Canadian Urological Association guideline: Diagnosis, management, and surveillance of neurogenic lower urinary tract dysfunction - Full text

Guideline: Neurogenic bladderPrior neurogenic guidelines vary in their clinical assessment, investigations utilized and surveillance strategies (2)(3)(4)(5)(6) .The primary reason is that there is limited evidence to support a common strategy.The purpose of this guideline is to help urologists to identify high-risk patients with NLUTD and to provide an approach to the management and surveillance of patients with NLUTD. ClassificationThe etiology of a NLUTD is often classified based on whether the primary lesion is suprapontine, suprasacral, sacral or infrasacral (7) .A complementary system was developed by Madersbacher et al. based on the function of the detrusor muscle and of the external sphincter (8) .These systems allow a physician to have a general idea of how the lower urinary tract is likely to behave in SCI patients with more complete injuries.(Figure 1).Newer systems using MR urography in combination with urodynamics (UDS) have also been proposed. (9) MethodologyThis review was performed according to the methodology recommended by the Canadian Urologic Association (10) .EmBASE and Medline databases were used to identify literature relevant to the early urological care of NLUTD patients.Recommendations were developed by consensus and graded using a modified Oxford system which identifies level of evidence (LOE) and grade of recommendation (GOR).This complete version includes the full text of the guidelines (including the sections in the executive summary). Canadian epidemiology of neurogenic bladderThere are 3.7 million Canadians living with a neurologic condition, (11,12) three common types of neurologic conditions are Multiple Sclerosis (MS), Spina Bifida (SB) and Spinal Cord Injury (SCI).In Canada there are 100,000 individuals living with a diagnosis of MS, making it the highest prevalence rate of MS in the world (13) .There are also 35,000 Canadian's living with SB, which is the leading cause of disabling birth defect within the country (11,12,14) .In Canada 86,000 persons are living with SCI and 4300 new cases of SCI occur each year. (15)These numbers are projected to increase to 121 000 individuals, with 5800 new cases a year by 2030. (15)Trauma is the most frequent cause of SCI in Canada and most commonly affects men in the 20-29 year age group. (15)Compared to international etiology where the majority of SCI is the result of motor vehicle accidents, in Canada, traumatic spinal cord injury is most commonly caused by falls. (15-17) .Relevant to our aging population statistics, research also demonstrates that a large proportion of traumatic SCI resulting from falls occurs in the senior population. (16,17) hese traumatic SCI cases more frequently result in tetraplegia.Non-traumatic SCI result from disease processes such as MS, SB, tumors and infections.Of Canadians living with both traumatic and non-traumatic SCI, 30,000 experience paraplegia and 13,000 experience tetraplegia. (15,17) he incidence rate of non-traumatic SCI increases concurrently with age. (17,18) LUTD presents a common and CUAJ -CUA Guideline Kavanagh et al Guideline: Neurogenic bladder important complication following neurologic disease.In our aging Canadian population, the amount of traumatic and non-traumatic SCI is expected to increase, along with secondary health complications that accompany SCI, such as neurogenic bladder.Research from the U.S. reports frequency of neurogenic bladder to be 40-90% in MS, 40-61% in SB and 70-84% in SCI. (19)A recent Canadian study looking at the impact of bladder, bowel and sexual dysfunction in 51 community dwelling individuals with traumatic SCI reported that 59% of these individuals had bladder dysfunction. (20)eurological conditions often result in physical disability requiring the need for assistance with activities of daily living, including assistance with or requiring devices to manage NLUTD.Giesbrecht et al. reported that of Canadians living at home with a physical disability, 51% of individuals using a mobility device required assistance with personal care needs and 36% of these individuals also required assistance with basic medical care. (21)Additionally it was noted that of individuals requiring assistance with care needs at home, those with physical disabilities received an average of 25 hours of care/week versus an 13 hours of care/work given to those without a physical disability. (21)Furthermore, for those individuals with physical disability receiving 25hours of care/week, this reportedly only partially met all the care needs they required. (21)eurogenic disease also places an increased demand for health professional services within our health care system and from this a resulting increase in health care costs.For example, a hospital admission for SCI individuals experiencing even uncomplicated urinary tract infections costs the Canadian healthcare system an average of $8, 000. (22)Along with requiring more support with care needs at home, individuals with traumatic and non-traumatic SCI are 2.7 times more likely to contact a physician to address health care needs and also 2.6 times more likely to be hospitalized for health complications. (15)One of the most common health complications causing specifically traumatic SCI individuals to require these additional health care services are urinary tract infections, (23) often experienced as a direct result of neurogenic bladder. The diagnosis of NLUTDTo diagnose someone with NLUTD, a defined neurologic condition, or a strong suspicion of an undiagnosed neurologic disease must be present.Potential symptoms which may be suggestive of an undiagnosed acquired neurologic disease include those that precede a diagnosis of MS, cauda equina syndrome, and occult neural tube defect. (7)In these situations, referral to a neurologist for an evaluation may be warranted. History and physical examIn the setting of a diagnosed or probable neurologic disease, a careful evaluation must be carried out to identify symptoms and signs associated with neurogenic bladder dysfunction, with an emphasis on identifying common and potentially serious complications.In most cases, investigations followed by appropriate management can minimize this morbidity.The general

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