Treatment and follow-up of patients with neurogenic lower urinary tract dysfunction: AUA/SUFU Guideline
USA: A recent study published in the Journal of Urology has reported guidelines on the treatment and follow-up of adults with neurogenic lower urinary tract dysfunction (NLUTD).
Varirty of factors need to be considered by clinician treating patients with NLUTD. In addition to patient's urologic symptoms and urodynamic findings, other issues may influence management options of the lower urinary tract including hand function, cognition, mobility, type of neurologic disease, and social and caregiver support.
The guideline, drafted by the American Urological Association (AUA) and Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU), allows the clinician to understand the options available to treat patients, understand the findings that can be seen in NLUTD, and appreciate which options are best for each individual patient. This allows for decisions to be made with the patient, in a shared decision-making manner, such that the patient's quality of life can be optimized with respect to their bladder management.
For developing the guideline, David A. Ginsberg, University of Southern California, Los Angeles, California, and colleagues conducted a comprehensive search for studies assessing patients undergoing evaluation, surveillance, management, or follow-up for NLUTD from January 2001 through October 2017 and was rerun in February 2021 to capture newer literature.
This second part of the AUA/SUFU guideline covered recommendation statements 32 through 59 on treatment and management of adult neurogenic lower urinary tract dysfunction. Recommendations cover non-surgical management (eg, pelvic floor therapy, medical therapy, preference for intermittent catheterization, appropriate and inappropriate use of antibiotics, and use of onabotulinumtoxinA injection), surgical management (eg, sphincterotomy, stress incontinence procedures and bladder neck closure, neuromodulation, augmentation cystoplasty, catheterizable channel, and incontinent diversions such ileovesicostomy), as well as follow-up post-treatment.
Non-surgical Treatment
- Clinicians may recommend pelvic floor muscle training for appropriately selected patients with NLUTD, particularly those with multiple sclerosis or cerebrovascular accident, to improve urinary symptoms and quality of life measures.
- Clinicians may recommend antimuscarinics, or beta-3 adrenergic receptor agonists, or a combination of both, to improve bladder storage parameters in NLUTD patients.
- Clinicians may recommend alpha-blockers to improve voiding parameters in NLUTD patients who spontaneously void.
- Clinicians should recommend intermittent catheterization rather than indwelling catheters to facilitate bladder emptying in patients with NLUTD.
- For appropriately selected NLUTD patients who require a chronic indwelling catheter, clinicians should recommend suprapubic catheterization over an indwelling urethral catheter.
- In NLUTD patients who perform clean intermittent catheterization with recurrent urinary tract infection, clinicians may offer bladder instillations to reduce the rate of urinary tract infections.
- Clinicians may counsel NLUTD patients with recurrent urinary tract infection who use various forms of catheter management that cranberry extract has not been demonstrated to reduce the rate of urinary tract infections.
- In NLUTD patients with spinal cord injury or multiple sclerosis refractory to oral medications, clinicians should recommend onabotulinumtoxinA to improve bladder storage parameters, decrease episodes of incontinence, and improve quality of life measures.
- In NLUTD patients, other than those with spinal cord injury and multiple sclerosis, who are refractory to oral medications, clinicians may offer onabotulinumtoxinA to improve bladder storage parameters, decrease episodes of incontinence, and improve quality of life measures.
- In NLUTD patients who spontaneously void, clinicians must discuss the specific risks of urinary retention and the potential need for intermittent catheterization prior to selecting botulinum toxin therapy.
Surgical Treatment
- Clinicians may offer sphincterotomy to facilitate emptying in appropriately selected male patients with NLUTD but must counsel them of the high-risk of failure or potential need for additional treatment or surgery.
- Clinicians may offer urethral bulking agents to NLUTD patients with stress urinary incontinence but must counsel them that efficacy is modest and cure is rare.
- Clinicians should offer slings to select NLUTD patients with stress urinary incontinence and acceptable bladder storage parameters.
- Clinicians may offer artificial urinary sphincter to select NLUTD patients with stress urinary incontinence and acceptable bladder storage parameters.
- After a thorough discussion of risks, benefits, and alternatives, clinicians may offer bladder neck closure and concomitant bladder drainage methods to select patients with NLUTD and refractory stress urinary incontinence.
- Clinicians may offer posterior tibial nerve stimulation to select spontaneous voiding NLUTD patients with urgency, frequency, and/or urgency incontinence.
- Clinicians may offer sacral neuromodulation to select NLUTD patients with urgency, frequency, and/or urgency incontinence.
- Clinicians should not offer sacral neuromodulation to NLUTD patients with spinal cord injury or spina bifida.
- Clinicians may offer augmentation cystoplasty to select NLUTD patients who are refractory to, or intolerant of, less invasive therapies for detrusor overactivity and/or poor bladder compliance.
- Clinicians may offer continent catheterizable channels, with or without augmentation, to select NLUTD patients to facilitate catheterization.
- Clinicians may offer ileovesicostomy to select patients with NLUTD and must counsel them on the risks, benefits, alternatives, and the high-risk of needing additional treatment or surgery.
- Clinicians should offer urinary diversion to NLUTD patients in whom other options have failed, or are inappropriate, in order to improve long-term quality of life.
- Other potential treatments for NLUTD should be considered investigational and patients should be counseled accordingly.
Follow-up and post-treatment
- In NLUTD patients with impaired storage parameters and/or voiding that place their upper tracts at risk, clinicians should repeat urodynamic studies at an appropriate interval following treatment.
- In NLUTD patients with impaired storage parameters that place their upper tracts at risk and are refractory to therapy, clinicians should offer additional treatment.
- In NLUTD patients who have undergone lower urinary tract reconstruction incorporating a bowel segment(s), the clinician should assess the patient annually with:
- focused history, physical exam, and symptom assessment.
- basic metabolic panel.
- urinary tract imaging.
- Clinicians may perform urodynamics following sphincterotomy to assess outcome.
- In NLUTD patients who have undergone lower urinary tract reconstruction utilizing bowel, and who also develop gross hematuria or symptomatic recurrent urinary tract infection, clinicians should perform cystoscopy.
"Repeat urodynamics is recommended at 2-year intervals in patients with stable high-risk features and more frequently in those with dynamic concerning findings," the authors wrote. Urodynamics may be repeated to assess the efficacy of the intervention. Patients who have undergone lower urinary tract reconstruction with bowel should undergo annual imaging and renal function assessment with cystoscopy reserved for those with recurrent infections or gross hematuria.
Reference:
"The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Treatment and Follow-up," is published in the Journal of Urology.
DOI: https://www.auajournals.org/doi/10.1097/JU.0000000000002239
