The traditional term “neurogenic bladder” has been redefined as “neurogenic lower urinary tract dysfunction” (NLUTD) to accurately encompass both bladder and outlet dysfunctions. The new AUA Guidelines address multiple neurologic conditions, offer recommendations for NLUTD evaluation, management, and follow-up, and discuss UTI and autonomic dysreflexia (AD) management.^1,2 Notably, pediatric NLUTD, fertility, erectile dysfunction, and neurogenic bowel dysfunctions were not addressed. The Guidelines stress the need to provide direction on how to stratify risk to determine appropriate surveillance and/or management.

Patients are first categorized as low or unknown risk. Unknown-risk patients undergo further evaluation (Figure 1; Table).

Table. Risk Stratification Criteria

Initial evaluation of low-risk NLUTD patients should not routinely include upper tract imaging, renal function assessment, or urodynamics (UDS). Cystoscopy is not necessary in the initial evaluation of the NLUTD patient, no matter their risk, but it is reserved for cases of hematuria, recurrent UTI, or suspected anatomic anomaly.

Urodynamics and upper tract imaging should be obtained in patients with unknown-risk NLUTD to establish their risk stratification based on the type of lower urinary tract impairment they may have and direct management.

Autonomic Dysreflexia

During UDS or cystoscopy, patients at risk for AD must be monitored for hemodynamic instability. If the patient develops AD during either study, the study should be terminated, and the bladder should be immediately drained. If AD continues, clinicians should administer pharmacologic management.

UTIs

Screening urine tests for asymptomatic NLUTD patients is not advised, nor is treating asymptomatic bacteriuria. Instead, clinicians should determine the need to test and treat based on the presence or absence of urinary symptoms and signs of infection. If no symptoms or signs of infection are present, then the use of antibiotics is not recommended. If the patient has a catheter and UTI is suspected, the specimen should be obtained after catheter exchange. Daily antibiotic prophylaxis should not be used in patients who perform clean intermittent catheterization (CIC) and do not have recurrent UTIs, nor should prophylaxis be used in patients with indwelling catheters. Patients who perform CIC and have recurrent UTIs may be offered daily prophylaxis or bladder instillations to reduce the rate of UTIs. Cranberry extract has not been demonstrated to reduce the rate of UTI in catheter-dependent patients. If a patient with a febrile UTI does not respond to appropriate antibiotic treatment or is not up to date with routine upper tract imaging, imaging should be obtained.

Management

Management focuses on whether there are problems with the storage and/or emptying functions of the lower urinary tract.

In NLUTD patients who void on their own, urinary frequency, urgency, or incontinence can be treated using antimuscarinic and/or β-3 agonists. They may also be offered posterior tibial nerve stimulation. Select NLUTD patients may benefit from sacral neuromodulation but this should not be offered to patients with spinal cord injury (SCI) or spina bifida. Intradetrusor onabotulinumtoxinA injections may be used in NLUTD patients refractory to oral medications, although patients who spontaneously void should be counseled on the risk of urinary retention and the potential need for CIC prior to proceeding with botulinum therapy.

In the NLUTD patient who performs CIC, antimuscarinics, β-3 agonists, and intradetrusor botulinum can also be used to improve bladder storage parameters such as detrusor overactivity and/or impaired bladder compliance. After treatment for impaired storage parameters, clinicians should repeat UDS to assess for improvement. Patients who are refractory or less tolerant of these therapies can be offered augmentation cystoplasty. For those patients who are not candidates or are unwilling to undergo lower urinary tract reconstruction, urinary diversion via chronic catheter can be considered. Other options that can be considered include intestinal urinary diversion to improve long-term quality of life. Patients who undergo lower urinary tract reconstruction incorporating a bowel segment should undergo an annual assessment with a basic metabolic panel and upper tract imaging to evaluate for metabolic disturbances and to assess for obstruction, which may be due to the reconstruction.

NLUTD patients with stress urinary incontinence and acceptable storage parameters can be offered slings or artificial urinary sphincters. Select patients may also be offered bladder neck closure and concomitant bladder drainage.

For those patients with impaired emptying, α-blockers can improve voiding parameters in patients who spontaneously void. For those who cannot void spontaneously, mechanical drainage with catheter assistance is needed. Ideally, clean intermittent catheterization is preferred over an indwelling catheter. However, CIC requires adequate dexterity or caregiver support. It is important to remember to confirm safe storage parameters if CIC is employed. If an indwelling catheter is indicated, suprapubic catheterization is preferred as a long-term urethral catheter can lead to traumatic hypospadias in men or urethral erosion in women. Select patients may benefit from continent catheterizable channels to facilitate catheterization as some patients may find a fixed continent stoma on their abdomen, which will allow easier CIC performance. Sphincterotomy may be offered to appropriate male patients with NLUTD to facilitate emptying but with a high risk of failure.

Surveillance

Risk stratification of the patient with NLUTD guides the surveillance protocol outlined in Figure 2.

Low-risk NLUTD patients who present with new-onset signs and symptoms, new complications (AD, UTI, stones), hydronephrosis, or worsening renal function should undergo repeat risk stratification.

Moderate- and high-risk patients with urinary symptom changes may undergo repeat UDS. Surveillance cystoscopy is not recommended for NLUTD patients, regardless of catheter usage. In those with an indwelling suprapubic or urethral catheter, the catheter and catheter site should be inspected at regular intervals to ensure no iatrogenic trauma. CIC is preferred over an indwelling catheter when feasible.

Practice Questions

A 70-year-old female with history of stroke reports urinary frequency, urgency, urge incontinence, and nocturia. She notes no improvement with a trial of oxybutynin, tolterodine, or mirabegron. The exam shows normal female genitalia with mild hypermobility but no stress incontinence. Urinalysis is negative, and PVR is 10 mL.

1. 1. What is the risk stratification?
      1. Low
      2. Medium
      3. High
      4. I don’t know
   2. Is surveillance required?
      1. Yes
      2. No
   3. What is the next step?
      1. Dual medications with oxybutynin and mirabegron
      2. Cystoscopy
      3. Urodynamics
      4. Cystoscopy with Botox 100
      5. Chronic suprapubic tube

A 31-year-old male with T12 SCI after a car accident 6 months ago. No prior urologic issues. He has been on bethanecol and tamsulosin. PVR 250 mL.

1. 1. What is the risk?
      1. Low
      2. Medium
      3. High
      4. I don’t know

Labs are within normal limits, and ultrasound shows no hydronephrosis; UDS is shown in Figure 3.

1. 1. What are the UDS findings?
      1. Detrusor overactivity
      2. Detrusor areflexia
      3. Detrusor sphincter dyssynergia
      4. Normal study
   2. What is the risk stratification?
      1. Low
      2. Medium
      3. High
      4. I don’t know
   3. What should the management plan be?
      1. CIC alone
      2. Bladder medication alone
      3. CIC with bladder medications
      4. CIC with bladder Botox injection
   4. What should the surveillance plan be?
      1. Annual visit, with renal function, renal ultrasound every 1-2 years
      2. UDS annually
      3. Cystoscopy after 5 years
      4. All of above

A 44-year-old male with C4 SCI for 18 months. His caretaker performs CIC every 4 hours, and he takes oxybutynin XL 30 mg daily. He leaks between catheterizations and often gets “goose bumps,” which resolve with catheterization. He also reports febrile UTI every 6 weeks. Renal ultrasound shows right moderate hydronephrosis.

1. 1. What is the risk?
      1. Low
      2. Medium
      3. High
      4. I don’t know
   2. What should the next step be?
      1. Convert to Foley catheter
      2. Cystoscopy with bladder injection of onabotulinumtoxinA 200 units
      3. Low-dose suppression with sulfamethoxazole/trimethoprim
      4. CT-urogram
      5. Videourodynamics
   3. During UDS, the patient begins to get goosebumps, sweats, and a headache. What is the next best step?
      1. Give Tylenol and cool the room down
      2. Stop the study and administer steroids for possible allergic reaction to the contrast
      3. Finish the study as quickly as possible
      4. Stop the study and decompress the bladder as quickly as possible
      5. Admit to the ICU
   4. What is the next step if he continues to have symptoms after decompression?
      1. Remove the Foley catheter
      2. Administer ½ inch of nitropaste to the thigh
      3. Apply 1 inch of nitropaste to the shoulder/neck
      4. Administer 20 mg furosemide immediately and monitor basic metabolic panel
      5. Admit to the ICU

UDS shows a capacity of 220 mL and detrusor external sphincter dyssynergia. Detrusor pressure reaches 58 with a leak, and there is grade 3 right vesicoureteral reflux.

1. 1. What should the management plan be?
      1. Cystoscopy with chemodenervation of bladder with onabotulinumtoxinA
      2. Implant sacral neuromodulation
      3. Diazepam
      4. Transurethral resection of the prostate

A 64-year-old male with C3 SCI managed with a chronic suprapubic tube for 19 years, which is exchanged every 4 weeks. He denies UTIs and had a negative surveillance cystoscopy 9 years ago.

1. When should his next surveillance cystoscopy be?
   1. This year
   2. Next year
   3. Five years
   4. He should not have any more surveillance cystoscopy

Answer Key

1: A; 2: B; 3: D; 4: D; 5: B; 6: B; 7: A; 8: A; 9: C; 10: E; 11: D; 12: C; 13: A; 14: D