Page 5 - Diagnosis, management, and surveillance of neurogenic lower urinary tract dysfunction – Executive Summary

Kavanagh et al

Focused history, physical exam, PVR, and UA

SCI, spina bifida, advanced MS Other neurological diseases
All *Selected patients Most

Baseline UDS, renal US, renal function

Optimize bladder
Determine if risk factors are management technique,
present based on: incontinence, urinary
1. Bladder management symptoms, and UTI risk
2. UDS
3. Renal US
4. Renal fuction

High-risk Moderate-risk Low-risk

*Clinically significant PVR
Treatment & Optimization Bothersome incontinence
Frequent UTIs
Use of catheters for bladder management
Known high-risk features
Considering more invasive management options
Fig. 2. Initial investigations and risk stratification for neurogenic lower urinary tract dysfunction (NLUTD) patients. High-risk patients are considered those with
spinal cord injury (SCI), spina bifida, advanced multiple sclerosis (MS), or select other neurogenic diseases with evidence of significant urological complications
or morbidity in addition to: 1) bladder management technique: Valsalva/crede/reflexive voiding; or 2) known high-risk features on urodynamics (UDS) without
confirmation of appropriate attenuation after treatment (detrusor-sphincter dyssynergia [DSD], neurogenic detrusor overactivity [NDO], impaired compliance
(<20 ml/cmH O), detrusor leak point pressure [DLPP] >40 cmH O, vesico-ureteral reflex); or 3) new/worsening renal imaging (hydronephrosis, atrophy, scarring);
2
2
or 4) new/worsening renal insufficiency. Patients with SCI, spina bifida, or advanced MS without high-risk features are considered moderate-risk. PVR: post-void
residual; UA: urinalysis; US: ultrasound; UTI: urinary tract infection.
couraged in most patients due the potential risk of renal - A seven-day course of antimicrobials is recommended
deterioration (GOR B, LOE 3). for NLUTD patients with a UTI and a prompt clinical
- Patients with indwelling urethral catheters should be response; 10–14 days of therapy should be used for
offered conversion to a suprapubic catheter in the set- those with significant infection or a delayed response
ting of significant urethral damage (GOR A, LOE 3). (GOR A, LOE 3).
- In NLUTD, a UTI is defined as bacteriuria with an - When possible, clean intermittent catheterization (CIC)
appropriate colony count for the source of the urinary should be used over other types of catheters to mini-
sample, evidence of pyuria, and relevant signs/symp- mize UTI risk (GOR A, LOE 2).
toms (such as fever, urinary incontinence/failure of - Routine antimicrobial prophylaxis for NLUTD UTI is
control or leaking around catheter, increased spastic- not recommended for most patients (GOR A, LOE I).
ity, malaise, lethargy or sense of unease, cloudy urine,
malodorous urine, back pain, bladder pain, dysuria, Treatment of NLUTD
and autonomic dysreflexia). Cloudy or malodorous
urine should not be relied on in isolation to identify a
clinically relevant UTI (GOR A, LOE 3). Assisted bladder drainage
- Numerous studies clearly demonstrate that screening
and treatment of asymptomatic bacteriuria in persons This is included in the complete online reference (available
with NLUTD should be avoided (aside from pregnancy at cuaj.ca). In summary,
and prior to certain urological interventions), as it pro- - Selection of an assisted bladder drainage method (CIC,
motes microbe resistance and can increase the likeli- urethral or suprapubic catheter) should be individual-
hood of symptomatic UTI (GOR A, LOE 2). ized to the patient’s motor functions, anatomic limita-
- Urine cultures should always be obtained prior to tions, bladder characteristics, prior urological compli-
antimicrobial therapy due to the increased risk of cations, and quality of life (GOR A, LOE 3).
nosocomial and multidrug-resistant microorganisms
(GOR A, LOE 2).

160 CUAJ • June 2019 • Volume 13, Issue 6