I Am a Urology Patient

Neurourological Disorders

Neurourological Disorders

What is a neurourological disorder? What is neurogenic lower urinary tract dysfunction?

A neurourological disorder is a disturbance of the nervous system that leads to a dysfunction of the lower urinary tract. The lower urinary tract consists of the bladder and urethra and also includes the prostate in men. The bladder is the organ that stores the urine produced by the kidneys. It is a hollow stretchy bag made of muscle tissue that sits on the pelvic floor muscles. Normally the bladder is able to store urine without building up higher pressure. Below the bladder, the ‘sphincter’ helps store the urine and prevent leakage. It is composed of different parts and muscle layers.

urinary tract
Fig. 1: lower urinary tract

Besides storage, the main function of the lower urinary tract is the passing of urine. Both functions are regulated by the nervous system, which coordinates interaction of the bladder and the sphincter. For normal storage, the bladder muscle should be relaxed and the sphincteric muscles tense. For urination, the bladder muscle should contract to build up pressure and to press the urine out, and the sphincter should relax to allow for easy and complete emptying without resistance. Many parts of the nervous system are involved, including the brain, the spinal cord, and the peripheral nerves. Any disturbance of the participating parts can lead to malfunction of the normal storage and voiding process and can result in many symptoms. This disturbance is called neurogenic lower urinary tract dysfunction, regardless of the specific symptoms.

What symptoms and harm can be caused by neurogenic lower urinary tract dysfunction?

You may have a neurogenic lower urinary tract dysfunction if you also have one or more of the following conditions:

  • a neurologic disease
  • past spinal or pelvic surgery or trauma
  • previous radiation
  • deformity of the spine
  • a slipped disc
  • a tumour that affects or infiltrates the nervous system
  • diabetes

Maybe you recognize that normal storage and passing of urine is disrupted. Sometimes a dysfunction doesn’t cause any discomfort. Normally, the extent of dysfunction after sudden disturbances like spinal trauma is worse and more dangerous than that in case of chronic problems.

The symptoms and possible hazards of neurogenic lower urinary tract dysfunction depend on the extent and location of the disturbance in the nervous system.

Symptoms include:

  • slow or incomplete emptying of the bladder
  • no sensation of the bladder
  • feeling abdominal fullness
  • spasticity
  • a frequent and compelling urge to empty the bladder, day or night, that is difficult to defer
  • incontinence
  • pain in the bladder or genital region

Neurogenic lower urinary tract dysfunction can cause a variety of short- or long-term complications. The most significant long-term complication is impaired kidney function caused by high pressure in the bladder. If the bladder builds up high pressure during storage or urination, this can cause deterioration of the bladder itself, which might lose its ability to empty. Incomplete emptying of the bladder or reflux of urine to the kidneys might cause recurrent urinary tract infections, which can lead to dangerous effects on organs or even the whole body. Delay of treatment might lead to worsening of all aspects of lower urinary tract function, which results in a need for more drastic therapy. Generally, treatment and intensity of follow-up examinations are based on the type of neurourological disorder and the underlying cause.

Prevalent Neurourological Disorders

  • Stroke
  • Dementias: Alzheimer’s disease, parkinsonian syndrome/disease, multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration, Lewy body dementia
  • Brain tumours
  • Cerebral palsy
  • Spinal cord injury
  • Spina bifida
  • Lumbar spine degenerative disease
  • Disc prolapse
  • Lumbar canal stenosis
  • Pelvic nerve lesions
  • Peripheral neuropathy (caused by diabetes, alcohol abuse, herpes, Guillan-Barré syndrome, porphyria, sarcoidosis)
  • Multiple sclerosi

Classification

The pattern of lower urinary tract dysfunction following neurological disease is determined by the site and nature of the lesion.

Diagnostic evaluation

When diagnosing neurourological symptoms, your doctor will initially take a thorough medical history, do a physical examination, and ask you to keep a bladder diary. Early diagnosis and treatment are essential in neurourological disorders. Early intervention can prevent irreversible changes of the lower and upper urinary tract.

Patient history

For your medical history, your doctor will ask about past and present symptoms and disorders. Your doctor might also want to know all medications you are taking on a regular basis. The medical history is the cornerstone of evaluation because the answers will aid in diagnostic investigations and treatment options. The questions may address urinary and bowel symptoms as well as sexual function. Patients with neurourological symptoms may have related neurogenic bowel and sexual dysfunction.

Bladder diaries

Your doctor may ask you to keep a bladder diary. You will be asked to document the number of times you urinated, the volume of urine passed, pad weight if you are using pads, and incontinence and urgency episodes. This is typically done over 24 hours and for 3 consecutive days and helps identify the problem.

Patient quality of life questionnaires

Your doctor may ask you to fill out several questionnaires to assess your present and future quality of life. This can be important to evaluate and monitor the effect of your therapy.

Physical examination

Your doctor will also do a thorough physical examination. The examination will include the testing of all sensations and reflexes in the urogenital area as well as the anal sphincter and pelvic floor functions. It is essential to have this clinical information to reliably interpret later diagnostic investigations.
Your doctor may also decide to perform urinalysis and blood chemistry. Ultrasound or other imaging techniques may be recommended to evaluate the urinary tract.

Urodynamics

Urodynamic tests help your doctor to assess the function of your bladder.

During the tests, your bladder is filled and then emptied while pressure readings are taken from your bladder and your abdomen. The examination involves instilling fluid through a catheter into the bladder and evaluating the bladder’s muscle and nerve function. Various parameters are measured, including the pressure within the bladder, the sensation of urgency that you feel when your bladder is filled, and muscle contractions by the bladder wall. It may be combined with the use of x-rays or fluoroscopy. In that case, the bladder is then filled with a liquid contrast dye.

Your doctor may also decide to perform further specialist uroneurophysiological tests such as electromyography of the pelvic floor muscles, urethral sphincter, and/or anal sphincter or sensory testing of the bladder and urethra. Some patients have a risk of autonomic dysreflexia during urodynamic testing, which has to be managed.

Autonomic dysreflexia

Autonomic dysreflexia is a sudden and exaggerated autonomic response to various stimuli in patients with spinal cord injury or spinal dysfunction. The stimulus can be a distended bladder or bowel. It can also be secondary to sexual stimulation or a noxious stimulus, for example, an infected toe nail or pressure sore. Autonomic dysreflexia is defined by an increase in blood pressure and can have life-threatening consequences if not properly managed.

Renal function

In many patients with neurourological disorders, the upper urinary tract—and thus kidney function—is at risk. Patients with spinal cord injury or spina bifida have an especially high risk of developing kidney failure. Your doctor will watch carefully for any signs or symptoms of a possible deterioration of kidney function.

Disease Management

In neurourological patients, the primary aim is to protect the upper urinary tract. Kidney failure may result from many neurological conditions, for instance, spinal cord injuries. Your urologist may suggest a treatment to protect your kidney function even if you don’t have bothersome symptoms. Restoring the normal function of the lower urinary tract and achieving or maintaining continence to improve quality of life are also priorities in neurourology, provided that your kidneys are safe.

Non-invasive conservative treatment

Assisted bladder emptying

Incomplete bladder emptying is a serious risk factor for urinary tract infection, high pressure inside the bladder (with upper urinary tract deterioration), and incontinence. Methods to improve urination are usually necessary. The specific approach—non-invasive, invasive or pharmacological—should be decided with your doctor after careful and complete urological assessment.

Bladder expression (Credé manoeuvre) and urinating by abdominal straining

These manoeuvres can help empty the bladder but are rarely recommended. Pressure inside the bladder may rise over acceptable limits and impair kidney function over time (Figure 3). Only in very particular cases may your urologist suggest these techniques. The same applies to triggered reflex voiding, which is possible in some patients—for instance, by tapping a specific body location—but only following medical advice.

External appliances

These devices are designed to collect urine leaked during incontinence. Pads and diapers are the most well-known external appliances. For men, a condom catheter with a urine collection device is a practical alternative. Penile clamps should not be used in many cases like detrusor overactivity, low compliance, or altered or absent genital sensation.

Neurourological rehabilitation

A variety of office-based techniques are available. Electrical stimulation of specific nerves, pelvic floor muscle training and biofeedback have shown some positive results for specific neurourological conditions. Experience of the multidisciplinary team and equipment availability may vary. Ask your urologist which methods are available and recommended in your situation.

Drug treatment

No single, optimal medical therapy is available for neurourological symptoms. Medications are often used in combination (one drug or more) with other techniques, such as intermittent catheterization, and are tailored to the patient.

Drugs for storage symptoms

Antimuscarinic drugs—for example, oxybutynin, trospium, tolterodine, propiverine, darifenacin and solifenacin—are the first choice to treat overactive bladder (see also Patient information on overactive bladder), to increase bladder capacity, and to reduce urinary incontinence caused by bladder overactivity in neurourological patients. These medications have some side-effects, such as dry mouth, than can be reduced by lowering the dose or taking the drug a different way, for instance, through the skin.

The use of a recently introduced category of medications, called beta-3 adrenegic receptor agonists, in neurourological patients is currently being studied.

Drugs for voiding symptoms

Alpha blockers such as tamsulosin and naftopidil seem to be effective in improving urination and may reduce the risk of autonomic dysreflexia. Medical treatment to increase bladder contractility (in underactive bladder) or sphincter activity (in severe stress urinary incontinence) is not recommended.

Catheterisation

Intermittent catheterization by yourself or a health care provider is preferred for neurourological patients who cannot effectively empty their bladders. This technique can be done outside the health care setting. Catheter sizes and frequency of catheterisation should be discussed with your urologist or nurse practitioner.

Intermittent catheterisation prevents many complications associated with catheters that stay in place (indwelling: transurethral or suprapubic), including a high risk of urinary tract infections.

Correct performance of intermittent catheterisation is most important in managing the urinary tract of patients with neurourological symptoms.

Botulinum toxin injections in the bladder

This minimally invasive treatment is most effective for neurogenic bladder overactivity in patients with multiple sclerosis or spinal cord injury. The injection can be done by simple cystoscopy and causes reversible denervation for about 9 months. This means that repeated injections may be necessary. The treatment continues to be effective in the following administrations. After the injection, the bladder may not empty completely. Intermittent catheterisation may be necessary for a time. Urinary tract infections also may occur with this treatment.
See also in-depth information at: http://patients.uroweb.org/i-am-a-urology-patient/overactive-bladder-syndrome/second-line-treatment-for-oab/

Bladder neck and urethral procedures

Your neurourologic condition might hamper your urination by excessive resistance at the bladder neck or the sphincter. In this case, your doctor might suggest minimally invasive treatment to improve urination and to protect the upper urinary tract.

Sphincterotomy

The urinary sphincter may be cut, for example, by using a laser, to reduce sphincter resistance to urine passage without completely losing the closure function of the urethra. Incontinence may occur afterwards and can be managed. This procedure has to be repeated in many patients and does not have severe adverse effects. The implantation of urethral stents may be an alternative in some patients, although  the costs, complications, and need for reintervention have limited their use.

Bladder neck incision

This technique is used for fibrosis at the bladder neck, which might be a later result of previous procedures.

Surgical treatment

If conservative or minimally invasive treatment fails to control your symptoms or the risk to the upper urinary tract, your doctor will suggest more invasive surgical treatment. Depending on the existing problem, several procedures can be performed.

Read more about surgical treatment of urinary incontinence here.

Bladder neck and urethral procedures

Some procedures may be recommended to increase bladder neck or sphincter resistance to achieve continence. This should be attempted only if the pressure inside the bladder is already low. Several procedures are available. Your doctor will recommend a particular technique based on your situation.

Procedures used to increase the resistance in the bladder neck and urethra

  • Urethral slings (synthetic, autologous)
  • Artificial urinary sphincter
  • Functional sphincter augmentation
  • Bladder neck and urethral surgical reconstruction

Denervation, deafferentation, and sacral neuromodulation

In patients with a complete spinal lesion, a device can be implanted that is connected to parts of the spinal cord below the lesion to stimulate the bladder and cause urination if activated. This is called sacral anterior root stimulation and also may be used to induce defecation or erection. This approach has been used successfully in patients with some specific problems. Severing of other nerves, called sacral rhizotomy, is used mostly in support of this procedure but also was shown to reduce detrusor overactivity.

Sacral neuromodulation is a less invasive technique. Small electrodes are implanted next to the sacral nerves, which modulate the activity of the nerves. This technique is widely used in patients without neurological disease and also might help neurourological patients, but its role has not been well established yet.

Bladder covering by striated muscle

Surgical covering of the bladder with muscle tissue from the belly or the back is used to strengthen the bladder and establish a new way to control urinary function (voluntarily or by electrical stimulation) This complex procedure has been used successfully in some neurourological patients.

Bladder augmentation

Bladder capacity may be increased and overactivity improved through surgical expansion. This may be achieved by resecting part of the bladder muscle (autoaugmentation) or by using intestine or other expandable coverage. Augmentation cystoplasty is associated with possible complications such as recurrent infection, stone formation, and perforation. Candidates for these major reconstructive procedures should be chosen carefully.

Urinary diversion

Urinary diversion means creating an artificial way to pass urine produced by the kidneys by bypassing the bladder. When all other therapies have failed, this option can protect your kidneys and improve your quality of life. Although undoing the diversion is possible, it may be technically difficult. Discuss this treatment extensively with your doctor before choosing this option.

Continent diversion

Several techniques are available to create a pouch that can be used by the patient for intermittent catheterization. Frequent complications such as leakage or stenosis may occur.

Incontinent diversion

In patients who are not able to catheterize or whose upper urinary tract is already severely damaged, an incontinent diversion may be used. Your doctor with surgically create a stoma, which is a small portal in the area of your belly. The urine flows through the stoma to an attached collecting bag. This is technically easier to achieve than a continent diversion and usually has fewer complications.

Read more about urinary diversions here.

Urinary tract infection in neurourological patients

Urinary tract infection (UTI) is the onset of signs and/or symptoms accompanied by laboratory findings like a significant amount of bacteria or white blood cells in the urine.

UTI in neurourological patients can be caused by weakened defence mechanisms, impaired washout, and catheterization. The exact working mechanisms remain unknown.

Asymptomatic bacteriuria, which means the presence of bacteria in the urine without symptoms, is much more common in spinal cord injury patients than in the general population. It varies depending on bladder management—for example, clean intermittent catheterisation or an indwelling catheter—and should not be routinely screened for.

If you have a symptomatic UTI, you may have other signs and symptoms in addition to or instead of traditional signs and symptoms of a UTI. The most common signs and symptoms are fever, new onset or increase in incontinence, increased spasticity, malaise, lethargy or sense of unease, cloudy urine with increased urine odour, discomfort or pain over the kidney or bladder, dysuria, or autonomic dysreflexia.

If a symptomatic UTI is present, your doctor will do urinalysis and take a urine culture to identify the bacteria involved.

Disease management

Asymptomatic bacteriuria in patients with neurourological disorders should not be treated. Treatment of asymptomatic bacteriuria results in significantly more resistant bacterial strains without improving the outcome. If an antibiotic treatment is necessary, a single-dose treatment is not advised. In most cases, your doctor will prescribe a 5- to 7-day course of antibiotic treatment that can be extended up to 14 days, depending on the extent of the infection.

Recurrent UTI and prevention

Recurrent UTI in patients with neurourological disorders may be a sign of a suboptimal management of the underlying functional problem, for instance, incomplete bladder emptying or bladder stones. Your doctor will try to improve the bladder situation or other direct supporting factors as early as possible.

If the improvement of bladder function and removal of foreign bodies/stones is not successful, other strategies can be used to prevent UTI. In general, no preventive measure for recurrent UTI in patients with neurourological disorders can be recommended without limitations. Your doctor will consider individualized approaches like dietary supplements. A low-dose, long-term, antibiotic prophylaxis cannot reduce UTI frequency but increases bacterial resistance and thus is not recommended.

Sexual (Dys)function and fertility

The impact of neurourological disease on the sexual lives of patients develops at three different levels (Figure 2)

Presentation1.jpg-page-001
Fig. 2: Different levels at which neurourological diseases affect sexual function

The negative effect may be caused by direct neurological impairment of the nerves innervating the pelvic and genital area. General disability also may contribute towards sexual dysfunction. The psychosocial and emotional impact of the disease can play a negative role and must be addressed along with other causes.

Erectile dysfunction (ED)

If you have problems achieving and maintaining a sufficient erection, called erectile dysfunction, your doctor will usually start treatment after doing diagnostic tests, as for non-neurological patients.

Read more about erectile dysfunction here.

Male fertility

A combination of ED, ejaculation disorder, and impaired sperm quality is often present in the neurological patient and results in decreased fertility. If you want to father a child and it is not possible naturally, different means are available to retrieve sperm for further use in artificial insemination. In men with spinal cord injury, especially at Th6 or above, autonomic dysreflexia might occur during sexual activity and ejaculation. If you have a spinal cord injury, you should keep this in mind and tell your fertility clinic.

Retrograde ejaculation can be reversed using specific drugs or a balloon that prevents sperm from going inside the bladder as ejaculation occurs. Prostatic massage, vibrostimulation, or transrectal electroejaculation may allow for sperm retrieval (transrectal electroejaculation is more invasive and yields less viable sperm). If these techniques fail, sperm can be retrieved through microsurgery of the epididymis or surgical extraction of testicular pulp.

Since the introduction of intracytoplasmatic sperm injection (ICSI), spinal cord injury patients have a good chance of becoming biological fathers independent of the technique used to collect sperm.

Female sexuality

Most of the information available on this subject is from women with spinal cord injury and multiple sclerosis. Several areas of sexual life are frequently impaired in neurourological female patients, such as sexual desire, lubrication and orgasm. Most women continue to be sexually active but show decreased satisfaction levels.

Multidisciplinary teams should be available to address the different aspects of sexual dysfunction in neurourological patients.

Female fertility

Women with spinal cord injury are usually able to achieve pregnancy following a short period of absent menstruation (about 6 months) after the injury occurs.
Special care must be taken during labour and delivery because complications such as bladder problems, spasticity, pressure sores, anaemia, and autonomic dysreflexia may occur.

Living with neurourologic disorder

Many neurourologic disorder characteristics, symptoms, and hazards depend on the underlying cause. It’s possible that you aren’t bothered by symptoms but are at risk of developing complications. A timely and thorough diagnostic evaluation helps prevent worsening of the situation. Many treatment options enable individualized therapy. Safety and quality of life are main goals of therapy. Sometimes these aspects seem to be in competition, although this may be true only in the short term. The main aspect of safety is kidney function.

Depending on the characteristics, a neurourologic disorder can lead to impairment of kidney function. This condition is serious and might lead to intensive, time-consuming treatment, substantial reduction in quality of life, and early death. The primary aim of treatment of neurourologic disorders is the conservation of kidney function. Therapeutic measures like catheterization may represent a significant reduction of your quality of life but prevent even more serious constraints.

If your doctor’s treatment advice seems unreasonable to you, you should discuss your concerns and ask for alternatives.

Depending on the characteristic of your neurourological disorder, your doctor might want to check your kidney function on a regular basis. Your family doctor or general practitioner should be informed and should look for signs of impaired kidney function. Neurourological disorders are often unstable, and the symptoms may vary considerably, even within a relatively short period. Regular follow-up is necessary. The time interval depends on the underlying cause.

Urinary incontinence may have a significant impact on your social life. There are many treatment options. You shouldn’t be embarrassed to discuss your situation with your doctor.

A lot of tools exist like different catheters, pads, or condom catheters. Some can help in your daily life, and some might be better suited to your lifestyle than others. If you try to explain the details of your problem, your doctor can help you select the right tools.
You might also want to take a look at the patient information regarding urinary incontinence, overactive bladder syndrome, erectile dysfunction and nocturia for additional information.

Questions to ask your doctor

Because neurourological disorders can present in many different ways, a specific diagnosis and therapy is very important. EAU Patient Information gives you an overview of the possibilities. You will have questions specific to your individual situation. Your doctor is the person to answer these questions. It can be helpful to prepare a list of questions before you go see your doctor. Examples of questions you may want to ask are:

  • Why do I have this problem?
  • What are the risks of my condition?
  • What can I do to prevent complications and worsening of the situation?
  • Which treatment option do you recommend for me?
  • What can I expect from that treatment?
  • What are the possible side effects or risks of this treatment?
  • What treatment alternatives exist?
  • What are the benefits and drawbacks of the treatment options?
This information was produced by the Europan Association of Urology (EAU) Working Group

Dr. P. Honeck, Bensheim (DE)
D
r. J-P. Jessen, Sindelfingen (DE)
D
r. R. Pereira e Silva, Lisbon (PT)

 

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