AUA Guideline: Evaluation and Treatment of Neurogenic Lower Urinary Tract Dysfunction

By: David A. Ginsberg, MD | Posted on: 06 Aug 2021

The term neurogenic lower urinary tract dysfunction (NLUTD) refers to abnormal function of the bladder and/or sphincters, related to a neurological disorder. Abnormal bladder activity could include storage (urinary frequency, urgency, urgency incontinence) or emptying symptoms (urinary retention, obstructive voiding symptoms, incomplete bladder emptying), or urodynamic abnormalities such as detrusor overactivity (DO), loss of bladder compliance and poor or absent detrusor contractility. Abnormal sphincter activity could include detrusor-external sphincter dyssynergia, leading to obstruction, as well as loss of normal sphincteric function, leading to symptoms of stress incontinence. One of the challenges in treating patients with NLUTD is understanding the various signs and symptoms (and levels of risk) that are associated with the neurological entities that can cause NLUTD. Some of the more common neurological diagnoses that can lead to NLUTD include cerebrovascular accident (CVA, ∼795,000 people experience a CVA every year in the United States),1 multiple sclerosis (prevalence of 288–309 cases per 100,000)2 and spinal cord injury (∼17,700 new cases/year).3

To formulate this guideline a literature search of relevant article was performed that included studies published from January 2001 through February 2021. This resulted in 172 studies for qualitative synthesis. Like all AUA Guidelines, recommendations were stratified as Strong, Moderate or Conditional based on the net benefit and harm and were assigned a strength rating (A–high, B–moderate, C–low) based on the level of literature (or Clinical Principle or Expert Opinion if the literature was insufficient).

The initial portion of the NLUTD Guideline focuses on the risk stratification of the NLUTD patient. This risk stratification is essential as it later places patients into different categories in regards to followup. The 3 risk categories are low, moderate and high (see table). Low-risk NLUTD patients are by definition those with a neurological diagnosis that is low-risk to the upper urinary tract (ie stroke, Parkinson’s disease, dementia), void with a low post-void residual (PVR) and have not suffered any urological complications or recurrent urinary tract infections (UTIs). Because of their low-risk neurological conditions, these patients do not require upper tract imaging, renal function assessment, or urodynamic studies at initial presentation or require regular urological followup unless new urinary signs or symptoms occur.

Table. NLUTD risk stratification

Low Risk Moderate Risk High Risk
Urodynamics Balanced voiding (if assessed) Neurogenic retention
DO w/incomplete emptying
Poor compliance
Vesicoureteral reflux (if done with videos)
High storage pressures
with DO
PVR (voiding pts): Low Elevated
Ultrasound findings Normal/stable Normal findings Hydro, new renal scaring, loss of parenchyma, and staghorn/ large stone burden
Renal function Normal/stable Normal/stable Abnormal/unstable

Patients not in the low-risk category should initially undergo evaluation with upper tract imaging, renal function assessment and multichannel urodynamics to further stratify their risk category. Potential findings of moderate-risk NLUTD include urinary retention and neurogenic detrusor overactivity (NDO) with incomplete emptying and it is recommended that patients with moderate-risk NLUTD undergo annual examination and symptoms assessment, annual renal function assessment and upper tract imaging every 1–2 years. Potential findings of high-risk NLUTD include poor bladder compliance, vesicoureteral reflux, elevated detrusor storage pressures (with NDO), hydronephrosis, large stone burden and abnormal/unstable renal function, and it is recommended that patients with high-risk NLUTD undergo annual examination and symptoms assessment, annual renal function assessment, annual upper tract imaging and repeat urodynamic evaluation when clinically indicated. In addition, a new abnormal sign or symptom that could suggest a change in lower urinary tract function would be an indication for re-evaluation, as indicated.

Urinary tract infection in patients with NLUTD is also addressed. This can be an especially challenging issue due to chronic bacteriuria secondary to both indwelling catheters and the use of clean intermittent catheterization in this patient population. Due to this, it is recommended that patients with symptoms of UTI have a urinalysis and culture obtained prior to initiating antibiotic therapy and that screening urine studies, including culture, not be obtained in asymptomatic patients.

The clinician treating patients with NLUTD needs to balance a variety of factors when making treatment decisions. In addition to patient symptoms and urodynamic findings (if applicable), other issues that may influence management options of the lower urinary tract include cognition (which can be impacted by the neurological disorder), hand function, type of neurological disease (progressive versus stable), and mobility. This Guideline should aid the clinician caring for patients with NLUTD to better understand which of these options may be best for each individual patient and to appreciate how treatment decisions are made in a shared decision making fashion. Treatment options that are discussed include various oral medications, catheters (both indwelling and intermittent), neuromodulation, botulinum toxin and surgeries such as bladder augmentation and urinary diversion.

  1. Roger VL, Go AS, Lloyd-Jones DM et al: Heart disease and stroke statistics–2011 update: a report from the American Heart Association. Circulation 2011; 123: e18.
  2. Wallin MT, Culpepper WJ, Campbell JD et al: The prevalence of MS in the United States: a population-based estimate using health claims data. Neurology 2019; 92: e1029.
  3. National Spinal Cord Injury Statistical Center: Spinal Cord InjuryFacts and Figures at a Glance. Available at https://www.Nscisc.Uab.Edu/public/facts%20and%20figures%20-%202018.pdf.
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