Neurourological disorders NEW

What is a neurourological disorder?

The nervous system connects the brain and spinal cord to all parts of the body through a network of nerves. A disturbance in that network can cause problems storing and passing urine. Urinary problems caused by the nervous system are called neurourological disorders.

What is neurogenic lower urinary tract dysfunction?

The lower urinary tract consists of the bladder and urethra and includes the prostate in men (Figure 1). The bladder 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 high pressure. Below the bladder, the urinary sphincter helps store the urine and prevent leakage. It is composed of different parts and muscle layers. The urethra is the tube through which urine passes from the bladder out of the body.

The main functions of the lower urinary tract are storing and passing 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 sphincter 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.

These functions involve many parts of the nervous system, including the brain, the spinal cord, and the peripheral nerves. Any disturbance of these parts can lead to malfunction of normal storage and voiding and cause many symptoms. This disturbance is called 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 such as dementia, stroke, or multiple sclerosis
  • Previous surgery or injury to the spine or pelvis
  • Previous radiation
  • Deformity of the spine
  • A slipped disc
  • A brain tumour or abnormal cell growth that affects the nervous system
  • Diabetes
  • Numbness or pain in the hands or feet (called peripheral neuropathy)
Fig. 1a: The male lower urinary tract.
Fig. 1a: The male lower urinary tract.
Fig. 1b: The female lower urinary tract.
Fig. 1b: The female lower urinary tract.

Diagnosis

Early diagnosis and treatment are essential in neurourological disorders. Early intervention can prevent irreversible changes of the lower and upper urinary tract.
When diagnosing neurourological symptoms, your doctor may:

  • Take a thorough medical history
  • Ask you to keep a bladder diary
  • Ask you to complete a quality-of-life questionnaire
  • Do a physical examination
  • Test how your bladder fills and empties with pressure measurements (urodynamics)
  • Check your kidney function

Medical history

The medical history is the cornerstone of evaluation. The answers will help determine diagnosis and treatment options. Your doctor will ask you about past and present symptoms and illnesses. Your doctor also might want to know all medications you are taking regularly. The questions may address urinary and bowel symptoms as well as sexual function. Patients with neurourological symptoms may have related bowel and sexual problems.

Bladder diary

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 to help identify the problem.

Quality-of-life questionnaires

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

Physical examination

Your doctor will also do a thorough physical examination. The examination test all sensations and reflexes in the urogenital area as well as the anal sphincter and pelvic floor functions. This information is needed to understand later diagnostic tests.

Your doctor may also decide to analyse your urine 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.

Kidney function

In many patients with neurourological disorders, kidney function is at risk. Patients with spinal cord injury or birth defects of the spinal cord have an especially high risk of developing kidney failure. Your doctor will watch carefully for any signs or symptoms of possible deterioration of kidney function.

Treatment

If you have a neurourological problem, the main goal is to protect your kidneys and ureters. These organs compose 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.

Provided that your kidneys are safe, priorities in neurourology treatment are:

  • Restoring the normal function of the bladder
  • Achieving or maintaining continence to improve quality of life

Urinary tract infection in neurourological patients

Urinary tract infection (UTI) is diagnosed by common signs and/or symptoms:

  • Strong urge to urinate that doesn’t go away
  • Burning sensation or discomfort when urinating (dysuria)
  • Passing frequent, small amounts of urine
  • Cloudy urine with increased urine odour
  • Pink, red, or brownish urine
  • Pain above the pubic bone in women

Laboratory findings like a lot of bacteria or white blood cells in the urine confirm the diagnosis.

In neurourological patients, UTI can be caused by:

  • Weakened defence mechanisms
  • Inability to empty the bladder completely
  • Catheterisation

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

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:

  • Fever
  • Incontinence
  • Unpredictable need to urinate
  • Malaise
  • Lethargy or sense of unease
  • Discomfort or pain over the kidney or bladder
  • Sudden occurrence of high blood pressure (autonomic dysreflexia)

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

Treatment asymptomatic bacteriuria

Treating asymptomatic bacteriuria does not have a urological effect but causes many more resistant bacterial strains to develop. For this reason, it should not be treated in patients with neurourological disorders.

Recurrent UTI and prevention

If UTIs keep coming back in patients with neurourological disorders, it may be a sign that the underlying problem—for instance, incomplete bladder emptying or bladder stones—is not being addressed completely.

Sometimes improving bladder function and or removing a stone will solve the problem. If not, your doctor may consider individualised approaches like dietary supplements.

If an antibiotic treatment is necessary for UTI, 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.

Sexual (Dys)function and fertility

Neurourological disease affects patients’ sexual lives physically, psychologically, and sensory (Figure 4). A negative effect may be caused by direct impairment of the nerves that signal the pelvic and genital area. The psychosocial and emotional impact of neurourological disease can also be negative and must be addressed along with other causes.

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

Male fertility

Male neurological patients often have a combination of ED, ejaculation disorder, and impaired sperm quality. This combination causes decreased fertility. If you want to father a child and it is not possible naturally, sperm can be collected for later use in assisted reproduction. In men with spinal cord injury, especially of the thoracic spine (Th6 disc or above), sudden high blood pressure (autonomic dysreflexia) might occur during sexual activity and ejaculation. If you have a spinal cord injury, you should keep this in mind and tell the staff at your fertility clinic.

Some men have retrograde ejaculation, which causes sperm to go inside the bladder during ejaculation instead of out of the penis. It can be reversed using specific drugs or a balloon that prevents sperm going to the bladder.

Different techniques can be used to collect sperm from men with spinal cord injury.

Techniques like prostatic massage or stimulation with a vibrator may be used for sperm collection. Transrectal electroejaculation uses a light electrical current to cause ejaculation while the patient is asleep under anaesthesia, but it yields less viable sperm.

If these techniques do not work, sperm can be collected through microsurgery of the tube that carries sperm from the testicles (epididymis) or surgical removal of testicular pulp.

Intracytoplasmic sperm injection is an assisted reproductive technology. Since its introduction, spinal cord injury patients have a good chance of becoming biological fathers regardless of the technique used to collect sperm.

Fig. 4: Different levels at which neurourological diseases affect sexual function
Fig. 4: Different levels at which neurourological diseases affect sexual function

Female sexuality

Most of the information available 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.

Female fertility

Women with spinal cord injury may have a short period without menstruation (about 6 months) immediately after the injury. However, many are able to become pregnant once menstruation returns.

Special care must be taken during labor and delivery because complications can occur such as bladder problems, spasticity, pressure sores, anemia, and sudden high blood pressure (autonomic dysreflexia).

Living with a neurourological disorder

Many characteristics, symptoms, and hazards of neurourological disorders depend on the underlying cause. It’s possible that you are not bothered by symptoms but have a risk of developing complications. A timely and thorough diagnostic evaluation helps prevent worsening of the situation.

Many treatment options enable individualised therapy. Safety and quality of life are the main goals of therapy, with kidney function being the main aspect of safety.

Questions to ask your doctor

Because neurourological disorders can present in many different ways, a specific diagnosis and therapy is 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 see your doctor.

Here are some questions you might want to ask:

  • 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 EAU Patient Information Working Group, March 2017.

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