Definitions for the levels of evidence (1a-4) and grades of recommendation (A-B) are provided at the end of the "Major Recommendations" field.
Classification of Neurogenic Lower Urinary Tract Dysfunction (NLUTD)
The Madersbacher classification system (Wyndaele et al., 2005; Madersbacher, 1990) (see Figure 2.1 in the original guideline document) is recommended for clinical practice (Grade of recommendation: B).
Diagnosis
History
- An extensive general history is mandatory, concentrating on past and present symptoms and conditions for urinary, bowel, sexual, and neurological functions, and on general conditions that might impair any of these.
- Special attention should be paid to the possible existence of alarm signs, such as pain, infection, haematuria, fever, etc., that warrant further specific diagnosis.
- A specific history should be taken for each of the four mentioned functions.
Physical Examination
- Individual patient handicaps should be acknowledged in planning further investigations.
- The neurological status should be described as completely as possible. Sensations and reflexes in the urogenital area must all be tested.
- The anal sphincter and pelvic floor functions must be tested extensively.
- Urinalysis, blood chemistry, voiding diary, residual and free flowmetry, incontinence quantification and urinary tract imaging should be performed.
Urodynamics and Uro-neurophysiology
- Urodynamic investigation is necessary to document the (dys-)function of the lower urinary tract (LUT) (Grade of recommendation: A).
- The recording of a bladder diary is advisable (Grade of recommendation: B).
- Non-invasive testing is mandatory before invasive urodynamics is planned (Grade of recommendation: A).
- Video-urodynamics is the gold standard for invasive urodynamics in patients with NLUTD. If this is available, then a filling cystometry continuing into a pressure flow study should be performed (Grade of recommendation: A).
- A physiological filling rate and body-warm saline must be used (Grade of recommendation: A).
- Specific uro-neurophysiological tests are elective procedures (Grade of recommendation: C).
Treatment
Non-invasive Conservative Treatment
Conclusions
- Long-term efficacy and safety of anticholinergic therapy for neurogenic detrusor overactivity (NDO) is well documented (Level of evidence: 1a, Grade of recommendation: A).
- A combination of therapies is often considered to maximize outcomes for NDO (Level of evidence: 1a, Grade of recommendation: A).
- There is no drug with evidence of efficacy for underactive detrusor (Level of evidence: 2a, Grade of recommendation: B).
- Alpha-blockers have been partly successful for decreasing bladder outlet resistance and autonomic dysreflexia prophylaxis in spinal cord injury (SCI) patients (Level of evidence: 2a, Grade of recommendation: B).
- There is a lack of prospective randomized controlled studies in the medical management of NLUTD.
Guidelines for Non-Invasive Conservative Treatment
- The first aim of any therapy is the protection of the upper urinary tract.
- The mainstay of treatment for overactive detrusor is anticholinergic drug therapy (Level of evidence: 1, Grade of recommendation: A).
- Lower urinary tract rehabilitation may be effective in selected cases.
- A condom catheter or pads may reduce urinary incontinence to a socially acceptable situation.
- Any method of assisted bladder emptying should be used with the greatest caution (Grade of recommendation: A).
Catheterization
- Intermittent catheterization (IC) is the standard treatment for patients who are unable to empty their bladder (Level of evidence: 2, Grade of recommendation: A).
- Patients should be well instructed in the technique and risks of IC.
- Aseptic IC is the method of choice (Level of evidence: 2, Grade of recommendation: B).
- The catheter size should be 12-14 Fr (Grade of recommendation: B).
- The frequency of IC is 4 to 6 times per day (Grade of recommendation: B).
- The bladder volume should remain below 400 mL (Grade of recommendation: B).
- Indwelling transurethral and suprapubic catheterization should be used only exceptionally, under close control, and the catheter should be changed frequently. Silicone catheters are preferred and should be changed every 2 to 4 weeks, while (coated) latex catheters need to be changed every 1 to 2 weeks. (Grade of recommendation: A).
Minimal Invasive Treatment
- See the guidelines for catheterization above.
- Botulinum toxin injection in the detrusor is the most effective minimally invasive treatment to reduce neurogenic detrusor overactivity (Level of evidence: 1, Grade of recommendation: A).
- Sphincterotomy is the standard treatment for detrusor sphincter dyssynergia (DSD) (Level of evidence: 2, Grade of recommendation: A).
- Bladder neck incision is effective in a fibrotic bladder neck (Level of evidence: 3, Grade of recommendation: B).
Surgical Treatment
- Detrusor
- Overactive
- Detrusor myectomy is an acceptable option for the treatment of overactive bladder when more conservative approaches have failed. It is limited invasive and has minimal morbidity (Level of evidence: 2, Grade of recommendation: B).
- Sacral rhizotomy with sacral anterior root stimulation (SARS) in complete lesions and sacral neuromodulation in incomplete lesions are effective treatments in selected patients (Level of evidence: 2, Grade of recommendation: B).
- Bladder augmentation is an acceptable option for decreasing detrusor pressure whenever less invasive procedures have failed. For the treatment of a severely thick or fibrotic bladder wall, a bladder substitution might be considered (Level of evidence: 2, Grade of recommendation: B).
- Underactive
- SARS with rhizotomy and sacral neuromodulation are effective in selected patients (Level of evidence: 2, Grade of recommendation: B).
- Restoration of a functional bladder by covering with striated muscle is still experimental (Level of evidence: 4).
- Urethra
- Overactive (DSD): refer to guidelines for minimal invasive treatment above
- Underactive
- The placement of a urethral sling is an established procedure (Level of evidence: 2, Grade of recommendation: B).
- The artificial urinary sphincter is very effective (Level of evidence: 2, Grade of recommendation: B).
- Transposition of the gracilis muscle is still experimental (Level of evidence: 4).
Quality of Life (QoL)
- Assess QoL to evaluate lower urinary tract symptoms (LUTS) in neurogenic patients and during any type of treatment for neurogenic bowel dysfunction (Level of evidence 2a, Grade of recommendation: B).
- Available tools are: Qualiveen, a specific tool for spinal cord lesion and multiple sclerosis patients, Visual Analogue Scale (VAS) for bother. However, generic (SF-36) or specific tools for incontinence (I-QOL) questionnaires could be used too. (Level of evidence: 2a, Grade of recommendation: B).
- There is a lack of disease-specific outcome measures assessing health-related QoL in patients with NLUTD.
Follow-Up
- Possible urinary tract infection (UTI) checked by the patient (dip stick).
- Urinalysis every second month.
- Upper urinary tract, bladder morphology, and residual urine every 6 months (ultrasound).
- Physical examination, blood chemistry, and urine laboratory every year.
- Detailed specialist investigation every 1 to 2 years and on demand when risk factors emerge. The investigation is specified according to the patient's actual risk profile, but should in any case include a video-urodynamic investigation and should be performed in a leading neuro-urological centre.
- All of the above should be more frequent if the neurological pathology or the NLUTD status demands this.
Definitions:
Levels of Evidence
1a Evidence obtained from meta-analysis of randomized trials
1b Evidence obtained from at least one randomized trial
2a Evidence obtained from one well-designed controlled study without randomization
2b Evidence obtained from at least one other type of well-designed quasi-experimental study
3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities
Grades of Recommendation
- Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
- Based on well-conducted clinical studies, but without randomized clinical trials
- Made despite the absence of directly applicable clinical studies of good quality