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Evaluation of NMLUTD

Evaluation

• Timing: do not perform urodynamics in acute setting of spinal shock or brain injury, as symptoms and neural pathways may change as injury heals over 6-24mo
• Catheter exam: assess for bladder neck incompetence in women, traumatic hypospadias in men, SPT site bleeding (treat with silver nitrate)
• Prolapse: vaginal (up to 33%) and rectal (up to 32%) seen over 5-6yrs follow up for both genders
• Stones: kidney stones seen in 34-64% SCI patients, bladder stones in up to 23% SCI patients and 8-41% chronic catheter patients
• Urinalysis: not required for regular screening, pyuria and hematuria normal/expected with catheterization
• Cystoscopy: warranted for rUTI, hematuria, or anatomic abnormalities, but screening surveillance not warranted even if chronic catheter (no benefit to bladder cancer cystoscopy screening), consider screening bladder augments
• Renal function: trend creatinine, may be abnormally low compared to non-NMLUTDS, alternatives include Cystatin C and renal scan
• Probability of regaining volitional voiding at 1yr (per ASIA): A (1.7%, no motor/sensory or sacral sparing), B (5.1%, sensory only, no motor below lesion), C (25.9%, 50% muscles less than Grade 3 below lesion), D (76.2%, 50% muscles more than Grade 3 below lesion), E (100% intact motor/sensory)

AUA 2021 Guidelines Risk Recommendations

• Low risk definition: suprapontine lesion, peripheral lesions, spontaneous voiding, low PVR, no hydronephrosis, no bladder stones, no UTI, normal renal function, no DSD (if assessed), stable voiding symptoms
• Unknown risk (determine moderate/high): suprasacral lesion, hydronephrosis, bladder stones, elevated PVR, recurrent UTI, worsening LUTS
• Moderate risk definition: UDS w/ BOO/retention/DO, elevated PVR, normal upper tracts, normal renal function
• High risk definition: UDS w/ poor compliance/elevated pressures w/ DO/DSD/VUR, hydronephrosis, new renal scarring, parenchymal loss, staghorn or increased stone burden, worsening renal function
• Low risk surveillance: not indicated, reassess risk if new symptoms develop
• Moderate risk surveillance: annual H&P + renal function, upper tract imaging q1-2yrs, UDS as needed
• High risk surveillance: annual H&P + renal function + upper tract imaging, UDS as needed
• Surveillance after incorporating bowel: annual H&P, BMP, B12 (if ileum used), and renal US, consider cystoscopy if hematuria develops

Treatment

Treatment goals

• Protect upper tracts: avoid high-pressure bladder that refluxes to upper tracts
• Minimize UTIs: ensure adequate emptying/drainage, avoid unnecessary antibiotics
• Avoid leakage: provide acceptable and realistic urinary drainage, ensure patient/caregiver can perform
• NGB adjuncts: optimize bowel and sexual function

Low-risk patients

• Pelvic floor PT: beneficial in properly selected patients, low risk
• Passive voiding: only viable if low-pressure bladder and minimal outlet resistance, can void into diaper, use valsalva or crede
• Neuromodulation: sacral or posterior tibial, consider for low risk patients with storage symptoms who spontaneously void, not recommended for SCI or spina bifida (response too variable)

Retention

• Catheter: optimizes bladder drainage, can be urethral, suprapubic, or CIC via urethra or catheterizable channel
• Alpha blockers: decreases outlet resistance
• Botox: reduces bladder contractility, can use 200-300U, no specific injection location/pattern, transient effects
• Sphincterotomy: can perform for male patients managing with condom catheter, but high risk of failure and need for repeat procedures

Incontinence

• Anticholinergics and B-3 agonists: reduces detrusor overactivity, decreases leakage between CIC
• Outlet obstruction: manage SUI, can consider bulking agents (low overall efficacy), slings (avoid synthetic if needing CIC), or artificial sphincter
• Bladder neck closure: consider for refractory SUI, may be beneficial with simultaneous augment if poorly compliant or low capacity bladder, fistulization risk up to 25%

End-stage bladder (poor compliance, resistant to more conservative treatments)

• Augment: improves volume to reduce CIC frequency, best option for poorly compliant bladder, complications 15-17%, low risk for bladder cancer (0.6-4.5%)
• Catheterizable channel: recommended for bladder neck closure, urethral strictures, or female patients desiring CIC, stenosis occurs in 4-32%
• Diversion: last-resort for high pressure low volume contracted bladder
• Ileovesicostomy: alternative to augment and diversion if unable to CIC, no need for ureteral anastomosis, potentially reversible
• Simple cystectomy: avoids risk of pyocystis
• Spence procedure: iatrogenic vesicovaginal fistula to prevent pyocystis

Specific management issues

Urinary tract infections

• Difficult to accurately diagnose UTI in patients with catheter use, no clearly sensitive or specific signs
• Screening: not warranted, risks > benefits
• Ideal treatment criteria: bacteruria, suspicious signs/symptoms, and no other infectious source
• Collection: place new catheter, plug to have urine build up, do not collect form tubing or bag
• Imaging indications: persistent fevers despite antibiotics, no recent upper tract imaging in moderate/high risk patients
• "Recurrent" UTI: frequency not defined, perform non-contrast upper tract imaging and cystoscopy to assess for a source, consider UDS if workup otherwise negative
• Prophylaxis: not recommended for indwelling catheters to prevent UTI, not recommended for CIC in absence of rUTI, can consider for CIC with rUTI but risk for increased antibiotic resistance
• Irrigation: can consider saline or antibiotic irrigation or instillation, although unclear benefits

Catheters

• CIC provides lower UTI risk compared to urethral catheter or SPT
• Indwelling catheter (urethra or suprapubic) have same infectious risks
• Suprapubic catheter overall preferred for long-term management, overall low risks for placement and exchange
• Hydrophilic catheters may provide some benefit for UTI and urethral trauma (specific benefits unclear)
• No increased risk for clean catheterization vs sterile catheterization
• Potential benefit to volume-dependent catheterization compared to time-dependent catheterization
• Pre-lubricated tend to be easier and more comfortable

Autonomic Dysreflexia

• Cause: sympathetic response to stimulus if SCI above T6, presents with headache + HTN + bradycardia + flushing/sweating
• Stimuli: bladder/rectal distension, urethral stimulation (catheter, UDS probes)
• Treatments: remove stimulus, apply 1-2 inches of 2% nitroglycerin paste above level of lesion, IV nitroprusside or B-blockers if IV access available, terazosin/prazosin, nifedipine 10mg sublingual (risk of hypotension)
• Prevention: lidocaine gel for clinic procedures, use monitors

Cerebral diseases

Stroke (cerebrovascular accident)

• Urinary incontinence: 32-79% on admission, 25-28% on discharge, 12-19% months later
• Urinary incontinence is ppredictive of poor survival and functional independence (more than depressed consciousness)
• Lenticulocapsular strokes more likely to cause incontinence (52% have incontinence)
• Relationship with fecal incontinence: both present (33%), urinary only (12%), fecal only (8%)
• Insensate incontinence more common (12-58% vs 9-42% sensate)
• Phasic detrusor overactivity is most common post-CVA LUTD - 60-65% have DO, whereas 30-40% have DUA
• Consider UDS prior to BOO surgery to confirm cause of urinary symptoms

Parkinson Disease (PD)

• Caused by dopamine deficiency in nigrostriatal pathway, presents with tremor + rigidity + bradykinesia
• LUTD present in 35-70% - nocturia (86%), frequency (71%), urgency (68%)
• UDS findings: DO most common, true DSD is uncommon, pseudoDSD common due to bradykinesia, DUA uncommon
• Symptoms may be exacerbated by bromocriptine but not other medications
• TURP is okay if PD (not MSA), as striated sphincter acontractility is rare - but get UDS to confirm

Parkinson+ syndromes

• Diagnoses: multiple system atrophy (MSA), progressive supranuclear palsy (PSP), corticobasilar ganglionic degeneration, vascular parkinsonism, Lewy body dementia
• PD vs parkinson+: combination of asymmetric symptoms, resting tremor, and response to L-dopa indicates likely PD
• Concerning findings: dementia, falls, symmetric symptoms, wide gait, normal eye movements, autonomic dysfunction
• Usually present with storage symptoms - nocturia, frequency, urgency
• May require botox, sacral neuromodulation

Multiple system atrophy (MSA)

• Urologic findings concerning for MSA over PD: LUTS prior to parkinsonism, incontinence, elevated PVR, erectile dysfunction, and abnormal sphincteric function on EMG
• Symptoms may be parkinsonian dominant (MSA-P) or cerebellar dominant (MSA-C)
• Urinary symptoms usually preclude parkinson symptoms, the opposite for PD
• Difficult to treat, may require CIC, do not perform outlet procedure (sphincteric incompetence)

Traumatic Brain Injury

• DSD may be present if pontine micturition complex (PMC) is damaged
• DUA common in acute setting, transitions to DO with synergic sphincter activity
• Incontinence more common with poor functional status and bilateral lesions
• Retention more common if diabetes or fecal impaction

Other diseases

• Brain tumor: variety of presentations, more associated with area affected than tumor type
• Cerebellar ataxia: poor movement coordination, presents with retention and DO but usually sphincteric synergy
• Normal pressure hydrocephalus (NPH): dementia + ataxia + incontinence, caused by DO + sphincteric synergy, treatment (VP shunt) shold improve incontinence
• Cerebral palsy: nonprogressive brain injury causing neuromuscular disability, most patients have normal storage/emptying, but voiding symptoms warrants UDS to rule out high pressure bladder, conservative management can be used for most
• Dementia: ncontinence is common but unclear if abnormal mechanism or just poor awareness, anticholinergic use may exacerbate symptoms (brain loss of cholinergic neurons)

Spinal cord diseases

Multiple sclerosis (MS)

• Symptoms: 50-90% have LUTS, 37-72% have incontinence
• UDS findings: DO (34-99%), DSD (30-65%), DUA (12-38%)
• Factors predicting urologic complications: DSD in men, high filling pressures, and indwelling catheters
• Renal injury rare, < 10% require surgical intervention for medication failure
• Treatment options: meds + CIC (57%), meds (13%), CIC (15%), behavioral therapy
• 50% have DSD improvement with a-blockers
• Avoid irreversible treatments, as MS symptoms may change with flares and disease progression

Spinal cord injury (SCI)

• 43% have incontinence, 7% have kidney stones within 10yrs injury (greatest risk within 1st 3mo)
• Spinal shock: bladder becomes areflexic immediately after injury, striated sphincter does not close during filling (absent guarding reflex), no voluntary control, incontinence only occurs with overflow, manage with catheterization, lasts usually 6-12 weeks but up to 1-2yrs
• Suprasacral SCI: DO, DSD, smooth sphincter synergia
• Sacral SCI: DUA with varying compliance, nonrelaxing smooth sphincter and fixed striated sphincter
• DSD causes functional obstruction, poor emptying, high detrusor pressures
• Treat based on symptoms and urodynamic findings, which may (not) correlate
• Asymptomatic bacteruria: common, only treat if signs/symptoms of UTI, prophylaxis warranted for rUTI without underlying cause, not warranted for ongoing catheter usage
• Bladder cancer: similar risk to general population but more likely to be muscle-invasive at diagnosis, unclear evidence for screening cystoscopy (or timing) but no other options currently available
• Follow-up: annually for at least 5-10 years after injury, check renal/bladder US, PVR (if applicable), and BMP

Spina bifida

• May have vertebral defects or meningeal sac herniation with(out) cord or nerve root evagination
• Usual findings include DUA, open bladder neck, overflow incontinence, stress incontinence, DSD only seen in 10-15%
• Treatments include CIC/catheter, augment, diversion, slings, botox, anticholinergics
• Tethered cord: presents with lower extremity weakness, sensory loss, bowel/bladder incontinence, treat based on urodynamic findings, post-treatment improvement seen in 95% within 6 months

Other diseases

• Cervical myelopathy: caused by cord compression, majority have some form of voiding symptoms
• Acute transverse myelitis: acute onset with variable recovery, variety of residual urinary deficits
• Tabes dorsalis (syphilitic myelopathy) and pernicious anemia: insensate bladder with DUA
• Polio: retention, DUA, intact sensation, seen in 4-42%

Lower motor neuron diseases

Lumbar disc disease

• Cauda equina compression may occur in 1-15% due to central prolapse (as opposed to posterolateral)
• Prelaminectomy UDS may be warranted to determine whether voiding improves after surgery
• Cauda equina syndrome: perineal sensory loss with bowel/bladder incontinence, decompress within 48hr recommended, autonomic function usually slower to recover after surgery than somatic function

Spinal stenosis (narrowing of canal/foramina)

• Presents with back/extremity pain with exercise and relieved with rest
• Urologic symptoms variable, ~50% improve after laminectomy, preop UDS may be helpful to determine improvement

Pelvic surgery

• Hypogastric plexus runs along rectum and vagina, can be injured during abdominoperineal resection (20-68%) and radical hysterectomy (16-80%)
• LUTD may be permanent in 15-20%, due to denervation, nerve tethering, bladder/urethral injury or devascularization
• Presents with decreased bladder contractility, decreased compliance, fixed striated sphincter (decreased voluntary relaxation), open/nonfunctional smooth sphincter
• Treat with CIC, monitor for improvement (may take 6-12mo)

Diabetes

• LUTD in 5-59%
• Incontinence: more likely urge than stress, 20% increased risk compared to non-DM
• UDS: impaired bladder sensation, increased capacity, decreased contractility, decreased flow
• Encourage timed voiding to optimize emptying and prevent detrusor decompensation

Herpes

• Sacral nerve root infection can cause retention (DUA) within days-weeks after initial primary viral manifestations
• Can be secondary to genital or anal inefctions
• Cystoscopy may show bladder mucosa vesicles
• Elsberg syndrome: bilateral sacral nerve root involvement, sphincteric incontinence, CSF pleocytosis

Guillain Barre Syndrome

• Presents with rapid limb weakness, loss of reflexes, and variable autonomic deficiencies
• LUTD seen in 25-80%, retention present in 11-30%

Voiding syndromes

Detrusor sphincter dyssynergia

• True DSD only exists in presence of neurologic injury/disease between brainstem (PMC) and sacral spinal cord
• Untreated DSD leads to VUR, upper tract injury, stones, sepsis, and UVJ obstruction
• Treatment requires decreasing abnormal sphincter activity (botox, sphincterotomy) or bypassing sphincter (CIC)

Dysfunctional voiding

• Involuntary sphincteric obstruction in the absence of neurologic disease, difficult to prove on UDS
• May be a response to discomfort with voiding or attempt to augment voiding
• Non-neurogenic urinary retention: PVR > 300mL for > 6mo, manage high risk patients (hydro, CKD, rUTI) with catheterization

Bladder neck dysfunction

• Incomplete opening during voiding
• Usually seen in younger men with chronic LUTS in absence of BPH on cystoscopy
• Diagnose via UDS which confirms outlet obstruction at level of bladder neck
• Manage with a-blockers and TUIP (unilateral decreases risk of retrograde ejaculation)
• Smooth sphincter dyssynergia: UDS finding in patient with autonomic hyperreflexia

Female bladder outlet obstruction

• Non-neurogenic voiding dysfunction confirmed with videourodynamics showing obstruction between bladder neck and distal urethra
• Surgical treatment risks sphincteric incontinence
• New Solomon-Greenwell nomogram helps predict BOO

Bashful bladder (low-flow voiding)

• May be due to detrusor hyperactivity with impaired contractility, leading to frequency + hesitancy + poor stream
• Minimal additional diagnostic benefit to using ambulatory UDS
• Manage with behavioral modification, usually no benefit to surgery

Fowler syndrome

• Urinary retention in younger women in absence of neurologic disease
• Presents with infrequent urination, abdominal discomfort, no urgency or sensation to void
• Responds best to neuromodulation (up to 70% success)

Post-operative urinary retention

• Contributing factors: foley trauma, overdistension, decreased sensation/contractility, increased outlet resistance, pain reflex, pre-existing obstruction
• Postoperative catheter drainage improves postop retention risk compared to CIC
• Unclear benefit to preop/postop a-blocker initiation

Irradiated bladder

• Storage symptoms common within 4-6 weeks of XRT, return to normal within 6 months
• Late effects are uncommon but can be progressive and irreversible, due to tissue fibrosis

Defunctionalized bladder

• UDS shows decreased capacity, involuntary contractions, decreased compliance
• Can treat with cycling with increasing volumes
• Renal transplant is safe if capacity > 100mL and voiding pressure < 100cm