A young man with T6 paraplegia has urinary incontinence due to neurogenic detrusor overactivity (NDO) refractory to antimuscarinics. A trial of botulinum toxin seems like the obvious answer. But what if he has C5 complete quadriplegia? Or what if he were a woman with a T6 injury who has good hand function but can’t transfer to self-catheterize? How about a woman with stable multiple sclerosis (MS) and NDO vs a woman with rapidly progressive MS and NDO? Each of these situations requires a tailored approach, and putting every patient through the same algorithm can lead to frustration and poor outcomes.

At this year’s AUA Annual Meeting, Dr. Sean Elliott will moderate a Crossfire Debate on “Management of Neurogenic Bladder: Suprapubic Cystostomy, Botulinum Toxin and Augmentation Cystoplasty.”Debaters will include Drs. Anne Pelletier-Cameron (defending suprapubic cystostomy), Katherine Theisen (defending botulinum toxin) and Jeremy Myers (defending augmentation cystoplasty).

Suprapubic cystostomy, botulinum neurotoxin (BoNT) and augmentation cystoplasty are all appropriate treatments. So, rather than focusing on which treatment is the best for NDO, the panel will discuss when each treatment is superior. Panelists will highlight the phenotypes of patients they believe are most appropriate for the therapy they are defending.

Clean intermittent catheterization (CIC) remains the gold standard method of bladder emptying. When CIC is paired appropriately with a bladder storage aid such as antimuscarinics, BoNT or augmentation cystoplasty, patients can achieve an excellent quality of life. But if administration of antimuscarinics or BoNT does not completely resolve NDO, then patients can suffer from bladder spasms and incontinence. Furthermore, we often do not appreciate the challenges of CIC—due to spasticity, motor weakness, genital anatomy or obesity. How many of us have watched our patients catheterize?

For the purposes of this article, we will go through the example of spinal cord injury (SCI) to highlight the different phenotypes of neurogenic bladder and how to select the best treatment; but in the Crossfire Debate we will also discuss phenotypes of MS, spina bifida and cerebral palsy.

SCI patients are often young and thin. Compared to patients with congenital neurogenic bladder, they lived a good deal of their life without a neurological injury and, according to surveys, they strongly value independence.¹ They have a fixed lesion (compared to progressive lesions with MS). Of SCIs in the United States 60% are quadriplegia, but most of those are incomplete. After their injury, patients spend weeks to months in acute rehabilitation with a team of providers who teach and help them perform CIC. Over half are on CIC at the time they exit acute rehabilitation, but only 20% remain on CIC long-term.² The strongest predictor of remaining on CIC is upper extremity function, followed by male gender and low body mass index.³ Most of those who exit CIC opt for an indwelling catheter. Unfortunately, this indwelling catheter is most often a urethral catheter, which is associated with more complications long-term than a suprapubic cystostomy.⁴

SCI patients with an indwelling catheter develop twice as many urinary tract infections per year as those on CIC⁵ and are more likely to develop stones, hydronephrosis and poor bladder compliance.⁶ Yet, when we surveyed 1,479 people with SCI, those on CIC had a lower urinary quality of life than those with augmentation cystoplasty or an indwelling catheter.⁷ The most common reasons cited by patients for abandoning CIC are inconvenience, incontinence and recurrent urinary tract infections.^8,9 Clearly, we could do a better job of optimizing who gets put on a regimen of CIC and who goes right to a suprapubic cystostomy.

In SCI, BoNT is most appropriate for someone who can self-catheterize through their native urethra. These are more likely to be (but not only) men with paraplegia. Patients should be dry in between BoNT injections and should be able to go at least 6 months between injections. If a patient cannot self-catheterize through their native urethra but can do so through a catheterizable channel, then one should strongly consider an augmentation cystoplasty at the time of channel creation. Typically, these are women with paraplegia who cannot transfer or SCI patients of either gender with partial quadriplegia; these are people who typically can catheterize a stoma more easily than their urethra. Lastly, someone with a complete high cervical injury will be unable to catheterize themselves. While some will be motivated to pursue CIC and can do so if they have adequate in-home support, most will be better served by early placement of a suprapubic cystostomy before they default to a urethral catheter.

The real winner of this Crossfire Debate will be the audience members, who will leave with a better understanding of how different phenotypes of neurogenic bladder patients fare with different treatment options. While every patient is different and we need to listen to their preferences, it can ease the evaluation and discussion of management options if we can compare our patients in clinic to the different phenotypes presented in this debate.