Adult Neurogenic Lower Urinary Tract Dysfunction Flashcards
1
Q
What does the term neurogenic lower urinary tract dysfunction (NLUTD) refer to?
A
Abnormal function of either the bladder, bladder neck, and/or its sphincters related to a neurologic disorder
2
Q
What patient factors may influence decision making for options for neurogenic lower urinary tract dysfunction?
A
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)
3
Q
What should one do at initial evaluation of a patient with neurogenic lower urinary tract dysfunction?
A
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
4
Q
What imaging should be obtained in patients with NLUTD?
A
Imaging:
- -Low risk: NO routine upper tract imaging, renal functional assessment, or urodynamics
- -Unknown risk: upper tract imaging, renal function assessment, and multichannel urodynamics
5
Q
Should clinicians do a cystoscopy in the initial evaluation of NLUTD patients?
A
No
6
Q
Risk Category: Patients with suprapontine lesions (CVA, brain tumor, CVA)
A
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.
7
Q
Risk Category: Lesions distal to the spinal cord
A
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.
8
Q
Risk Category: Suprasacral Spinal Cord Lesion (SCI, MS, Transverse Myelitis)
A
Greatest risk for detrusor overactivity (DO) and detrusor-external sphincter dyssyneria (DESD)
Unknown risk category until UDS, upper tract imaging, assessment of renal function
9
Q
Risk Category: Low Risk NLUTD
A
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
10
Q
Surveillance: Low Risk NLUTD
A
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
11
Q
Risk Category: Unknown-Risk NLUTD
A
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
12
Q
Risk Category: Moderate Risk NLUTD
A
Urodynamics demonstrating urinary retention, BOO, or DO with incomplete bladder emptying
PVR: Elevated
Upper tract imaging: normal
Renal function: normal / stable
13
Q
Surveillance: Moderate Risk NLUTD
A
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
14
Q
Risk Category: High Risk NLUTD
A
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
15
Q
Surveillance: High Risk NLUTD
A
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
16
Q
NLUTD Risk Stratification Flow Chart
A
17
Q
When should you perform workup for acute neurological event resulting in NLUTD?
A
Once the neurological condition has stabilized
18
Q
What is the spinal cord level associated with autonomic dysreflexia?
A
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.
19
Q
What happens in autonomic dysreflexia?
A
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.
20
Q
Autonomic Dysreflexia - when should you monitor, how do you treat?
A
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)
21
Q
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…
A
Re-evaluate and repeat risk stratification
22
Q
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…
A
May perform multichannel urodynamics
23
Q
In the NLUTD patient with concomitant hematuria, recurrent urinary tract infections, or suspected anatomic anomaly (e.g., strictures, false passage), clinicians should…
A
Should perform cystoscopy
24
Q
In NLUTD patients, should clinicians perform screening / surveillance cystoscopy?
A
No
25
Should clinicians perform screening surveillance cystoscopy in NLUTD patients with chronic indwelling catheter?
NO
26
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.
27
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.
28
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.
29
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.
30
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.
31
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.
32
Should clinicians use daily antibiotic prophylaxis in patients with
(1) indwelling catheters?
(2) clean intermittent catheterization without recurrent UTIs?
NO
33
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.
34
CIC or indwelling catheters for NLUTD? (Ideally)
CIC
35
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.
36
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.
37
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
38
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.
39
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.
40
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.
41
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.
42
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.
43
Who with NLUTD cannot get sacral neuromodulation?
Clinicians should not offer sacral neuromodulation to NLUTD patients with spinal cord injury or spina bifida.
44
Who with NLUTD can get sacral neuromodulation?
Clinicians may offer sacral neuromodulation to select NLUTD patients with urgency, frequency, and/or urgency incontinence.
45
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.
46
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.
47
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.
48
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.
49
What kind of testing may be done after sphincterotomy for NLUTD?
Clinicians may perform urodynamics following sphincterotomy to assess outcome.
50
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.\*
51
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.
52
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.
53
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
54
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.
55
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.
56
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
57
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
58
Describe enterocystoplasty:
1. Bivalve bladder
2. Harvest 25-30 segment of ileum at least 15 cm proximal to ileocecal valve
3. Open the anti mesenteric border and fold posterior wall back on itself and sew together using 2-0 absorbable suture
4. Attach ileal patch to dome
5. Place SPT?, drain, Foley
Discuss possible need for CIC
59
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.
60
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.
61
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.
62
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.
63
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.
64
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.
65
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.
66
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.
67
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.
68
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.
69
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.
70
What is the risk of bladder cancer in SCI patients compared to the general population?
The overall risk of bladder cancer in SCI patients is 0.3%, which is higher than the general population but still low.
71
What is the average age of presentation of bladder cancer in NLUTD patients according to a systematic review?
According to a systematic review, the average age of presentation of bladder cancer in NLUTD patients was 56.1 years, and it occurred after a long period of neurological disease (mean: 24.5 years).
72
Why has routine cystoscopy been suggested for NLUTD patients with a higher risk of bladder cancer?
Routine cystoscopy has been suggested for NLUTD patients with a higher risk of bladder cancer as it might be beneficial in the early detection of bladder cancer, reduce overall morbidity and mortality.
73
What is the evidence for the utility of screening cystoscopy in NLUTD patients without hematuria?
Multiple studies have assessed the utility of screening cystoscopy in NLUTD patients without hematuria and found that it leads to over detection of benign lesions and is not useful in the detection of bladder cancer. There is an absence of high-level evidence that supports initial or annual cystoscopic surveillance for bladder cancer in reducing morbidity and mortality in this population.
74
Why are indwelling catheters a risk for complications in NLUTD patients?
Indwelling catheters are a risk for complications in NLUTD patients because they are chronic foreign bodies present in the urinary tract, and their site of entry is inherently at risk for complications. The urethra is at risk for catheter hypospadias in men and dilation of the bladder outlet and urethral loss in women. The catheter itself can cause pressure necrosis of the tissue of the urethra or pubic bone over prolonged periods of time.
75
What is the risk of urethral erosion in NLUTD patients with urethral catheterization?
The risk of urethral erosion in NLUTD patients with urethral catheterization is up to 23%.
76
What is the solution for urethral dilation in women with indwelling catheters?
The solution for urethral dilation in women with indwelling catheters is to investigate the cause of leakage and consider a suprapubic tube to halt further injury. In women with milder urethral dilation, an autologous sling may suffice, but if the urethra is lost, bladder neck closure with suprapubic catheter placement or urinary diversion may be necessary.
77
What are the risks of suprapubic catheterization in NLUTD patients?
Suprapubic catheterization in NLUTD patients can lead to granulation tissue around the catheter site, which can bleed and make tube changes more difficult. However, this can be easily treated with topical silver nitrate application.
78
What should clinicians perform 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. This is a moderate recommendation with evidence level Grade C.
79
Low-Risk
* Suprapontine lesion* (CVA, Parkinson’s, brain tumor,
traumatic brain injury, cerebral palsy) without identified
potentially-related NLUTD complications
* Lesion distal to the spinal cord* (disk 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
HUN, 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 PVR/poor emptying with lesions in these locations, if
so place in Unknown Risk category and continue risk stratification
80
Unknown-Risk
Suprasacral spinal cord lesion (SCI, multiple
sclerosis, transverse myelitis, spinal dysraphism)
* Other neurologic lesions with identified GU
complications potentially related to NLUTD such
as HUN, bladder stones, elevated PVR, recurrent
UTI
* Change in LUTS
81
Moderate-Risk
* Urodynamics demonstrating
urinary retention, BOO, or DO with
incomplete emptying
* PVR: elevated
* Upper tract imaging: normal
* Renal function: normal stable
82
High-Risk (any of these=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, parenchyma loss, staghorn,
large or increased stone burden
* Renal function: abnormal/unstable
83
Surveillance Moderate-Risk
History, examination, and symptom
assessment: annual
* Renal function assessment: annual
* Upper tract imaging q 1-2 years
* UDS: repeat if change in signs
and symptoms, new complications
(e.g., AD, UTIs, stones,) and/or
upper urinary tract or renal function
deterioration
84
Surveillance High-Risk
* History, examination, and symptom
assessment: annual
* Renal function assessment: annual
* Upper tract imaging: annual
* UDS: repeated when clinically indicated
or change in signs and symptoms, new
complications (e.g., AD, UTIs, stones),
and/or upper urinary tract or renal
function deterioration
85
What is the recommendation for NLUTD patients with indwelling catheters who are at risk for upper and lower urinary tract calculi?
In NLUTD patients with indwelling catheters who are at risk for upper and lower urinary tract calculi, clinicians should perform urinary tract imaging every 1-2 years. (Moderate Recommendation; Evidence Level: Grade C)
86
Why are NLUTD patients with indwelling catheters at unique risk for stones?
NLUTD patients with indwelling catheters are at unique risk for stones because of the chronic presence of a foreign body in their urinary tract which increases the risk of UTIs and bacteriuria and can **serve as a nidus for biofilm and crystal formation.**
87
What is the advantage of detecting stones when they are small?
The advantage of detecting stones when they are small is that they can be **easily treated**, such as being irrigated in the clinic or managed with a simple cystolithalopaxy.
88
What is the recommendation for performing surveillance/screening urine testing in asymptomatic NLUTD patients?
Clinicians should not perform surveillance/screening urine testing, including urine culture, in asymptomatic NLUTD patients.
89
What is the rationale for screening asymptomatic NLUTD patients?
The rationale to screen asymptomatic NLUTD patients is to treat those with positive urine cultures with antibiotics, to reduce bacteriuria, and to prevent the development of a future symptomatic UTI.
90
Why is the need for screening in the asymptomatic NLUTD population eliminated?
The need for screening in the asymptomatic NLUTD population is eliminated because the risk of developing a UTI in this patient population appears to be low enough to not justify treatment.
91
What is the overall incidence of symptomatic UTI in asymptomatic NLUTD patients?
The overall incidence of symptomatic UTI in asymptomatic NLUTD patients is less than one per year.
92
What is the concern with antibiotic resistance and need for antibiotic stewardship?
The concern with antibiotic resistance and need for antibiotic stewardship is that avoiding surveillance/screening urine cultures will decrease the likelihood of patients receiving unnecessary courses of antibiotics and developing resistant bacteria.
93
What is the recommendation from the Infectious Disease Society of America (IDSA) 2019 Clinical Practice Guidelines?
The IDSA 2019 Clinical Practice Guidelines strongly recommend against screening asymptomatic persons with SCI or in patients with long-term indwelling catheters, which includes many NLUTD patients.
94
What is the recommendation for treating asymptomatic bacteriuria in patients with NLUTD?
Clinicians should not treat asymptomatic bacteriuria in patients with NLUTD.
95
Why should the unnecessary use of antibiotics be avoided in patients with NLUTD?
Antibiotic resistance is a significant problem in patients with NLUTD, and the unnecessary use of antibiotics, such as for treating asymptomatic bacteriuria, should be avoided at all costs.
96
When is an exception made for treating asymptomatic bacteriuria in NLUTD patients?
An exception is made for pregnant patients and prior to urologic procedures where urothelial disruption or upper tract manipulation is anticipated.
97
What is the recommendation for perioperative antimicrobial treatment in NLUTD patients?
Perioperative antimicrobial treatment or prophylaxis is recommended for contaminated or clean-contaminated procedures to avoid postoperative sepsis/UTI.
98
Why is it important to obtain a urinalysis and urine culture in NLUTD patients with signs and symptoms suggestive of a UTI?
The diagnosis of UTI in NLUTD patients can be challenging due to the altered sensation and changes in bladder management. There are no specific and sensitive signs and symptoms to predict UTI in all patients with NLUTD. Obtaining a urinalysis and urine culture allows for optimal diagnosis and the use of culture-specific antibiotics, especially in patients with NLUTD who may be at risk of harboring resistant organisms.
99
What are the challenges of diagnosing UTI with symptoms alone in NLUTD patients?
Classic UTI symptoms such as dysuria, urgency, and frequency may not be applicable to many patients with NLUTD due to changes in lower urinary tract sensation and altered modes of bladder management. The signs and symptoms of UTI can also be impacted by the specific neurologic disorder, the severity of the disorder, and the degree of altered bladder sensation. There are no signs and symptoms that are adequately specific and sensitive enough to predict the presence of UTI in all patients with NLUTD.
100
What is the importance of obtaining a urine culture in NLUTD patients with signs and symptoms of UTI?
Obtaining a urine culture allows for the treatment of UTI with culture-specific antibiotics and the practice of antibiotic stewardship, especially in patients with NLUTD who may be at greater risk of harboring resistant organisms. It is also important to check prior culture results if empiric antibiotics are to be started in NLUTD patients with signs and symptoms of UTI.
101
What should clinicians do in NLUTD patients with a febrile UTI?
In NLUTD patients with a febrile UTI, clinicians should order upper tract imaging if the patient does not respond appropriately to antibiotic therapy or if the patient is moderate- or high-risk and is not up to date with routine upper tract imaging, regardless of their response to therapy.
102
Why is it important to maintain a high degree of concern when NLUTD patients have a febrile UTI?
NLUTD patients may have a structural or functional abnormality of their lower urinary tract, which can result in a complicated UTI at baseline. In addition, the potential alteration of normal sensation may impact signs and symptoms, such as flank or abdominal pain, that would normally inform the caregiver of a potentially more dangerous condition. Fever remains a warning sign that should not be ignored and may be a sign of issues such as hydronephrosis, pyonephrosis, or renal abscess and/or urinary tract stones.
103
What should clinicians do if a NLUTD patient with a febrile UTI does not respond to appropriate antibiotic therapy?
If a NLUTD patient with a febrile UTI does not respond to appropriate antibiotic therapy, they should undergo evaluation of the upper tract (e.g., US, CT) to evaluate for diagnoses such as stones and hydronephrosis.
104
What is the recommended frequency of upper tract imaging for moderate-risk and high-risk NLUTD patients?
Patients with moderate-risk NLUTD are to have upper tract imaging every one to two years and patients with high-risk NLUTD are to have upper tract imaging annually.
105
What should clinicians do when a NLUTD patient with a suspected urinary tract infection has an indwelling catheter?
Clinicians should obtain the urine culture specimen after changing the catheter and allowing for urine accumulation while plugging the catheter. Urine should not be obtained from the extension tubing or collection bag.
106
What is the recommendation from the IDSA for obtaining urine specimens in patients with suspected UTI and short-term indwelling catheterization?
The IDSA recommends obtaining urine specimens aseptically through the catheter port in patients with short-term indwelling catheterization and suspected UTI. The urine should be obtained from a freshly placed catheter and not from the drainage bag.
107
What is the concern regarding obtaining urine specimens from a chronically placed catheter in patients with UTI?
The concern is that specimens obtained via a chronically placed catheter may not be optimal due to the presence of biofilm and may not accurately assess the urine.
108
What do the studies evaluating placement of a new catheter to obtain urine in patients with chronic indwelling catheters suggest?
The studies suggest that urine from the bladder is more likely to result in urine specimens with a CFU/mL count of less than 105, compared to the catheter specimens. Additionally, the duration of bladder management with an indwelling catheter has an effect on the bacterial counts, with patients with a catheter in place for a longer period of time being more likely to have bacterial counts greater than 105.
109
What is a recurrent UTI in women according to the AUA Guideline?
A recurrent UTI in women is defined as two episodes of acute bacterial cystitis within six months or three episodes within one year.
110
What is the evaluation process for recurrent UTIs in NLUTD patients?
In NLUTD patients with recurrent UTIs, both the upper and lower urinary tracts should be evaluated with imaging and cystoscopy.
111
Why is cystoscopy a necessary part of the evaluation process for recurrent UTIs in NLUTD patients?
The risks of lower urinary tract evaluation via cystoscopy are low, making it a necessary part of the evaluation process for recurrent UTIs in NLUTD patients.
112
Is direct visualization of the ureter recommended for recurrent UTIs in NLUTD patients?
No, direct visualization of the ureter via ureteroscopy is not recommended as the risks outweigh the benefits.
113
Is contrast required for the initial evaluation of recurrent UTIs in NLUTD patients?
No, contrast studies are not required in the initial evaluation of recurrent UTIs in NLUTD patients.
114
What is the purpose of performing urodynamic evaluation in NLUTD patients with recurrent urinary tract infections?
Urodynamic evaluation may be performed in NLUTD patients with recurrent UTIs and unremarkable evaluation of the upper and lower urinary tract to diagnose abnormalities in lower urinary tract function and identify potential causes of recurrent UTIs, such as bladder underperfusion, elevated PVR and VUR, alterations in hydrokinetics, and underlying NLUTD.
115
What is the estimated rate of UTI in NLUTD patients?
The estimated rate of UTI in NLUTD patients is 2.5 episodes of infection per patient per year.
116
What are some of the theories as to why NLUTD patients are at a greater risk of UTI?
Some of the theories for the increased risk of UTI in NLUTD patients include method of bladder management/catheterization, alteration of protective flora, defective glycosaminoglycan layer, impaired immune response, defective apoptosis, bladder ischemia, elevated PVR and VUR, and disturbed hydrokinetics.
117
What is the significance of Lapides' hypothesis in 1979?
Lapides hypothesized in 1979 that reduced blood flow to the bladder is a risk factor for UTI. This theory has indirect evidence to support the potential benefit of UDS in NLUTD patients with recurrent UTIs.
118
What is the potential benefit of onabotulinumtoxinA injection in NLUTD patients with recurrent UTIs?
The potential benefit of onabotulinumtoxinA injection in NLUTD patients with recurrent UTIs is a decrease in UTI incidence, improvement in bladder capacity and incontinence, and reduction in elevated PVR and VUR.
119
What is the significance of UDS evaluation in patients with LUTS attributed to recurrent UTI?
UDS evaluation may be considered in patients with LUTS attributed to recurrent UTI, even if evaluation is not consistent with a true infection, as LUTS may be a sign of underlying NLUTD that would benefit from further evaluation with UDS.
120
Morton et al. 2002 study
A systematic review that evaluated the use of antimicrobial prophylaxis in patients with spinal cord dysfunction. The study concluded that prophylaxis did not significantly decrease symptomatic infections and resulted in a two-fold increase in antimicrobial-resistant bacteria.
121
What is the recommendation for daily antibiotic prophylaxis in NLUTD patients who manage their bladder with clean intermittent catheterization and do not have recurrent UTIs?
The recommendation is not to use daily antibiotic prophylaxis.
122
What is the conclusion of Morton et al.'s systematic review on the use of antibiotic prophylaxis in SCI patients?
The conclusion was that antibiotic prophylaxis did not significantly decrease the rate of symptomatic UTIs and resulted in an approximate 2-fold increase in bacterial resistance.
123
What was the conclusion of the 2012 systematic review on the use of antibiotic prophylaxis in comparison to giving antibiotics when clinically indicated?
The final conclusion was that there was not enough evidence to support the use of prophylactic antibiotics over giving antibiotics when clinically indicated.
124
What was the conclusion of the 2012 systematic review on the use of antibiotic prophylaxis in comparison to giving antibiotics when clinically indicated?
The final conclusion was that there was not enough evidence to support the use of prophylactic antibiotics over giving antibiotics when clinically indicated.
125
What is the recommendation for using daily antibiotic prophylaxis in NLUTD patients who manage their bladder with clean intermittent catheterization and do not have recurrent UTI?
The recommendation is not to use daily antibiotic prophylaxis in these patients.
126
What is unclear about using antibiotic prophylaxis in patients who manage their bladder with CIC and have recurrent UTIs?
It is unclear if antibiotic prophylaxis would be beneficial in these patients.
127
What was the result of the study of women with standard rehabilitation plus pelvic floor muscle training and bladder education compared to those with standard rehabilitation without lower urinary tract elements?
Women who engaged in pelvic floor muscle training showed significantly improved daytime frequency, 24-hour pad test, and pelvic floor strength and endurance compared to the control group, but both groups had comparable QoL scores on the Short Form 36 (SF-36) and the Incontinence Impact Questionnaire (IIQ).
128
What was the result of the study comparing a systematic voiding program (including comprehensive voiding, continence assessment, and bladder training) to a control arm (with support of facilitators to optimize involvement and goal achievement)?
For the primary outcomes of incontinence at 6 and 12 weeks post-stroke, there were no differences between the two groups.
129
What are the two types of drugs that may be recommended to improve bladder storage parameters in NLUTD patients?
Antimuscarinics and beta-3 adrenergic receptor agonists or a combination of both.
130
What type of drug may be recommended to improve voiding parameters in NLUTD patients who spontaneously void?
Alpha-blockers.
131
What is the risk of bias for studies reporting on bladder storage and voiding parameters?
The risk of bias for studies reporting on bladder storage parameters was serious and evidence was downgraded for inconsistency of results and imprecision in the reported outcomes. The risk of bias for studies reporting on voiding parameters was serious and evidence was further downgraded for imprecision.
132
What are the benefits of antimuscarinics in treating NLUTD patients?
Antimuscarinics increase maximum cystometric capacity, decrease detrusor pressure, and may improve urgency and incontinence across diverse NLUTD pathologies.
133
What is the Panel's view on the potential risks of anticholinergic therapy?
The Panel acknowledges and appreciates the potential risks of long-term treatment with anticholinergic agents with regards to cognitive impairment and dementia. The Panel advocates a shared decision-making process with the patient to discuss the benefits of therapy balanced with the data reflecting anticholinergic use and potential cognitive decline or development of dementia.
134
What is the evidence for using alpha-blockers in treating NLUTD patients?
There is emerging evidence for the use of alpha-blockers in treating NLUTD patients, but the evidence is less robust and there is insufficient high-quality evidence for particular medications in specific patient categories over clinically relevant periods of time.
135
What is the evidence for using antimuscarinics in treating NLUTD patients?
There is limited quality evidence for antimuscarinics in treating NLUTD patients due to relatively short follow-up durations, small sample sizes, lack of consideration for clinically important outcomes, and diverse patient categories.
136
What is the effect of solifenacin on PD patients?
The administration of the antimuscarinic solifenacin decreased 24-hour frequency, nocturia, and incontinence episodes in the setting of minor AEs.
137
What is the effect of doxazosin on PD patients?
The administration of the alpha-blocker doxazosin improved maximum flow rate and self-reported urinary symptoms with mild AEs.
138
What are the benefits of intravesical oxybutynin administration?
Intravesical administration of oxybutynin has been shown to increase maximum bladder capacity, decrease maximum detrusor pressure, and increase bladder compliance when chronically administered in patients with neurogenic lower urinary tract dysfunction (NLUTD). Adverse events may occur less frequently with intravesical administration compared to oral formulations. In select patients with NLUTD who are currently performing clean intermittent catheterization (CIC), the use of intravesical oxybutynin may improve UDS storage parameters and decrease incontinence episodes with acceptable tolerability.
139
What is phenoxybenzamine?
Phenoxybenzamine is an alpha blocker. One observational study administered phenoxybenzamine (15 to 30 mg daily) to 43 patients. At six months, fewer than half the patients continued with the medication. In the 21 patients who persisted on active treatment, PVRs were generally reduced. One-quarter of patients discontinued for adverse events (such as severe orthostatic hypotension, severe tachycardia).
140
What was the outcome of the tolterodine crossover trial?
The tolterodine crossover trial compared placebo to tolterodine (4 mg daily) in 14 patients followed for two weeks. The trial found that tolterodine treatment resulted in significantly larger catheterized volumes and reduced incontinence compared to placebo. When patients were allowed to choose their dose of tolterodine or oxybutynin, the drugs exhibited similar efficacy in terms of catheterization volumes, incontinence, and MCC.
141
What is the SONIC trial?
The SONIC trial is a randomized study that compared placebo to oxybutynin immediate-release (15 mg daily), solifenacin 5 mg daily, or solifenacin 10 mg daily in patients with spinal cord injury or multiple sclerosis. The study followed patients for one month.
142
What were the results of the SONIC trial?
The SONIC trial found that all three active treatments (oxybutynin immediate-release, solifenacin 5 mg, and solifenacin 10 mg) increased maximum cystometric capacity (MCC) compared to placebo, with the largest increases seen with oxybutynin IR and solifenacin 10 mg. Significant improvements were also seen in patients receiving active treatment in terms of reduced maximum detrusor pressure, decreased leak point pressure, decreased incontinence episodes, and improved quality of life.
143
What is the recommendation for bladder emptying in patients with NLUTD?
Clinicians should recommend intermittent catheterization rather than indwelling catheterization to facilitate bladder emptying in patients with NLUTD.
144
What are the benefits of hydrophilic catheters?
Hydrophilic catheters may be associated with lower rates of UTI and urethral trauma, specifically among SCI patients.
145
What is the incidence of UTI in patients managed with indwelling catheters?
The highest rates of UTI and recurrent UTI occur in patients managed with transurethral indwelling catheters.
146
What is the incidence of bladder stones in patients managed with different catheter types?
Rates of bladder stone occurrence generally increase as follow-up duration increases; suprapubic catheters are associated with higher rates of bladder stones than intermittent catheterization or urethral catheters.
147
Is there a preferred method of catheterization frequency?
A study randomized patients to two techniques for catheterization frequency and found that volume-dependent catheterization demonstrated significantly lower numbers of catheterizations per day and no UTIs compared to the time-dependent group.
148
Is pre-lubricated or patient-applied lubrication preferred?
A comparison of pre-lubricated and patient-lubricated catheters found that rates of UTI were higher with the patient-lubricated catheters and patients rated the pre-lubricated model as easier to insert and extract, more comfortable, and easier to handle.
149
What was the majority of patients' feedback regarding suprapubic catheterization?What is the recommendation for NLUTD patients who require a chronic indwelling catheter?
The majority of patients reported satisfaction with the SPC (72%) and a preference for the SPC compared to their prior urethral catheter (89%).
150
What was the intraoperative complication rate reported by Ahluwalia et al.?
The intraoperative complication rate was reported at 10% (anesthesia 1.8%, bowel injury 2.3%, catheter malposition 2.7%).
151
What are the additional AEs reported in the follow-up of patients after SPC placement?
The additional AEs reported were surgical site infection, urethral incontinence, urethral fistula, UTI with sepsis, and SPC malfunction.
152
What is the recommendation regarding oral antimicrobial prophylaxis for NLUTD patients who perform clean intermittent catheterization (CIC) with recurrent urinary tract infections (UTIs)?
The recommendation is that clinicians may offer oral antimicrobial prophylaxis to reduce the rate of UTIs following shared decision-making and discussion regarding increased risk of antibiotic resistance. (Conditional Recommendation; Evidence Level: Grade C)
153
What is the evidence for the use of oral antimicrobial prophylaxis for recurrent UTIs in NLUTD patients performing CIC?
The evidence is limited, with a majority of studies being observational studies of limited quality, small sample size, and heterogeneous in terms of protocols and measures. There is limited evidence that antibiotics can reduce the rate of UTIs, but the evidence is contradictory and there is a concern for increased antibiotic resistance.
154
What is the WOCA regimen for oral antimicrobial prophylaxis for recurrent UTIs in NLUTD patients performing CIC?
The WOCA regimen (Weekly Oral Cycling Antibiotic) consists of the alternate administration of two different antibiotics once a week based on prior cultures obtained. The antibiotics used may include amoxicillin, cefixime, fosfomycin-trometamol, nitrofurantoin, and trimethoprim/sulfamethoxazole. Two small observational studies using the WOCA regimen showed a significant reduction in symptomatic and febrile UTIs, reduced hospitalizations, and reduced antibiotic consumption without the emergence of multidrug-resistant bacteria.
155
What are the potential harms of using oral antimicrobial prophylaxis for recurrent UTIs in NLUTD patients performing CIC?
The major concern is the development of antimicrobial resistance in addition to potential side effects of the medication. Studies have demonstrated increased antibiotic resistance for each antibiotic used in the prophylaxis group. Shared decision-making and full discussion of the potential harms related to acquiring an antibiotic-resistant infection should be considered when deciding on antimicrobial prophylaxis for UTI prevention.
156
What is the conclusion of the study by Cox et al. on gentamicin instillation in NLUTD patients managed on self-intermittent catheterization?
In a study by Cox et al., gentamicin instillation was shown to result in fewer symptomatic UTIs, fewer courses of UTI treatment, and less overall oral antibiotic usage in NLUTD patients managed on self-intermittent catheterization. However, caution is still required regarding antibiotic resistance development and adverse events.
157
What is the conclusion of the study by Waites et al. on bladder irrigation in NLUTD patients with asymptomatic bacteriuria?
In a study by Waites et al., there were no statistically significant differences among groups in bacterial load, pyuria, or inflammation when comparing normal saline, 0.25% acetic acid, and neomycin-polymyxin bladder irrigation in NLUTD patients with asymptomatic bacteriuria.
158
What were the results of the studies on cranberry extract and UTIs in NLUTD patients?
The results of the studies on cranberry extract and UTIs in NLUTD patients were consistent across most studies, indicating that there is no evidence to support the use of cranberry extract to reduce the rate of UTIs in NLUTD patients on various forms of catheter management.
159
What are the benefits of using onabotulinumtoxinA in NLUTD patients with spinal cord injury or multiple sclerosis?
The use of onabotulinumtoxinA in NLUTD patients with spinal cord injury or multiple sclerosis improves bladder storage parameters, decreases episodes of incontinence, and improves quality of life measures.
160
: Are there any differences in efficacy between a 200 U dose and a 300 U dose of onabotulinumtoxinA?
There is no difference in efficacy between a 200 U dose and a 300 U dose of onabotulinumtoxinA.
161
What are the most common side effects of using onabotulinumtoxinA in NLUTD patients with spinal cord injury or multiple sclerosis?
The most common side effects reported are urinary tract infections, urinary retention, and the need for patients to start using clean intermittent catheterization.
162
Does efficacy diminish with repeated injections of onabotulinumtoxinA in NLUTD patients with spinal cord injury or multiple sclerosis?
Efficacy does not appear to diminish with repeated injections of onabotulinumtoxinA in most patients.
163
What was the impact of onabotulinumtoxinA on HRQoL in non-catheterizing MS patients?
Improved HRQoL was reported in a randomized controlled trial (RCT) with non-catheterizing multiple sclerosis (MS) patients receiving 100 U onabotulinumtoxinA.
164
What is the rate of UTIs in the onabotulinumtoxinA group compared to the placebo group in non-catheterizing MS patients?
In non-catheterizing multiple sclerosis (MS) patients, the rate of UTIs was 25.8% in the onabotulinumtoxinA group and 6.4% in the placebo group.
165
Injection Location
A meta-analysis of 2 RCTs compared 55 SCI patients receiving onabotulinumtoxinA 300 U injections into the detrusor or submucosa. Both groups improved in terms of number of catheterizations, UI episodes, catheterized volume, MCC, RV, MDP during filling, and bladder compliance at 3 months. No significant differences were found between the groups in clinical and UDS parameters.
166
What is the purpose of offering urethral bulking agents to NLUTD patients with stress urinary incontinence?
Urethral bulking agents are offered to NLUTD patients with stress urinary incontinence as a minimally invasive treatment option with low risk for adverse effects, although the success rates are not high and long-term outcomes are poor.
167
What is the success rate of urethral bulking agents in NLUTD patients with stress urinary incontinence?
According to observational studies, the success rate of urethral bulking agents in NLUTD patients with stress urinary incontinence is modest, with complete symptom resolution reported in 22.2% of patients, at least 50% improvement reported in 22.2% of patients, moderate improvement reported in 22.2% of patients, and no improvement reported in 33.3% of patients.
168
What is the recommendation for NLUTD patients with stress urinary incontinence?
Clinicians should offer slings to select NLUTD patients with stress urinary incontinence and acceptable bladder storage parameters.
169
What should be considered before offering a sling to a NLUTD patient with SUI?
Assessment of bladder storage parameters with UDS should be performed, and the patient should be able to void on their own. The risk of subsequent voiding dysfunction and the possibility of neurogenic disease that may cause future voiding problems should be discussed with the patient.
170
What type of slings should be considered for NLUTD patients?
The Panel recommends using autologous fascia or other biologic grafts instead of synthetic material.
171
What is the success rate of slings for SUI in NLUTD patients?
meta-analysis by Farag et al. reported a success rate of 58% and a failure rate of 22% for slings in patients with SUI and NLUTD.
172
What is the recommendation for offering artificial urinary sphincter to NLUTD patients with stress urinary incontinence?
The recommendation is conditional and the evidence level is Grade C. The statement is based on five observational studies with a very serious risk of bias, and evidence was downgraded for inconsistency of results.
173
What is the recommendation for offering artificial urinary sphincter to NLUTD patients with stress urinary incontinence?
The recommendation is conditional and the evidence level is Grade C. The statement is based on five observational studies with a very serious risk of bias, and evidence was downgraded for inconsistency of results.
174
: What are the benefits of PTNS for NLUTD patients?
PTNS has been shown to offer improvement in daily urgency episodes, weekly incontinence episodes, bladder capacity, voiding volume, post-void residual, urinary frequency, and nocturia in select NLUTD patients, especially those with MS.
175
What is the prognosis and mortality for children with neural tube defects?
1/3 die by 5 years of age
| Another 1/4 die by 40 years of age.
176
What is the most common cause of neurogenic bladder dysfunction in children?
Abnormal development of the spinal cord.
177
When does formation of the spinal cord take place?
days 18 to 35 of gestation
178
What is the incidence of neural tube defects?
0.3-4.5 per 1000 live births.
179
What race is most and least likely to have neural tube defects?
Most likely: hispanics
| Least likely: African Americans
180
What helps prevent neural tube defects?
Folic acid 4 weeks before and during pregnancy.
181
What other malformation is almost always associated with myelomeningocele?
Arnold-Chiari.
182
What is the association between vertebral level and neurologic lesion in myelomeningocele?
The neurologic lesion does not correlate with the vertebral lesion as they may differ by up to 3 levels in either direction.
183
What is the two hit hypothesis for myelomeningocele?
1. The initial failure of the neural tube to form properly.
| 2. Ongoing injury to the neural tube by the intrauterine environment.
184
What is the impact of prnatal closure of myelomeningocele on bladder function?
The literature indicates that prenatal closure of myelomeningocele does not improve bladder functional outcomes. It may improve neuromotor function but increases pregnancy complications.
185
What is the immediate post natal managment of myelomeningocele?
Evaluation should begin as soon as possible.
Renal US
PVR
UA
Urine culture
Cr
Urodynamics when healed from spinal surgery
186
What are the indications for VCUG in neonatal myelomeningocele patients?
Hydronephrosis
Thickened bladder wall
Detrusor overactivity
Poor compliance
Elevated LPP
DSD
187
What should be done if there is an abnormality on renal ultrasound or VUR on VCUG?
Obtain a DMS scan.
188
What proportion of newborns with myelomeningocele have a structural abnormality of the urinary tract?
10%
189
What are the rate bladder contractions, DO, acontractile bladder?
Bladder contractions 63%
50% DO
37% acontractile
190
What are the three categories of LUT dynamics seen in newborns with myelomeningocele?
Synergic 26%
Dyssynergic 37%
Complete denervation 36%
191
Which of the three categories of LUT dysfunction after MMC are associated with upper tract deterioration?
DSD 71%
Complete denervation 23%
Synergic 17%
192
What constitutes early intervention for MMC (myelodysplasia)?
CIC
| Anti-muscarinic therapy.
193
What is the impact of CIC and early intervention on outcomes newborns with MMC (myelodysplasia)?
CIC significantly reduces the rate of UTI, Upper urinary tract deterioation, VUR, and Surgery.
194
For which myelodysplasia patients does early intervention not benefit?
Those that can empty their bladders spontaneously.
195
How can GFR be measured in children with myelodysplasia?
Gold standard: renal scan
Cystatin C
Cr does not accurately reflect GFR in children.
196
What is the impact of spina bifida on kidney size?
Spina bifida is associated with small kidneys. This is thought to be due to hyperhomocysteinemia related to placental vasculopathy.
197
What is the rate of renal dysfunction in children with spina bifida?
30-50%
198
What is the rate of ESRD in children with spina bifida?
18% before puberty
| 15-30% after puberty
199
What is the impact of early intervention with CIC and anti-muscarinics on renal dysfunction and ESRD?
Renal dysfunction decreases from 30-50% to 6%
ESRD decreases from 15-30% to 1.6%
200
What factors are associated with increased risk of renal deterioration?
```
DSD
High detrusor pressure
DO
Hydronephrosis
VUR
Febrile UTI
```
201
What are the sexual differences seen in patients with spina bifida?
50% are dissatisfied with their sex life.
Females reach puberty on average 2 years earlier than normal (10.9-11.4years)
30% of women with spina bifida experience sexual abuse.
202
What is the fertility rate for males and females with spina bifida?
Males: 17-39%
Females: 70-80%
203
Is spina bifida hereditary?
Both males and females with spina bifida have an increased risk of having a child with spina bifida (3.7% if on parent)(15% if both parents)
204
What is the rate of erectile dysfunction in men with myelomeningocele?
75%
205
What treatments are available for men with ED and myelomeningocele?
PDE5i (80% effective)
| Ileoinguinal to dorsal penile nerve graft (experimental)
206
What is the rate of fecal incontinence in patients with spina bifida?
2/3 over age 6.
| 1/3 age 16-25.
207
What is the treatment approach to constipation in patients with spina bifida?
1. High fiber and polyethylene glycol
2. Post prandial toilet regimen (10%)
3. Digital stimulation (16%)
4. Tap water enemas 500ml-1L (42%)
5. Antegrade continence enemas (ACE) (32%)
208
What is the follow up for neurogenic bladder in newborns and toddlers?
US Q 6 months till 2yo
Urodynamics q12months
DMSA if VUR or febrile UTI
209
What are the follow up recommendations for toddlers to adolescents with neurogenic bladder?
US q1-2 years
UDS when neurologic change
DMSA when febrile UTIs
210
What are the follow up recommendations for Adolescents to adults with neurogenic bladder?
US q12 months
UDS when change in symptoms
VCUG with rUTI
211
What is the follow up for adults with neurogenic bladder secondary to spina bifida?
US q 3 years
| UDS with change in symptoms
