Neurogenic Bladder: Epidemiology, Diagnosis, and Management

Lower urinary tract dysfunction is a common sequel of neurological disease resulting in symptoms that significantly impacts quality of life. The site of the neurological lesion and its nature influence the pattern of dysfunction. The risk for developing upper urinary tract damage and renal failure is considerably lower in patients with slowly progressive nontraumatic neurological disorders, compared with those with spinal cord injury or spina bifida. This acknowledged difference in morbidity is considered when developing appropriate management algorithms. The preliminary evaluation consists of history taking, and a bladder diary and may be supplemented by tests such as uroflowmetry, post-void residual measurement, renal ultrasound, (video-)urodynamics, neurophysiology, and urethrocystoscopy, depending on the clinical indications. Incomplete bladder emptying is most often managed by intermittent catheterization, and storage dysfunction is managed by antimuscarinic medications. Intra-detrusor injections of onabotulinumtoxinA have revolutionized the management of neurogenic detrusor overactivity. Neuromodulation offers promise for managing both storage and voiding dysfunction. In select patients, reconstructive urological surgery may become necessary. An individualized, patient-tailored approach is required for the management of lower urinary tract dysfunction in this special population

The Role of Pelvic Neurophysiology Testing in the Assessment of Patients with Voiding Dysfunction

PURPOSE OF REVIEW: The role of pelvic neurophysiology testing in the evaluation of patients with lower urinary tract (LUT) symptoms is explored in this review. RECENT FINDINGS: Different neurophysiology tests such as sphincter EMG and pudendal somatosensory evoked potentials are useful in evaluating the sacral somatic afferent and efferent innervation. S2 and S3 dermatomal evoked potentials assess individual sacral roots and are feasible to perform using standard neurophysiology machines. SUMMARY: The innervation of the LUT has a substantial contribution from splanchnic and somatic nerves arising from the sacral segments. Pelvic neurophysiology tests, which assess somatic nerve functions, are therefore a useful tool in assessing sacral nerve functions in patients presenting with unexplained voiding dysfunction. In this review, the commonly performed neurophysiology studies that assess the S2, S3 and S4 sacral afferent and efferent pathways are outlined, and their clinical applications reviewed

Fowler's syndrome: a primary disorder of urethral sphincter relaxation

Key content: Urinary retention is a relatively uncommon presentation in young women. Women with Fowler's syndrome are often found to have an abnormally elevated urethral pressure profile, increased urethral sphincter volume and characteristically abnormal electromyography of the urethral sphincter. The only treatment that has been found to restore voiding in women with Fowler's syndrome is sacral neuromodulation. Sphincter injections of botulinum toxin are a possible outpatient‐based alternative. / Learning objectives: To review the typical symptoms and signs associated with Fowler's syndrome. To share the current understanding about why this condition may occur. To understand how to evaluate and treat a woman with suspected Fowler's syndrome. / Ethical issues: Fowler's syndrome should be considered in women presenting with urinary retention where the cause for retention is uncertain

The cognitive effect of anticholinergics for patients with overactive bladder

Overactive bladder (OAB) is often treated with medications that block the cholinergic receptors in the bladder (known as anticholinergics). The effect of this medication class on cognition and risk of dementia has been increasingly studied over the past 40 years after initial studies suggested that the anticholinergic medication class could affect memory. Short-term randomized clinical trials demonstrated that the administration of the anticholinergic oxybutynin leads to impaired memory and attention, and large, population-based studies showed associations between several different anticholinergic medications and dementia. However, trials involving anticholinergics other than oxybutynin have not shown such substantial effects on short-term cognitive function. This discordance in results between short-term cognitive safety of OAB anticholinergics and the long-term increased dementia risk could be explained by the high proportion of patients using oxybutynin in the OAB subgroups of the dementia studies, or a study duration that was too short in the prospective clinical trials on cognition with other OAB anticholinergics. Notably, all studies must be interpreted in the context of potential confounding factors, such as when prodromal urinary symptoms associated with the early stages of dementia lead to an increase in OAB medication use, rather than the use of OAB medication causing dementia. In patients with potential risk factors for cognitive impairment, the cautious use of selected OAB anticholinergic agents with favourable physicochemical and pharmacokinetic properties and clinical trial evidence of cognitive safety might be appropriate

Botulinum toxin-A for the treatment of overactive bladder: UK contributions

Background: Botulinum toxin-A (BoNT/A) is now established second-line management for refractory overactivebladder (OAB) and recognised in many incontinence guidelines and pathways. For those with neurogenic detrusoroveractivity secondary to spinal cord injury or multiple sclerosis, the toxin is currently licensed in certain parts of theworld, including the UK. It is an effective treatment in those in whom antimuscarinics and conservative measures havefailed who have symptoms of OAB and or detrusor overactivity (DO). Methods: Treatment can be given in an outpatient setting and can be administered under local anaesthesia. Its efficacylasts for between six and 12 months. Results: It has an acceptable safety profile with the biggest risk being urinary tract infection and difficulty emptying thebladder, necessitating clean intermittent self-catheterisation (CISC). Medium-term follow-up suggests repeated injectionsare also safe and efficacious. Conclusions: The mechanism of action of the toxin is more complicated than originally thought, and it seems likelythat it affects motor and sensory nerves of the bladder. In the last 10 years much of the progress of this treatment fromearly experimental trials to mainstream clinical use, and a better understanding of how it works in the bladder, are as aresult of research conducted in the UK. This review summarises the significant and substantial evidence for BoNT/A totreat refractory OAB from UK centres. © British Association of Urological Surgeons 2013

The Management of Lower Urinary Tract Dysfunction in Multiple Sclerosis

Purpose of Review Multiple sclerosis (MS) is the most frequent neuroinflammatory disease of the central nervous system and is commonly associated with lower urinary tract (LUT) dysfunction. As a consequence, health-related quality of life is often impaired and the upper urinary tract might be at risk for damage. The aim of this review is to give an overview of current treatment options for LUT dysfunction in patients with MS. Recent Findings The treatment is tailored to the type of dysfunction—storage or voiding dysfunction—beginning with conservative treatment options and ending with invasive therapies and surgery. Additionally, alternative options, e.g., different intravesical therapies or cannabinoids, have been evaluated in recent years with promising results. Summary Current available therapies offer different possible treatments for LUT dysfunction in patients with MS. They address either voiding or storage dysfunction and therefore ameliorate LUT symptoms improve quality of life and protect the upper urinary tract

A practical approach to assessing and managing sexual dysfunction in multiple sclerosis

Sexual dysfunction is common in both men and women with multiple sclerosis but is often under-reported and undertreated. Neurologists report that a major barrier to discussing sexual dysfunction with patients is their lack of knowledge. Here we review the common presentations of sexual dysfunction, discuss its causes in people with multiple sclerosis, and provide a practical approach for neurologists to assess and manage these problems

Neurogenic lower urinary tract dysfunction: evaluation and management

The lower urinary tract (LUT) in health is regulated by coordinated multi-level neurological inputs which require an intact central and peripheral nervous system. Lower urinary tract dysfunction is, therefore, a common sequelae of neurological disease and the patterns of bladder storage and voiding dysfunction depend upon the level of neurological lesion. Evaluation includes history taking, bladder diary, urological examination when relevant, ultrasonography and urodynamic testing when indicated. Antimuscarinic agents are the first line treatment for patients with storage dysfunction. Alternative treatments include intradetrusor injection of onabotulinumtoxinA, which has been shown to be of benefit in patients with neurogenic detrusor overactivity (NDO), and neuromodulation. Intermittent catheterization remains the option of choice in patients with significant voiding dysfunction resulting in high post-void residual volumes

Lower urinary tract dysfunction in Parkinsonian syndromes

Purpose of review: The aim of this review is to outline the clinical presentation, pathophysiology and evaluation of lower urinary tract (LUT) dysfunction in Parkinson’s disease and other parkinsonian syndromes including multiple system atrophy, dementia with Lewy bodies, progressive supranuclear palsy and corticobasal degeneration. // Recent findings: LUT dysfunction commonly occurs in neurological disorders, including patients with parkinsonian syndromes. The pattern of LUT dysfunction and its severity are variable, depending upon the site of lesion within the neural pathways. Parkinsonian syndromes are broadly divided into Parkinson’s disease (PD) and a typical parkinsonian syndromes such as multiple system atrophy (MSA), dementia with Lewy bodies (DLB), progressive supranuclear palsy (PSP) and corticobasal degeneration (CBD). Different parkinsonian syndromes have distinct clinical features (e.g. dysautonomia, early dementia, supranuclear gaze palsy, higher cortical signs), and the pattern of LUT dysfunction and its severity can differ. // Conclusions: LUT dysfunction is a common feature in patients with parkinsonian syndromes. Recognising the pattern of LUT dysfunction during the assessment of these patients can help management and possibly facilitate an earlier diagnosis

Urinary tract infections in multiple sclerosis

BACKGROUND: Urinary tract infections (UTIs) are commonly reported by people with multiple sclerosis (PwMS) and significantly impact quality of life. OBJECTIVE: To provide an overview of the problem of UTIs in PwMS and offer a practical approach for the diagnosis and management. METHODS: A review of the literature through a Pubmed search up to October 2015 was performed using the following keywords: multiple sclerosis, neurogenic bladder, urinary tract infections, relapse, dipsticks, culture, recurrent and prevention. RESULTS: Noteworthy topics include the definition of a confirmed symptomatic UTI as a positive urine culture defined by >10(5) colony-forming units (CFU)/mL or >10(4) CFU/mL if a urethral catheter urine sample is taken, or any count of bacteria in a suprapubic bladder puncture specimen, both in addition to symptoms including fever, pain, changes in lower urinary tract symptoms or neurological status. Urinalysis is useful to exclude a UTI; however, on its own is insufficient to confirm a UTI, for which urine culture is required. Experts advise asymptomatic UTIs should not be treated except in the context of an acute relapse. From international guidelines, there is no validated strategy to prevent recurrent UTIs in PwMS. CONCLUSION: This review provides an overview of the diagnosis, treatment and prevention of UTIs in the setting of multiple sclerosis (MS)