NDO
Neurogenic bladder dysfunction can impact upper urinary tract function, affecting renal function, and can cause urinary incontinence, stones, and UTIs. It can also affect QoL, skin care problems, and sexual function. A significant number of patients with neurogenic bladder dysfunction may be both incontinent and require a wheelchair.
Bladder management goals include preserving the upper urinary tract, treating symptoms (incontinence, urgency), preventing UTIs, avoiding bladder overdistention, maintaining adequate bladder capacity with low compliance, promoting low-pressure micturition, minimizing use of indwelling catheter, and selecting therapy that minimizes risks to the patient while maximizing social, emotional, and vocational acceptability.29
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Table 3 summarizes the evaluation of bladder function in patients with neurologic disease.
Comprehensive History
History taking should cover a patient’s life span, with a special focus on pain, infection, hematuria, and fever that may point to the need for additional diagnostic testing. History should include:30
• Specific urinary history
• Mode/type of voiding (eg, catheterization); relief after voiding
• Bladder sensation
• Enuresis
• Initiation of micturition (normal, precipitate, reflex, strain, Credé)
• Interruption of micturition (normal, paradoxical, passive)
• Voiding/bladder diary where appropriate
• Bowel history
• Rectal sensation, fecal incontinence
• Desire to defecate; defecation pattern; initiation of defecation
• Sexual history
• Genital sensation
• Genital or sexual dysfunction symptoms
• Past and present general, medical, social factors
• Hereditary/familial risk factors
• History of diabetes, stroke;history of accidents or surgeries,especially
involving the spine orcentral nervous system
• QoL, social history (smoking,alcohol, drug use),life expectancy
Physical Examination
Physical examination should include a focused neurourologic evaluation. In addition to standard evaluation of the abdomen, back, rectum, pelvis, and genitalia, clinicians need to evaluate the dermatomes of spinal cord levels L2-S4 and urogenital and other reflexes in the lower spinal cord.30
Sensations to S2-S5 nerves on both sides should be assessed to determine their presence, type of sensation, and whether the bulbocavernous, perianal, and knee and ankle reflexes are increased, normal, reduced, or absent. Plantar responses (Babinski) should also be tested. The presence of anal sphincter tone will predict voluntary contractions of anal sphincter and pelvic muscles. A prostate examination in men and a pelvic prolapse examination in women should be done.30
Urgency and other urinary symptoms in neurologic patients may stem from non-neurologic etiologies. Conditions that should be ruled out include bladder abnormalities arising from bladder cancer, calculus, or interstitial cystitis; prostate or urethral abnormalities, prostate cancer or urethral stones in men/pelvic prolapse in women; and urogenital infections.
Urodynamic Studies
Urodynamic studies (see Table 3) can help guide management because symptoms and physical examination do not always correlate with type, extent, or level of injury or risk to renal function; in patients with spinal cord injury, the level of injury does not always correlate with urodynamic findings.31
The incidence of bladder dysfunction is among the highest in patients with spinal cord injury (68%). However, there are a variety of other neurologic disorders where bladder dysfunction is commonly seen, including multiple sclerosis (incidence of 37%-72%), myelodysplasia (50%-72%), Parkinson’s disease (35%-70%), diabetes (9%-33%), and cerebrovascular disease (12%-19%).32
