Adult Neurogenic Lower Urinary Tract Dysfunction: Diagnosis and Evaluation

• Neurogenic Lower Urinary Tract Dysfunction (NLUTD) is an abnormal function of the urinary bladder (the organ that stores urine), bladder neck, and/or its sphincters (ring-shaped muscles that open and close the bladder) related to a neurologic disorder.
• Another term for neurogenic lower urinary tract dysfunction is “neurogenic bladder” — these terms both describe the same medical condition.
• We will use the abbreviation NLUTD throughout this summary to refer to neurogenic lower urinary tract dysfunction or neurogenic bladder.
• Some of the most common causes of NLUTD are brain, spinal, or other nerve damage, as well as neurological conditions such as multiple sclerosis (MS), Alzheimer’s, and stroke.
• Symptoms include:
  • Losing control of your bladder.
  • Urine retention (inability to empty all the urine).
  • Recurrent urinary tract infection (UTI).
  • Autonomic dysreflexia (overreaction of the involuntary nervous system to stimulation). It includes severe headache, sweating, flushing, nasal congestion, nausea, vomiting, dizziness, and panic.
  • Others: sexual dysfunction, infertility, and bowel dysfunction are also common, but are not covered in this guideline.
• The goal of treatment is to improve your bladder function and control and improve your overall quality of life.
• This patient summary focuses primarily on the evaluation, risk classification, and surveillance of NLUTD.

Overview of Risk Categories

• The first step to getting your NLUTD under control is an evaluation to determine your risk category.
• Risk categories include low risk, moderate risk, high risk, and unknown risk.
• Understanding your risk category is one of the most important steps in helping to manage your NLUTD because all other surveillance and management approaches are based on the risk category you are grouped into.

Initial Evaluation

• During your initial evaluation, your doctor will ask you questions about your medical history and administer a physical exam and urine test, also called a urinalysis or UA.
• Some of the things your doctor will look for in your medical history and physical examination include:
  • thinking ability
  • function of your legs, ankles, feet, arms, wrists, and hands
  • muscles stiffness
  • hand skills in performing tasks
  • mobility
  • supportive environment.
  • specific nervous condition(s) causing your NLUTD
• Urinalysis: to assess for blood, pus, sugar, and protein in your urine.
• If you have NLUTD and can’t control when you urinate you will undergo a post-void residual (PVR) measurement. It measures urine left in the bladder after trying to empty it. There should be none. A high PVR requires a second measurement at a different visit.
• Optional: urinating diary (if you do not recall intake and urination information), pad test (A feminine pad collects uncontrolled urine then weighed to determine how much urine it contains), and non-invasive measurement of the quantity of urine passed into a measuring device in a specified time (If you can’t control when you urinate).
• If you have low-risk NLUTD, there is no need for routine x-rays, scans, or functional studies assessment. But, if you have unknown-risk NLUTD, you will need these assessments.
• If you have an acute neurological event (like spinal cord injury or brain injury) that causes NLUTD, your physician will perform a risk evaluation when the condition has stabilized.
• If you have autonomic dysflexia, your doctor will order additional tests.

Surveillance

Surveillance Overview

• In addition to evaluation and risk classification, surveillance is a critical step in the care process.
• Please contact your doctor if you develop:
  • New or worsening autonomic dysflexia (AD) or loss of urination control (urinary incontinence)
  • New or more frequent UTIs
  • Infections associated with fever or flank (side) pain
  • New upper tract signs and symptoms such as kidney stones or pain from a swollen kidney when urine flows backward
  • For those who use a catheter to drain the bladder: difficulty inserting the catheter
  • Blood in urine, which may be an early sign of bladder cancer
• If you are a low-risk NLUTD patient and you developed any of these symptoms, your physician will re-evaluate you.
• The types and frequency of surveillance techniques will depend on the risk category your NLUTD falls into. These are described in more detail below and also in the following table:

Surveillance for Low-Risk and Stable

• If you have low-risk NLUTD and your signs and symptoms are stable and not getting any worse, your care provider will perform the following assessments:
  • annual focused history, physical exam, and symptom assessment

Surveillance for Moderate-Risk and Stable

• If you have moderate-risk NLUTD and your signs and symptoms are stable and not getting any worse, your care provider will perform the following assessments:
  • annual focused history, physical exam, and symptom assessment
  • annual renal function assessment
  • upper tract imaging every 1-2 years

Surveillance for High-Risk and Stable

• If you have high-risk NLUTD and your signs and symptoms are stable and not getting any worse, your care provider will perform the following assessments:
  • annual focused history, physical exam, and symptom assessment
  • annual renal function assessment
  • annual upper tract imaging
  • additional studies
• If your NLUTD is at high risk, you are at a greater risk of urinary tract infections (UTIs), kidney problems, and worsening bladder complications. For this reason, it is important that your care provider orders adding imaging and urodynamic studies during regular surveillance.
• Worsening of symptoms or the development of vesicoureteral reflux (VUR) (urine flowing backward from your bladder into your kidneys) can be silent but are serious conditions requiring constant monitoring and action as needed.

Surveillance for Low-Risk and Changing Symptoms

• If you have low-risk NLUTD and are experiencing any new signs, symptoms, or complications, your care provider will re-evaluate your risk category and increase your risk level.
• If your risk category is increased, your care provider will perform surveillance according to the new category level.

Surveillance for Moderate-Risk and Changing Symptoms

• If you have low-risk NLUTD and are experiencing any new signs, symptoms, or complications, your care provider may perform multichannel urodynamics. The findings of this may result in changes to your treatment plan.
• If you also are experiencing hematuria, recurrent UTIs, or suspected anatomic anomaly, your care provider may also perform cystoscopy.

Surveillance for Indwelling Catheters

• If you have an indwelling catheter, your care provider will perform regular examinations of the catheter and the catheter site.
• If you have an indwelling catheter and you are also at a higher risk for complications, your care provider will perform additional urinary tract imaging every 1-2 years. You may be at a higher risk if you have a spinal cord injury, recurrent UTIs, immobilization, or hypercalciuria (excess calcium in your blood).

• You don’t need a urine culture if you have no symptoms.
• You need a urine culture and urinalysis if you have signs and symptoms suggesting a UTI such as burning when you urinate.
• If you have bacteria in the urine and do not have symptoms, you don’t need antibiotics (unless you are pregnant). The unnecessary use of antibiotics can cause bacterial resistance. This means if it comes back and does result in an infection with signs and symptoms, antibiotics may no longer work.
• If you are an NLUTD patient with a UTI associated with fever, your clinician will order a scan or x-ray if:
  • You do not respond well to an antibiotic or
  • You are moderate - or high - risk and are not up-to-date with routine upper tract studies such as x-rays or scans.
• The upper tracts (kidneys and ureters) are imaged by CT scans (“urogram”) — (CTU) or renal ultrasound (US). The lower tracts (bladder, urethra) are visualized by cystoscopy (inserting a thin telescope into the bladder).
• If you are an NLUTD patient with a suspected UTI and a catheter in your bladder, your doctor will get the urine culture sample after changing your catheter and after waiting for urine to accumulate while the catheter is plugged. The doctor will not get the urine from the extension tubing or collection bag.
• If you are an NLUTD patient with recurrent UTIs, your doctor will check the upper and lower urinary tracts with imaging and cystoscopy.
• “Recurrent UTI” is two episodes of acute bacterial cystitis within six months or three episodes within a year. But there is no clear-cut definition of “recurrent UTI” in NLUTD patients.
• If you are an NLUTD patient with UTIs and a non-diagnostic evaluation of the upper and lower urinary tract, your doctor may perform urodynamic testing (measurement taken while your bladder fills and empties).
• If you are an NLUTD patient who has a catheter in the bladder, you do not need daily antibiotic prophylaxis (treatment to prevent infection) to prevent urinary tract infection.
• If you are an NLUTD patient who has clean intermittent catheterization and does not have recurrent UTIs, you do not need daily antibiotic prophylaxis .

• Urology Care Foundation: https://www.urologyhealth.org/urology-a-z/n/neurogenic-bladder
• Johns Hopkins Medicine: https://www.hopkinsmedicine.org/health/conditions-and-diseases/neurogenic-bladder
• Cleveland Clinic: https://my.clevelandclinic.org/health/diseases/15133-neurogenic-bladder
• The Simon Foundation for Continence: https://simonfoundation.org/neurogenic-bladder/