Elsevier

The Lancet Neurology

Volume 14, Issue 7, July 2015, Pages 720-732
The Lancet Neurology

Review
Lower urinary tract dysfunction in the neurological patient: clinical assessment and management

https://doi.org/10.1016/S1474-4422(15)00070-8Get rights and content

Lower urinary tract (LUT) dysfunction is a common sequela of neurological disease, resulting in symptoms that have a pronounced effect on quality of life. The site and nature of the neurological lesion affect the pattern of dysfunction. The risk of developing upper urinary tract damage and renal failure is much lower in patients with slowly progressive non-traumatic neurological disorders than in those with spinal cord injury or spina bifida; this difference in morbidity is taken into account in the development of appropriate management algorithms. Clinical assessment might include tests such as uroflowmetry, post-void residual volume measurement, renal ultrasound, (video-)urodynamics, neurophysiology, and urethrocystoscopy, depending on the indication. Incomplete bladder emptying is most often managed by intermittent catheterisation, and storage dysfunction by antimuscarinic drugs. Intradetrusor injections of onabotulinumtoxinA have transformed the management of neurogenic detrusor overactivity. Neuromodulation offers promise for managing both storage and voiding dysfunction. An individualised, patient-tailored approach is required for the management of LUT dysfunction associated with neurological disorders.

Introduction

Lower urinary tract (LUT) dysfunction can result from a wide range of neurological disorders. The “neurogenic bladder” is not a homogeneous entity, but rather a broadly used term to denote LUT dysfunction as a sequela of neurological disease. The high prevalence of LUT dysfunction in neurological diseases reflects the complexity of the neural control of the LUT in health. The site of the lesion in the neurological axis determines the general pattern of LUT dysfunction, which is reflected in the patient's symptoms.

The importance of LUT dysfunction to patients' health and quality of life is now being recognised and is rightly attracting interest in neurological practice. Pelvic organ dysfunction in neurological disease encompasses LUT, sexual, and bowel dysfunction, and the complex interrelationship between these is now much better understood, with the recognition that a holistic approach is required for management. In this Review we aim to describe the principles that underpin the management of LUT dysfunction in the neurological patient, and to familiarise the clinician with the several recent advances that have transformed treatment.

Section snippets

Neurological control of LUT functions

In health, the coordinated activity of the urinary bladder and its outlet results in low-pressure filling and periodic voluntary emptying. A complex neural network distributed across parasympathetic, sympathetic, and somatic pathways acts as a switching circuit to maintain a reciprocal relation between the reservoir function of the bladder and sphincter function of the urethra. The frequency of micturition in a person with a bladder capacity of 400–600 mL will be once every 3–4 h. Voiding lasts

LUT dysfunction after nervous system damage

Lesions of the nervous system, central or peripheral, can result in patterns of LUT dysfunction that are influenced by the level of the lesion (figure 1).8 Lesions of the relevant suprapontine or spinal pathways regulating LUT functions affect the storage phase, resulting in reduced bladder capacity and detrusor overactivity, expressed as spontaneous involuntary contractions of the detrusor. The patient might report varying degrees of urinary urgency, frequency, nocturia, and incontinence

Risk of upper urinary tract complications

Detrusor overactivity in combination with DSD can result in high intravesical pressures, which in turn can lead to morphological changes in the bladder wall such as trabeculations and (pseudo-)diverticula, and increase the risk of upper urinary tract complications such as vesico-uretero-renal reflux, hydronephrosis, renal impairment, and eventually end-stage renal disease. One study assessing urodynamic changes in patients with spina bifida suggested that urethral leakage at detrusor pressures

Dementia

Incontinence is often a prominent symptom in the late stages of dementia, but the timing of its occurrence seems to vary according to the nature of the brain disease. Incontinence tends to occur early in normal pressure hydrocephalus, dementia with Lewy bodies, vascular dementia, and frontotemporal dementia, whereas generally it occurs late in the course of Alzheimer's disease or Parkinson's disease with dementia.15, 16 In patients with dementia and incontinence, pharmacological treatment of

Clinical assessment

The assessment and management of the neurological patient reporting LUT symptoms requires a close collaboration between neurologists and urologists. Table 1 provides an overview of the assessment, which should include evaluation of additional urological and gynaecological comorbidities such as prostate enlargement, stress incontinence, and pelvic organ prolapse.

Principles of management

The goals of management are to achieve urinary continence, improve quality of life, prevent UTIs, and preserve upper urinary tract function.29 The management of neurogenic LUT dysfunction should address both voiding and storage dysfunction (table 2) and is determined by the severity of symptoms and risk of developing upper urinary tract damage (Panel 1, Panel 2). LUT dysfunction should be seen in the context of the wider overall dysfunctions resulting from neurological disorders, and a

Physical treatments

The aim of behavioural interventions is to re-establish control of LUT function by correcting faulty habits such as frequent voiding, which are sometimes seen in individuals with urinary urgency. Behavioural therapies are considered appropriate in individuals whose incontinence is associated with cognitive deficits, and possibly also in patients with motor deficits. However, such treatments require support from caregivers and health-care professionals to be successful. Timed voiding involves

Management of voiding dysfunction

There is little consensus about the best time to begin intermittent catheterisation; however, several factors such as the PVR volume and risk of upper urinary tract damage should be considered. The PVR volume at which to begin intermittent catheterisation is related to the overall bladder capacity; patients with neurogenic LUT dysfunction often have a reduced bladder capacity, and a PVR volume consistently more than 100 mL has been advocated if the patient is symptomatic.42

Follow-up of patients with neurogenic LUT dysfunction

In the absence of prospective long-term natural history studies, there is no consensus about how often a patient with neurogenic LUT dysfunction should be followed up. The population of patients at high risk of upper urinary tract damage should be followed up regularly with a patient-tailored approach that aims to achieve best possible quality of life and to protect the upper urinary tract.97 Follow-up should reflect regional guidelines based upon resource allocation.29

Future perspectives

There are several emerging diagnostic and therapeutic approaches that are likely to affect the management of neurogenic LUT dysfunction. Non-invasive tests to assess neurogenic LUT dysfunction are being explored, such as sensory evoked potentials98 and MRI.99 Functional MRI has been used to non-invasively assess upper urinary tract functions without the need for contrast medium in non-neurological patients100, 101, 102 and might become an option in those with neurogenic LUT dysfunction.

There is

Conclusions

LUT dysfunction is common in neurological patients and has a pronounced effect on quality of life. The high prevalence of dysfunction reflects the wide distribution of neural control of LUT functions in health. The site and nature of the neurological lesion determine the pattern of dysfunction. In general, progressive non-traumatic disorders are less often associated with upper urinary tract damage than are spinal cord injury and spina bifida.

History taking supplemented by the bladder diary

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