Classification
(Bottom image from EAU guidelines)
Goals of treatment
- Protect the upper tracts
- Most acceptable continence and best quality of life
- Prevention or minimisation of stones, infections and other complications
History
- History of the underlying illness – timeframe, progression, other symptoms
- Level of injury
- History of autonomic dysreflexia
- LUTS
- Storage and voiding
- Current bladder management (catheters, ISC, Coude, pads)
- Bladder sensation
- Current degree of continence and bother level
- Progression or deterioration
- Other medical issues, medications, previous surgeries
- Mobility
- Hand function
- Cognitive function
- Other urological issues
- Stones, UTIs, haematuria
- Sexual function
- Interest in fertility
- Bowel management and function
Examination
- General inspection, mobility aids, deformities, limb function
- Habitus, wheelchair etc
- Blood pressure and be cautious about dysreflexia
- Abdominal exam – scars, stomas, palpable bladder, flank tenderness
- Look at the spine
- Genitals
- Development
- Prolapse
- Rectal examination – prostate, perianal/pudendal sensation and tone
- Bulbocavernosus and perianal reflexes
- Lower limb reflexes
Investigations
- Bloods – renal function
- Urinalysis, culture and microscopy
- Ultrasound – residual volume, hydronephrosis, stones, parenchyma
- Bladder diary
- If applicable – flow rate, pad weights, CT
- Video UDS
Bulbocavernosus reflex:
- When present, indicates intact spinal reflex arcs through S2 – S4 afferents and efferents through pudendal nerve
- Contractions of bulbospongiosus muscles and anal wink seen in response to squeezing glans or clitoris (or tugging on IDC)
- Presence of bulbocavernosus reflex suggests upper motor neuron lesion
- Correlated with detrusor overactivity and DSD
- More likely to have preserved erection / ejaculatory reflexes and orgasm
- Absence suggests lower motor neuron lesion
- Detrusor areflexia
- Flaccid paralysis of sphincter with subsequent stress incontinence
- Bulbocavernosus reflex may be absent during spinal shock after SCI, and is one of the first reflexes to recover
Urodynamics
The best way to objectively assess the lower urinary tract.
Reasons to perform UDS in neuropaths include:
- Assess bladder pressures and leak point pressures
- Upper tract changes and reflex associated with DLPP > 40 cm H2O
- Assess decreased flow
- Obstruction vs reduced detrusor contraction
- Assess the sphincter, outlet and possible contributors to incontinence
- Look for concurrent pathologies (BPH, SUI)
Perform UDS initially at diagnosis, and when there are clinical changes (especially in patients at risk of upper tract compromise).
Defining the problem
Management options:
The aim is to achieve low pressure storage and complete bladder emptying while promoting continence
Neurogenic detrusor overactivity:
Aim for a low pressure reservoir with normal compliance – protect upper tracts and maintain continence
- Conservative measures (?often not suitable)
- Anti-cholinergics and b3 agonists
- Botox
- SNS and PTNS? Dorsal rhizotomy?
- Augmentation
- Diversion
Detrusor underactivity:
Aim to keep bladder pressures low and avoid complications of high residual volumes – UTIs, stones
- Credé manoeuvre
- Intermittent self catheterisation
- Long term catheter (IDC or SPC)
- Continent catheterisable channel
- Sacral anterior root stimulator (SARS) – with dorsal rhizotomy to abolish overactivity
Outlet obstruction:
- Is this DSD
- Identify and treat other causes – BPH, stricture, prolapse
DSD:
- Intermittent self catheterisation (with anticholinergics/botox)
- Long term IDC or SPC
- External sphincterotomy
- Urethral stents (many issues)
SUI / open outlet:
- Conservative – pelvic floor physiotherapy, weight loss
- Containment devices
- Alpha agonists (?)
- Surgical – bulking agents, slings, AUS (ensure bladder pressure is controlled)