Neurogenic Lower Urinary Tract Dysfunction

Question 1

What history must you ask for a patient with neurogenic bladder?

Answer 1

1. Neurologic
2. Voiding
3. CIC?
4. Sexual Fxn
5. Bowel Fxn
6. PMH
7. PSH
8. Other urologic issues: stones?
9. Functional limitations

Question 2

What physical must you perform for a patient with neurogenic bladder?

Answer 2

1. Dexterity and upper extremity functionality
2. Abdominal exam
3. Pelvic exam - exam tonicity of pelvic muscles
4. Vaginal exam if female
5. Genitalia exam
6. DRE
7. General mental status
8. Skin integrity

Question 3

What other labs/diagnostics do you want?

Answer 3

UA, PVR

Optional: bladder diary, uroflow, pad test

Question 4

What makes a patient low risk?

Answer 4

Generally a suprapontine lesion (Parkinson’s, TBI, CP, etc), or below cord injury (pelvic surgery), in a patient with normal PVR (spontaneous voiding).

Must also have no rUTI and other GU issues (stones, upper tract scarring)

Question 5

What is the follow up on a low risk patient?

Answer 5

No follow up indicated, DO NOT NEED RBUS, UDS. re-evaluate if new issue

Question 6

What makes a patient an unknown risk?

Answer 6

supra sacral lesion (SCI, MS, transverse myelitis), or any lesion w/ GU issue / LUTS

Question 7

What work up do we need in an unknown risk patient?

Answer 7

Upper tract, serum Cr, + UDS.
NO CYSTO.

Question 8

When should a recent neurologic episode patient be evaluated - spinal shock?

Answer 8

Minimum six months from event. Can take up to 1-2 years before urinary symptoms clarify themselves.

Question 9

What are symptoms of AD?

Answer 9

headache, sweating, nasal congestion, flushing

Question 10

What are some systemic signs of AD?

Answer 10

reflex bradycardia and hypertension

Question 11

How to treat AD?

Answer 11

1. Remove stimulating issue (drain bladder, take out rectal tube). Sit them upright.
2. 2% nitroglycerin paste at level above lesion on chest / skin
3. Escalate care

Question 12

What is a medium risk patient?

Answer 12

Imaging and renal fin are normal, but PVR is elevated and/or UDS demonstrates retention, BOO, or DO w/ incomplete emptying

Question 13

What is surveillance for medium risk?

Answer 13

1. annual H&P
2. annual serum Cr
3. 1-2 year upper tract imaging
4. Repeat UDS only with NEW symptoms

Question 14

What is a high risk patient?

Answer 14

A patient that has abnormal unstable imaging (hydro scarring, stones, renal atrophy), and/or poor renal fxn, and/or UDS showing poor compliance, increase storage PDet, DSD, or VUR

Question 15

What is surveillance for high risk?

Answer 15

1. Annual HP
2. Serum Cr
3. Upper tract imaging

NO CYSTO.
UDS as needed

Question 16

Is surveillance cystoscopy required in a patient who has a chronic indwelling catheter?

Answer 16

No.

Question 17

What should you be concerned about in a patient with chronic indwelling catheter?

Answer 17

Stone formation - need RBUS annually

Question 18

Do you need to follow U/A in asymptomatic neurogenic patients?

Answer 18

NO

Question 19

If a neurogenic patient has a fUTI, when do you order imaging?

Answer 19

If doesn’t respond to Abe, or if medium/high risk and due for imaging

Question 20

What are non-surgical options for a NLUTD patient?

Answer 20

1. PFPT - especially in MS and CVA patients
2. pharmacological
3. intravesical botox
4. can consider alpha blockers as well

Question 21

What are some options for patients who CIC, and have recurrent UTI?

Answer 21

1. can consider prophylactic antibiotics
2. can consider bladder instillations - gentamicin, acetic acid, polymyxin, saline

Question 22

In which patient is a SNM not recommended for?

Answer 22

SCI and spina bifida patients

Question 23

For an ileovesicostomy, what must the patient characteristic be?

Answer 23

Continent, unwilling to do urethral CIC

Question 24

When bowel is used, what is the surveillance?

Answer 24

annual HP, BMP, upper tract imaging
cystoscopy is PRN - when has gross hematuria or rUTI

Question 25

What are contraindications to a continent bladder creation?

Answer 25

1. Poor renal fxn 2. Poor dexterity 3. poor compliance

Question 26

What are some potential complications of bladder augment?

Answer 26

spontaneous perforation, electrolyte abnormality, hematuria, stone formation, urge incontinence, malignancy, mucus formation STONE FORMATION IS MOST COMMON

Question 27

What is follow up post bladder augment?

Answer 27

1. Cystogram in three weeks 2. if ureteral reflux surgery performed, then do VCUG 3. Need Renal U/S annually (first one three months in) 4. Serum Cr and other electrolytes

Question 28

Which patients need antibiotics for UDS?

Answer 28

not routinely needed. need to check U/A, and postpone if UTI can give single dose of Bactrim for patients with neurogenic, elevated PVR, cic, immunosuppression, age over 70, urology anatomic abnormalities, recent joint sx

Question 29

Give me script to read UDS

Answer 29

Multichannel UDS - Looking at the filling phase- sensation first noted at... bladder capacity noted at... bladder compliance noted at.... bladder contractions (OAB) noted at.... SUI noted at... Looking at the voiding phase- Qmax - Pdet - Voided volume - PVR - how long it takes any abdominal straining? Can use 8 Cs -compliance, contractions, conscious sedation, continence, capacity -contractility, complete emptying, clinical obstruction

Question 30

Give me ALPP and DLPP definitions.

Answer 30

ALPP < 60 - consideration of ISD

Question 31

What are normal pdet

Answer 31

men - 40-60 women - 10-20

Question 32

What should EMG show?

Answer 32

increased activity as part of guarding during filling phase, and then abrupt removal on voiding phase

Question 33

If spina bifida patient with new onset hydro, what is workup?

Answer 33

UDS, and if poor characteristics, consider MRI to eval for tethered cord