUTD patients at risk for autonomic dysreflexia. (Clinical Principle)
For the NLUTD patient who develops autonomic dysreflexia during urodynamic testing and/or cystoscopic procedures, clinicians must terminate the study, immediately drain the bladder, and continue hemodynamic monitoring. (Clinical Principle)
For the NLUTD patient with ongoing autonomic dysreflexia following bladder drainage, clinicians should initiate pharmacologic management and/or escalate care. (Clinical Principle)
In patients with low-risk NLUTD who present with new onset signs and symptoms, new complications (e.g., autonomic dysreflexia, urinary tract infections, stones), and/or upper tract or renal function deterioration, clinicians should…
Re-evaluate and repeat risk stratification
In patients with moderate- or high-risk NLUTD who experience a change in signs and symptoms, new complications (e.g., autonomic dysreflexia, urinary tract infections, stones), or upper tract or renal function deterioration, clinicians…
May perform multichannel urodynamics
In the NLUTD patient with concomitant hematuria, recurrent urinary tract infections, or suspected anatomic anomaly (e.g., strictures, false passage), clinicians should…
Should perform cystoscopy
