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
In NLUTD patients, should clinicians perform screening / surveillance cystoscopy?
No
Should clinicians perform screening surveillance cystoscopy in NLUTD patients with chronic indwelling catheter?
NO
In NLUTD patients with indwelling catheters…
In NLUTD patients with a chronic indwelling catheter, clinicians should not perform screening/surveillance cystoscopy. (Strong Recommendation; Evidence Level: Grade B)
In NLUTD patients with indwelling catheters, clinicians should perform interval physical examination of the catheter and the catheter site (suprapubic or urethral).
In NLUTD patients with indwelling catheters who are at risk for upper and lower urinary tract calculi (e.g., patients with spinal cord injury, recurrent urinary tract infection, immobilization, hypercalcuria) clinicians should perform urinary tract imaging every 1-2 years.
UTI in asymptomatic NLUTD patients
In asymptomatic NLUTD patients, clinicians should not perform surveillance/screening urine testing, including urine culture.
Clinicians should not treat asymptomatic bacteriuria in patients with NLUTD.
In NLUTD patients with signs and symptoms of a UTI
In NLUTD patients with signs and symptoms suggestive of a urinary tract infection, clinicians should obtain a urinalysis and urine culture.
In NLUTD patients with a febrile urinary tract infection, clinicians should order upper tract imaging if:
a. The patient does not respond appropriately to antibiotic therapy.
b. The patient is moderate- or high-risk and is not up to date with routine upper tract imaging, regardless of
their response to therapy.
In NLUTD patients with a suspected urinary tract infection and an indwelling catheter, what should you do with the catheter? How do you collect the urine?
In NLUTD patients with a suspected urinary tract infection and an indwelling catheter, clinicians should obtain the urine culture specimen after changing the catheter and after allowing for urine accumulation while plugging the catheter. Urine should not be obtained from the extension tubing or collection bag.
In NLUTD patients with recurrent urinary tract infections…
In NLUTD patients with recurrent urinary tract infections, clinicians should evaluate the upper and lower urinary tracts with imaging and cystoscopy.
In NLUTD patients with recurrent urinary tract infections and an unremarkable evaluation of the upper and lower urinary tract, clinicians may perform urodynamic evaluation.
Should clinicians use daily antibiotic prophylaxis in patients with
(1) indwelling catheters?
(2) clean intermittent catheterization without recurrent UTIs?
NO
What should clinicians recommend for NLUTD in terms of non-surgical treatment?
Pelvic floor muscle training for appropriately selected patients with NLUTD, particularly those with multiple sclerosis or cerebrovascular accident, to improve urinary symptoms and quality of life measures.
Antimuscarinics or beta-3 adrenergic receptor agonists, or a combination of both, to improve bladder storage parameters in NLUTD patients.
Alpha-blockers to improve voiding parameters in NLUTD patients who spontaneously void.
CIC or indwelling catheters for NLUTD? (Ideally)
CIC
What is better for a NLUTD who needs a chronic catheter - foley or SPT?
For appropriately selected NLUTD patients who require a chronic indwelling catheter, clinicians should recommend suprapubic catheterization over an indwelling urethral catheter.
In NLUTD patients who perform clean intermittent catheterization with recurrent urinary tract infection…
In NLUTD patients who perform clean intermittent catheterization with recurrent urinary tract infection:
- Clinicians may offer oral antimicrobial prophylaxis to reduce the rate of urinary tract infections following shared decision- making and discussion regarding increased risk of antibiotic resistance.
- Clinicians may offer bladder instillations to reduce the rate of urinary tract infections.
- Cousel that cranberry extract has not been demonstrated to reduce the rate of urinary tract infections.
In NLUTD patients with spinal cord injury or multiple sclerosis refractory to oral medications, what should a clinician offer?
Clnicians SHOULD recommend onabotulinumtoxinA to improve bladder storage parameters, decrease episodes of incontinence, and improve quality of life measures
In NLUTD patients, other than those with spinal cord injury and multiple sclerosis, who are refractory to oral medications, what MAY a clinician offer?
Clinicians may offer onabotulinumtoxinA to improve bladder storage parameters, decrease episodes of incontinence, and improve quality of life measures.
What must you discuss before giving botox?
In NLUTD patients who spontaneously void, clinicians must discuss the specific risks of urinary retention and the potential need for intermittent catheterization prior to selecting botulinum toxin therapy.
When should you offer sphincterotomy in NLUTD?
Clinicians may offer sphincterotomy to facilitate emptying in appropriately selected male patients with NLUT but must counsel them of the high-risk of failure or potential need for additional treatment or surgery.
What surgical options can be offered to patients with NLUTD?
Sphincterotomy, urethral bulking, slings, AUS, bladder neck closure and concomitant bladder drainage methods
Clinicians may offer sphincterotomy to facilitate emptying in appropriately selected male patients with NLUT but must counsel them of the high-risk of failure or potential need for additional treatment or surgery.
Clinicians may offer urethral bulking agents to NLUTD patients with stress urinary incontinence but must counsel them that efficacy is modest and cure is rare.
Clinicians should offer slings to select NLUTD patients with stress urinary incontinence and acceptable bladder storage parameters.
Clinicians may offer artificial urinary sphincter to select NLUTD patients with stress urinary incontinence and acceptable bladder storage parameters.
After a thorough discussion of risks, benefits, and alternatives, clinicians may offer bladder neck closure and concomitant bladder drainage methods to select patients with NLUTD and refractory stress urinary incontinence.
When can you offer tibial nerve stimulation to NLUTD patients?
Clinicians may offer posterior tibial nerve stimulation to select *spontaneous voiding* NLUTD patients with urgency, frequency, and/or urgency incontinence.
Who with NLUTD cannot get sacral neuromodulation?
Clinicians should not offer sacral neuromodulation to NLUTD patients with spinal cord injury or spina bifida.
Who with NLUTD can get sacral neuromodulation?
Clinicians may offer sacral neuromodulation to select NLUTD patients with urgency, frequency, and/or urgency incontinence.
Who with NLUTD can get augmentation cystoplasty?
When would you add a continent catheterizable channel?
Clinicians may offer augmentation cystoplasty to select NLUTD patients who are refractory to, or intolerant of, less invasive therapies for detrusor overactivity and/or poor bladder compliance.
Clinicians may offer continent cathererizable channels, with or without augmentation, to select NLUTD patients to facilitate catheterization.
Clinicians may offer ileovesicostomy to select patients with NLUTD and must counsel them on the risks, benefits, alternatives, and the high-risk of needing additional treatment or surgery.
Who should be offered a urinary diversion with NLUTD?
Clinicians should offer urinary diversion to NLUTD patients in whom other options have failed, or are inappropriate, to improve long-term quality of life.
When should urodynamics be repeated in patient with impaired storage parameters and/or voiding that place their upper tracts at risk?
In NLUTD patients with impaired storage parameters and/or voiding that place their upper tracts at risk, clinicians should repeat urodynamic studies at an appropriate interval following treatment.
In NLUTD patients with impaired storage parameters that place their upper tracts at risk and are refractory to therapy, clinicians should offer additional treatment.
In NLUTD patients who have undergone lower urinary tract reconstruction incorporating a bowel segment(s), the clinician should assess the patient with what, and how frequently?
In NLUTD patients who have undergone lower urinary tract reconstruction incorporating a bowel segment(s), the clinician should assess the patient annually with:
a. focused history, physical exam, and symptom assessment.
b. basic metabolic panel.
c. urinary tract imaging.
What kind of testing may be done after sphincterotomy for NLUTD?
Clinicians may perform urodynamics following sphincterotomy to assess outcome.
In NLUTD patients who have undergone lower urinary tract reconstruction utilizing bowel, and who also develop gross hematuria or symptomatic recurrent urinary tract infection…
In NLUTD patients who have undergone lower urinary tract reconstruction utilizing bowel, and who also develop gross hematuria or symptomatic recurrent urinary tract infection, clinicians should perform *cystoscopy.*
In patients with moderate-risk NLUTD and stable urinary signs and symptoms, the clinician should assess the patient with:
In patients with moderate-risk NLUTD and stable urinary signs and symptoms, the clinician should assess the patient with:
a. annual focused history, physical exam, and symptom assessment.
b. annual renal function assessment.
c. upper tract imaging every 1-2 years.
In patients with high-risk NLUTD and stable urinary signs and symptoms, the clinician should assess the patient with:
In patients with high-risk NLUTD and stable urinary signs and symptoms, the clinician should assess the patient with:
a. annual focused history, physical exam, and symptom assessment.
b. annual renal function assessment.
c. annual upper tract imaging.
d. multichannel urodynamic studies, with or without fluoroscopy, which may be repeated when clinically
indicated.
History to obtain from a patient with NLUTD
Characterization of the neurological condition resulting in NLUTD: time of onset, severity, progression, prognosis, potential for recovery, disability, presence of ventriculoperitoneal shunt
Lower urinary tract management: voluntary void- ing, CIC, indwelling catheter
LUTS: frequency, urgency, hesitancy, straining, nocturia, nocturnal enuresis, pad use/diapers, pain
Catheterization use: type, frequency, size, pain
Incontinence: stress, urge, insensate
Sexual function and desire
Fertility function and desire (gynecologic/ reproductive history)
Bowel function and regimen (if appropriate)
Skin integrity: decubitus ulcers
AD: presence, triggers, and typical symptoms
Renal function tests and imaging
Current and prior assessments and management related to urinary, sexual, infertility, and bowel is- sues:
Behavioral, medical, and surgical
Efficacy: success, failure, limitations
Adverse events (AE) and complications
Complications: stones, UTIs, catheter issues (e.g., encrustations, catheter clogging), skin breakdown
Functional limitations: lifestyle, mobility, hand func- tion
Socio-economic situation and/or support (home) environment
Assessment of goals of evaluation and therapy in the context of the neurological condition (e.g., SCI versus dementia)
Co-existent genitourinary (GU) conditions, prior GU surgery (e.g., benign prostatic hyperplasia (BPH), urethral stricture, fistula, SUI)
Past medical history
Past surgical history
Medications
Allergies (including latex allergy)
Lifestyle factors: smoking, alcohol, or addictive drug use
Physical exam for a patient with NLUTD
General mental status, cognition
Assessment of mobility and upper extremity function
Abdominal and flank exam
Pelvic and vaginal examination in females
Genital examination and digital rectal exam
Rectal: tone, masses, reflexes, prostate assessment (in males)
Skin integrity of pelvis, perineum, buttocks, lower back, and lower extremities
Directed neurological assessment: sensory, motor, spasticity, etc.
Evaluation of bulbocavernosus, anal, and cremasteric reflexes
Tone of anal sphincter and voluntary con- traction of the anal sphincter and pelvic floor muscles
UA (dipstick and/or microscopic) is performed to assess for hematuria, pyuria, glucosuria, proteinuria, and other findings which may prompt further evaluation.
SCI patient OAB meds (general classes)
Administration of alpha-blockers can decrease PVRs and maximum urethral pressure (MUP) and increase MCC and voided volume; most AEs were minor.
Administration of antimuscarinics can increase MCC, RV, voided volume, and compliance and decrease MDP, incontinence episodes, and 24-hour frequency. Use of antimuscarinics in SCI patients may increase PVR how- ever AEs were generally minor.
Administration of the beta-3 agonist mirabegron may increase MCC and compliance, and decrease detrusor pressure, 24-hour frequency, and incontinence episodes with minimal associated AEs.
After APR for rectal surgery, a patient who fails TOVs and cannot void? Preferred mgmt?
likely has bladder dysfunction from injury to the autonomic pelvic plexus resulting in detrusor denervation
CIC if possible for continued “cycling” of bladder
UDS 2-3 mo post operatively (can take up to 6 months to return)
long term consider SPT, catheterizable stoma, non-continent ileovesicostomy
can trial SNM
Describe autoaugmentation:
Dissect detrusor muscle off bladder mucosa
Affix detrusor wings to psoas (care not to injure GF nerve)
Essentially creating large bladder tic
If mucosa sustains holes → repair with absorbable sutures
Place drain and Foley
Describe enterocystoplasty:
- Bivalve bladder
- Harvest 25-30 segment of ileum at least 15 cm proximal to ileocecal valve
- Open the anti mesenteric border and fold posterior wall back on itself and sew together using 2-0 absorbable suture
- Attach ileal patch to dome
- Place SPT?, drain, Foley
Discuss possible need for CIC
Question: What type of NLUTD patients should perform multichannel urodynamics?
Answer: 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.
Question: What is the utility of routine UDS in patients with NLUTD who have stable urinary symptoms and no urological complications?
Answer: The data is mixed, but the data is very consistent that UDS performed for specific symptoms or cause often yield important urodynamic findings that may result in treatment changes.
What kind of UDS findings may result in a change in risk stratification to high-risk?
Concerning features found in UDS such as loss of bladder compliance, high storage pressure, VUR, or worsening DO.
What should clinicians perform in a NLUTD patient with concomitant hematuria, recurrent UTIs, or suspected anatomic anomaly?
In a NLUTD patient with concomitant hematuria, recurrent UTIs, or suspected anatomic anomaly, clinicians should perform cystoscopy.
What is the evidence level of the statement “In the NLUTD patient with concomitant hematuria, recurrent urinary tract infections, or suspected anatomic anomaly (e.g., strictures, false passage), clinicians should perform cystoscopy”?
The statement is supported by a systematic review (Ismail 2018) with a serious risk of bias, and the evidence level is Grade B.
Why is cystoscopy necessary for any patient with painless gross hematuria?
Any patient with painless gross hematuria requires cystoscopy as well as upper tract imaging (i.e., CT urogram or renal US) because the presence of gross hematuria is the only patient factor correlating with bladder cancer in SCI patients.
Why are patients with indwelling catheters or those who perform CIC at risk of urinary tract irritation or catheter trauma?
Patients with indwelling catheters or those who perform CIC are at risk of urinary tract irritation or catheter trauma as the source of bleeding, but this cannot be determined without cystoscopic investigation.
Why is cystoscopy necessary for NLUTD patients with recurrent UTIs?
NLUTD patients with recurrent UTIs can have anatomic defects in the bladder such as foreign bodies or bladder diverticula, which can be diagnosed with cystoscopy.
Why is cystoscopy necessary for NLUTD patients with difficult urethral catheter passage or hematuria with catheterization?
NLUTD patients with difficult urethral catheter passage or hematuria with catheterization can have urethral strictures or a false passage from catheter trauma, particularly in those patients with external sphincter spasm during catheter passage. Cystoscopy can effectively diagnose these conditions and prompt treatment.
Should clinicians perform screening/surveillance cystoscopy in NLUTD patients?
No, clinicians should not perform screening/surveillance cystoscopy in NLUTD patients. This is a strong recommendation with evidence level Grade B.
Should clinicians perform screening/surveillance cystoscopy in NLUTD patients with a chronic indwelling catheter?
No, clinicians should not perform screening/surveillance cystoscopy in NLUTD patients with a chronic indwelling catheter. This is a strong recommendation with evidence level Grade B.
