Page 5 - Diagnosis, management, and surveillance of neurogenic lower urinary tract dysfunction – Full text

Guideline: Neurogenic bladder

Table 2. Indicators of NLUTD patient characteristics
potentially at higher risk of urological morbidity
High-risk diagnoses/features Recommendations
Etiology of SCI, spina bifida, advanced MS
neurogenic – When referred a new patient with neurogen-
bladder
Bladder Valsalva/crede/reflexive bladder emptying, ic bladder, a focused history and physical
management indwelling catheter exam, relevant to the neurogenic condition,
method SCI patients with autonomic dysreflexia should be performed (GOR A, LOE expert
associated with bladder function opinion).
Urodynamics DSD, NDO*, impaired compliance (<20 mL/ – All patients with NLUTD should have a uri-
cmH O), DLPP >40 cmH O), vesico-ureteral reflux
2 2 nalysis and PVR as part of their initial evalu-
Renal-bladder New-onset/worsening hydronephrosis, stone ation (GOR B, LOE 3).
imaging disease, renal atrophy/scarring – After a SCI, patients should have a baseline
Abnormal bladder morphology
Renal function New-onset/worsening renal insufficiency urological assessment within six months of
*The exact characteristics of NDO that are most concerning for renal dysfunction are SCI, or earlier if clinical concerns exist (GOR
not clearly defined. High-risk NDO should be interpreted based on the volume at onset, A, LOE 2).
duration, peak pressure, and associated incontinence. These urodynamic findings should – Patients with SCI, SB, or advanced MS should
be interpreted in the context of the normal voiding habits of the patient. DLPP: detrusor
leak point pressure; DSD: detrusor-sphincter dyssynergia; MS: multiple sclerosis; NDO: have a baseline UDS, renal ultrasound, and
neurogenic detrusor overactivity; NLUTD: neurogenic lower urinary tract dysfunction; SCI: measurement of renal function. Selected
spinal cord injury.
patients with NLUTD due to other diagno-
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there is suspicion of a bladder tumour. Patients with NLUTD ses may undergo these investigations when
and bladder cancer may present late due to hematuria being referred for specific urological concerns
attributed to catheter usage and atypical presentations, such (GOR A, LOE 3).
as frequent UTIs, urethral discharge, or abdominal mass. A – The treating clinician should identify patients
recent systematic review suggests that urine cytology outper- as either being high-, moderate-, or low-risk,
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forms cystoscopy in select populations. offer the patient appropriate initial therapy,
and consider a urological surveillance pro-
Summary gram as outlined below (GOR B, LOE 3).

The initial history, physical exam, and investigations serve to
identify high-risk features in patients with SCI, SB, or more
advanced MS patients (Table 2). Assignment of risk is based in urological prevention and management to improve renal
on relevant abnormalities within one of five domains; two are prognosis in the last decades. Historically, the mortality rate
determined from the patient history (etiology of NLUTD and due to renal insufficiency in SCI patients was as high as 50%
bladder management) and three are determined based on the in the 1960s and dropped to less than 3% currently. In con-
initial investigations (UDS, renal imaging, and renal function). temporary series, reported rates of chronic kidney disease
Among patients with NLUTD due to other etiologies (or (CKD) vary from 0.6–3.3% 44,47 for MS, 1.3–5.6% 47,48 for SCI,
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early stage MS), the majority can be managed with history, and up to 8% for MMC patients, which is higher than that
physical exam, urinalysis, and PVR (Fig. 2). The subset of of the general population. 50,51
these patients with a clinically significant PVR, bothersome In terms or risk factors for CKD, several studies have inves-
incontinence, frequent UTIs, need for catheters as part of tigated the prognostic value of urodynamic parameters on
their bladder management, known high-risk features on UDS, renal function deterioration. In 1981, McGuire et al stud-
renal imaging and renal function testing, or those consider- ied 42 myelodysplastic children followed for a mean of 7.1
ing more invasive management options may require UDS, years and reported that higher intravesical pressure (DLPP >40
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renal-bladder imaging, and renal function measurement. cmH O) was associated with VUR and ureteral dilatation.
2
In 1989, another groundbreaking study from Ghoniem et al
Genitourinary sequelae of NLUTD studied 32 children with MMC and noted that low bladder
compliance on UDS predicted risk of upper urinary tract
deterioration (UUTD). 53
Risk of upper urinary tract deterioration Weld et al studied 316 SCI patients over 18.3 years and
observed that low bladder compliance (<12.5 mL/cmH O)
2
Upper urinary tract preservation is a priority when managing was associated with VUR, radiographic upper tract abnor-VUR, radiographic upper tract abnor-
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patients with NLUTD. Remarkable progress has been made mality, pyelonephritis, and upper tract stones. In a retro-

CUAJ • June 2019 • Volume 13, Issue 6 E161