Spinal cord injury and neurogenic lower urinary tract dysfunction: what do we know and where are we going?

One of the well reported but difficult to manage symptoms of spinal cord injury (SCI) is neurogenic lower urinary tract dysfunction (NLUTD). The type of NLUTD is variable based on location and extent of injury. SCI affects more males and NLUTD is especially debilitating for men with incomplete injury. This review summarizes the anatomical basis of NLUTD in SCI and discusses current diagnostic and management strategies that are being utilized clinically. The last two sections address new innovations and emerging discoveries with the goal of increasing scientific interest in improving treatment options for people with SCI. Areas warranting further investigation are pinpointed to address current gaps in knowledge and/or appropriate technology

Postpartum urinary retention: what are the sequelae? A long-term study and review of the literature.

INTRODUCTION AND HYPOTHESIS Postpartum urinary retention (PUR) may cause long-term urogenital tract morbidity. The incidence ranges from 0.18 to 14.6%, but the importance of prompt diagnosis and appropriate management is often underappreciated. The paucity of data on long-term outcome after PUR contributes to these drawbacks. The aim of this study was to assess long-term persistence of elevated PVR (post-void residual urine) volume after PUR. Pathophysiology, risk factors and management of PUR are reviewed. METHODS In our tertiary referral urogynecology unit in the University Women's Hospital of Bern, Switzerland, all patients who were referred for PUR were asked to participate in this study. PVR was measured sonographically every 2 days until day 15, then after 6, 12, 24 and 36 months and, if increased, the patients were instructed to perform clean intermittent self-catheterization. If retention persisted longer than the lactation period, multichannel urodynamics was performed. RESULTS Sixty-two patients were included. The median PVR normalized at day 7. Long-term voiding disorders were found in 8.2%, 6.7%, and 4.9% after 1, 2, and 3 years respectively. Multichannel urodynamics confirmed in all patients with persisting retention an acontractile detrusor and de novo stress urinary incontinence in 4 cases. Quantile regression did not reveal any factor contributing to earlier recovery. Eighty-nine percent of the patients with PUR had operative vaginal deliveries, emphasizing the importance of this risk factor for PUR. CONCLUSIONS In most cases PUR resolves early, but voiding difficulties persist more often than previously thought, and for these patients the consequences are devastating. Obstetric awareness, early active management, and developing management strategies in the postpartum period might preclude lower urinary tract morbidity

VOIDING DYSFUNCTION AND DETRUSOR INSTABILITY AFTER THE COLPOSUSPENSION OPERATION FOR GENUINE STRESS INCONTINENCE

Colposuspension is an effective treatment for genuine stress incontinence. Continence is restored by positioning the bladder neck in a fixed and elevated retro-pubic position. Despite a high success rate of up to 90%, post-operative complications occur which may have an adverse effect on quality of life. Voiding difficulties develop in 0-43% of patients and detrusor instability in 2- 25%. This considerable variability is due to differences in definition, the timing of assessment, patient selection, and probably also in surgical technique. The natural history of these complications is not clearly known due to the lack of prospective follow-up studies. There is also general uncertainty with regards to their causes. While retrospective studies have attempted to identify pre-operative risk factors, there are no prospective studies which attempt to correlate the anatomical and functional changes caused by surgery with the development of voiding dysfunction and detrusor instability. This study has investigated prospectively 77 women undergoing the operation of colposuspension in relation to the incidence, natural history and causes of post-operative voiding dysfunction and detrusor instability. The complications were identified and followed-up objectively by means of serial urodynamic studies. Patients were also assessed clinically and using quality of life measures. The development of complications were correlated to a number of anatomical and functional changes caused by surgery. Anatomical changes were identified mainly by imaging the bladder neck with Magnetic Resonance Imaging (MRI). Functional changes were identified using urodynamic studies. Voiding dysfunction after colposuspension was common, with 69% of women requiring a catheter for more than seven days, and 28% for longer than 14 days. Improvement occurred gradually in most cases, with only 7. 7% and 2.5% of them needing catheterization at three months and one year respectively. De novo detrusor instability occurred in 21% of women at three months follow-up, and was symptomatic in 66% of these cases. Objective and subjective resolution was seen in 50% of these at one year follow-up. Quality of life after colposuspension improved in most cases despite the development of these complications, probably due to the resolution of their incontinence. Voiding dysfunction and detrusor instability after colposuspension were found to be multifactorial, due to patient related factors (age and detrusor contractility for voiding dysfunction, and age and a past history of bladder neck surgery for detrusor instability), and to operative factors (amount of bladder neck elevation and urethral compression). These findings might lead to the development of preventative measures

The value of home urodiagnostics in the assessment of men with lower urinary tract symptoms

PhD ThesisA third of all men experience unpleasant lower urinary tract symptoms (LUTS) such as a poor stream and being unable to postpone urination, usually later in life. Two important investigations for these men are: a one-o clinic-based measurement of urine ow rate, and the patient's hand written record of volumes passed over the course of several days. Well acknowledged deficiencies in these tests have spurred research into home-based alternatives. `Home urodiagnostic' devices have been developed that obtain multiple measurements of flow rate and an electronic voiding diary. However, little conclusive evidence exists as to their clinical utility. The aim of this thesis is to investigate the value of home urodiagnostics in the assessment of men with LUTS. First, the improvement in clinical performance of an average rather than single flow rate measurement is calculated based upon the theory of combining variance, predicting benefit for thousands of men per year. Next, finding existing devices deficient, the characteristics and technical performance of a novel device are presented. Despite its low cost, it is found to meet the required standard. In a study of conventional versus home urodiagnostics in men with LUTS, the latter is better tolerated, less likely to fail and gave more reliable measurement of flow rate. A study in which home urodiagnostics was performed before and after prostate surgery reveals large variation in the response of flow rate to surgery. Subtle changes within an individual are demonstrable. Finally, home urodiagnostics is piloted within primary care, where the resulting data suggests benefit from a change in the management strategy of over a third of patients studied. In conclusion, home urodiagnostics shows promise for improving the assessment of men with LUTS. The next step is to evaluate the effect on patient reported outcomes in a large scale trial.The Wellcome Trust

A practical guide to the evaluation and treatment of male lower urinary tract symptoms in the primary care setting

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/75555/1/j.1742-1241.2007.01491.x.pd