Part II: Clinical Challenges and Renal Considerations in Managing Gout

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Neurogenic lower urinary tract dysfunction—or neurogenic bladder (NGB) dysfunction—may be caused by various diseases and events affecting the nervous system controlling the lower urinary tract.


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The resulting dysfunction depends on location and extent of the neurologic lesion; thus, the population with NGB dysfunction is quite diverse (Table 1).1 Two common neurologic causes of neurogenic detrusor overactivity (NDO), which may cause symptoms similar to overactive bladder, are multiple sclerosis (MS) and spinal cord injury (SCI).2 Limitations imposed by the underlying disease and the broad range of symptoms encompassed by NGB dysfunction can have a significant effect on patient quality of life, necessitating both a multidisciplinary and an individualized approach to management and treatment.3


Treatment goals


One proposed treatment paradigm for patients with NGB dysfunction is to optimize oral therapy, provide local bladder treatment, and offer bladder augmentation and urinary diversion. Considerations in managing patients with NGB include the high rates of discontinuation of antimuscarinics,4 pharmacologic safety,5,6 and surgical and emerging therapies that can maximize adherence and minimize risk of systemic effects.7

The overarching goal for the patient with NGB dysfunction—including both NDO and detrusor sphincter dyssynergia, which can cause high intravesical pressure, leading to upper urinary tract damage—is to preserve renal function, decrease potential urologic complications, and improve quality of life by relieving symptoms. Patients with SCI or MS often have NDO, which also frequently causes urinary incontinence.8 The more independent a patient can become by reducing symptoms of urgency, frequency, and incontinence, the less likely he or she will need to rely on assistance or be institutionalized.


Individualized treatment plans should take into account a patient’s history and physical examination, urodynamic findings, renal function, and personal goals and limitations, including mobility, degree of disability, hand function, cognition, willingness and/or ability to perform clean intermittent catheterization (CIC), and the need for and ability of caregivers.9

Selection of therapy should focus on minimizing risks to patients while maximizing social, emotional, and vocational acceptability, including psychological, social, occupational, physical, and intimacy domains. There are no definitive 
consensus guidelines, however, for 
how to manage NDO symptoms in patients with MS and SCI.


Treatment options


Treatment for dysfunction usually includes a combination of both pharmacologic agents and nonpharmacologic approaches,10 including noninvasive, minimally invasive, and surgical options.