Neurogenic Lower Urinary Tract Dysfunctions Research Articles

Beyond the urothelium: Interplay between autonomic nervous system and bladder inflammation in urinary tract infection, bladder pain syndrome with interstitial cystitis and neurogenic lower urinary tract dysfunction in spinal cord injury-ICI-RS 2023.

Inflammation and neuronal hypersensitivity are reactive protective mechanisms after urothelial injury. In lower urinary tract dysfunctions (LUTD), such as urinary tract infection (UTI), bladder pain syndrome with interstitial cystitis (BPS/IC) and neurogenic LUTD after spinal cord injury (SCI), chronic inflammation can develop. It is unclear how the protective reactionary inflammation escalates into chronic disease in some patients. During its 2023 meeting in Bristol, the International Consultation on Incontinence-Research Society (ICI-RS) reviewed the urothelial and inflammatory changes after UTI, BPS/IC and SCI. Potential factors contributing to the evolution into chronic disease were explored in a think-tank. Five topics were discussed. (1) Visceral fat metabolism participates in the systemic pro-inflammatory effect of noradrenalin in BPS/IC and SCI. Sympathetic nervous system-adipocyte-bladder crosstalk needs further investigation. (2) Sympathetic hyperactivity also potentiates immune depression in SCI and needs to be investigated in BPS/IC. Gabapentin and tumor necrosis factor-α are promising research targets. (3) The exact peripheral neurons involved in the integrative protective unit formed by nervous and immune systems need to be further identified. (4) Neurotransmitter changes in SCI and BPS/IC: Neurotransmitter crosstalk needs to be considered in identifying new therapeutic targets. (5) The change from eubiosis to dysbiosis in SCI can contribute to UTI susceptibility and needs to be unraveled. The think-tank discussed whether visceral fat metabolism, immune depression through sympathetic hyperactivity, peripheral nerves and neurotransmitter crosstalk, and the change in microbiome could provide explanations in the heterogenic development of chronic inflammation in LUTD. High-priority research questions were identified.

Neurogenic urinary disorders in patients with tuberculous spondylitis before and after surgical treatment

ABSTRACT: Tuberculosis inflammation of vertebral column (spondylitis) can lead to neurogenic lower urinary tract dysfunction. There is lack of available publications for neurogenic lower urinary tract dysfunction in spinal tuberculosis.
 OBJECTIVE: To evaluate urodynamic disturbances in spinal tuberculosis before and after surgery for spondylitis.
 MATERIALS AND METHODS: We observed 19 patients with spinal tuberculosis, who had symptoms of micturitions impairment. 14 patients (73,6%) were male and 5 (26,4%) were female, average age was 43,7 7,9 years (2766). Control evaluation was performed after surgery on day 2128.
 RESULTS: Before surgery we found detrusor overactivity in 11 (57,9%) patients and 2 of those with detrusor overactivity had detrusor-sphincter dyssynergia. Detrusor hypo-/acontractility was diagnosed in 8 (42,1%). After surgery 5 patients (26,3%) exhibited improvement, in one case urodynamic disturbances were resolved. One patient developed detrusor overactivity and incontinence de novo and one patient had worsening neurological status, loss of sensitivity and acontractile bladder.
 CONCLUSION: Variable lower urinary tract dysfunction can be diagnosed in spinal tuberculosis. Only 26,3% of patients have improvement after surgery. New conditions or worsening of previous neurogenic lower urinary tract dysfunctions can be observed.

Systematic Literature Review and Meta-Analysis of Sacral Neuromodulation (SNM) in Patients with Neurogenic Lower Urinary Tract Dysfunction (nLUTD): Over 20Years' Experience and Future Directions.

IntroductionSacral neuromodulation (SNM) has been used in carefully selected patients with neurogenic lower urinary tract dysfunctions (nLUTD) for over two decades.MethodsThe aim of the current work was to perform a systematic literature review and meta-analysis of studies reporting the safety and effectiveness of SNM in patients with nLUTD (neurogenic detrusor overactivity, non-obstructive urinary retention, or a combination of both). For this purpose a systematic literature research was conducted using Embase (OvidSP), MEDLINE (OvidSP), MEDLINE In-Process Citations & Daily Update (OvidSP), MEDLINE (OvidSP) e-Pub ahead of print, Cochrane Central Register of Controlled Trials (CENTRAL), NIH Clinicaltrials.gov, and WHO International Clinical Trials Registry Platform (ICTRP) between 1998 and March 2020, supplemented by a hand search.ResultsForty-seven studies were included in the systematic literature review. Twenty-one studies comprising a total of 887 patients were included in the meta-analysis of test SNM. The pooled success rate of SNM test stimulation was 66.2% (95% CI 56.9–74.4). Depending on neurogenic conditions test success rates varied greatly. Twenty-four studies with a total of 428 patients were included in the meta-analysis of permanent SNM. The success rate of pooled permanent SNM was 84.2% (95% CI 77.8–89.0). Among the identified studies, the most common adverse events (AEs) were loss of effectiveness, infection, pain at implant site, and lead migration with AE rates of 4.7%, 3.6%, 3.2%, and 3.2%, respectively. Limitations entail lower level of evidence (Oxford classification 3–4) of included studies, significant risk of bias, small sample sizes in some studies, the inclusion of retrospective case series, substantial between-study heterogeneity, heterogeneous patient populations, insufficient disease classification, and variations in terms of outcome parameters as well as techniques. Furthermore, long-term data are limited.ConclusionThis meta-analysis supports not only the benefits of permanent SNM for various nLUTDs but also high overall success rates, similar to idiopathic patients. Current data of the analyzed studies showed that SNM is safe for these patients. However, more vigorous studies and/or registries are needed before definitive conclusions can be drawn.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12325-021-01650-9.

Role of videourodynamic study in precision diagnosis and treatment for lower urinary tract dysfunction.

Lower urinary tract symptoms (LUTS) are complicated and cannot be used alone to diagnose lower urinary tract dysfunctions (LUTDs) and guide treatment. Patients with bladder outlet obstruction (BOO), impaired detrusor contractility, and hypersensitive bladder might present with voiding predominant symptoms, whereas patients with detrusor overactivity (DO), dysfunctional voiding, or BOO might also present with storage symptoms. To clearly identify the pathophysiology of LUTD, a comprehensive urodynamic study (UDS) including pressure flow and image during the storage and emptying phases, naming videourodynamic study (VUDS), is necessary. This study is especially mandatory in the diagnosis of (1) male LUTS refractory to medical treatment for benign prostatic hyperplasia, (2) female voiding dysfunction and urinary retention, (3) diagnosis of overactive bladder syndrome refractory to first-line medication, (4) management of female stress urinary incontinence and postoperative LUTS, (5) diagnosis and management of neurogenic LUTD, (6) pediatric urinary incontinence and enuresis, (7) geriatric urinary incontinence, and (8) recurrent bacterial cystitis. Although VUDS should not be used as a screening test for any LUTS, it should be considered when the initial management cannot relieve LUTS, or when invasive surgical procedure is planning to undertake for patients with refractory LUTS. VUDS should be recommended as the second-line investigation when the initial diagnosis and treatment based on the symptoms alone or noninvasive tests fail to improve LUTS.

Transcranial magnetic stimulation and bladder function: A systematic review

ObjectiveWe aimed at assessing the usefulness of motor evoked potentials (MEPs) for exploring the integrity of striated sphincters and pelvic floor motor innervation in normal subjects and of repetitive transcranial magnetic stimulation TMS (rTMS) in patients with neurogenic bladder dysfunction. MethodsA systematic literature search was conducted using PubMed and Embase. ResultsWe identified, reviewed and discussed 11 articles matching the inclusion criteria. ConclusionsThe assessment of MEPs could represent a useful tool in the investigation of patients with urologic disorders. High frequency rTMS can improve detrusor contraction and/or urethral sphincter relaxation in patients with multiple sclerosis and bladder dysfunction. Low frequency (LF) rTMS seems to be an effective treatment of neurogenic lower urinary tract dysfunctions in subjects with Parkinson’s disease and possibly other neurodegenerative disorders. Furthermore, rTMS might have the potential to restore bladder and bowel sphincter function after incomplete spinal cord injury. LF rTMS could also relieve some symptoms of bladder pain syndrome and chronic pelvic pain. SignificanceThe clinical applicability of MEPs appears to be questionable, since a poor reproducibility was detected for all pelvic floor muscles. The use of rTMS in this field is emerging and the results of a few preliminary studies should be replicated in controlled, randomized studies with larger sample sizes.

Comparison of neurogenic lower urinary tract dysfunctions in open vs. closed spinal dysraphism: Results observed in a prospective cohort of 395 patients

Spinal dysraphism is the first congenital cause of neurogenic bladder. Open spinal dysraphism (mainly myelomeningocele) being diagnosed in the neonatal period, neurogenic lower urinary tract dysfunctions (NULTD) are well-known as they have been described in many series. Conversely, closed spinal dysraphisms are often diagnosed later and little data regarding NULTD exist. The aim of this study was to compare the NULTD in patients with closed dysraphism (CD) to those in patients with open dysraphism (OD). A prospective study was conducted between 2007 and 2016 including all spina bifida patients seen in a multidisciplinary national referral center. At the first visit, lower urinary tract function was assessed as follow: history of past urological surgery, type of spinal dysraphism, Abbreviated Injury Scale, method of bladder emptying, Urinary Symptom Profil (USP) and Qualiveen scores and urodynamic parameters. In total, 395 patients were included: 274 with OD (69.4%) and 121 with CD (30.6%). Patients in the CD group were older (35.9 vs. 29.5 years, P < 0.0001), and had lower BMI (23.8 vs. 28 years, P = 0.0002). The method of bladder emptying was spontaneous voiding, clean intermittent catheterization and transileal cutaneous ureterostomy in 47.1% vs. 29.3%; 47.1% vs. 59.4% and 5.7% vs. 11.2% of CD and OD patients respectively ( P = 0.01). The prevalence of urinary incontinence did not differ significantly between the two groups (44.7% vs. 53.5%), as well as the mean Qualiveen score (76.6 vs. 81.7). The main medical concern was NLUTD in 26% of patients with CD and in 27.8% of patients with OD ( P = 0.73). Surgery (augmentation cystoplasty, artificial urinary sphincter, continent cystostomy) was more common in patients with OD ( P < 0.01). NLUTD were as frequent and troublesome in patients with open vs. closed spinal dysraphism. However the need for a surgical treatment was more common in patients with OD.

1133 - Comparison of neurogenic lower urinary tract dysfunctions in open vs. closed spinal dysraphism: Results observed in a prospective cohort of 395 patients

1133 - Comparison of neurogenic lower urinary tract dysfunctions in open vs. closed spinal dysraphism: Results observed in a prospective cohort of 395 patients

Improving Outcomes in Patients With Refractory Idiopathic and Neurogenic Detrusor Overactivity: Management Strategies

Neurogenic detrusor overactivity (NDO) is a lower urinary tract dysfunction commonly seen in rehabilitation settings. The emotional, medical, and financial consequences of NDO can be substantial and management typically requires a multidisciplinary team approach. Physiatrists need to be able to identify patients who require referral to specialists for diagnostic testing or higher-tiered treatment and need to engender open lines of communication between their patients and all treating clinicians. This requires an understanding of the evaluation, diagnosis, and treatment of neurogenic lower urinary tract dysfunctions.

Chapter 12 - Lower urinary tract dysfunction in patients with peripheral nervous system lesions

The prevalence of lower urinary tract (LUT) dysfunction in peripheral nervous system (PNS) disorders is larger than in comparable control populations. This is particularly true for polyneuropathies with autonomic nervous system involvement, and for localized lesions with LUT innervation. LUT symptoms may be the guide to the diagnosis of processes localized in the lumbosacral spinal canal (as in cauda equina syndrome), and in the pelvis. Typical LUT dysfunctions (LUTD) caused by PNS involvement include bladder and sphincter hypoactivity with poor emptying, and incontinence. Paradoxically, bladder overactivity may also occur in pure PNS lesions. The acute cauda equina syndrome is an emergency requiring magnetic resonance imaging and surgery; in chronic neurogenic LUTD due to PNS involvement, the diagnosis of the lesion may be clarified by clinical neurophysiologic testing. Other important causes of neurogenic LUT dysfunction are perineoabdominal and pelvic surgeries. Surgeons are devising nerve-sparing techniques to prevent such major and often persistent complications in patients who are otherwise cured of the underlying disease. LUTD significantly affects the quality of life in patients and may lead to recurring urinary infections and upper urinary tract involvement. Thorough assessment of LUT function by urodynamics may be necessary in patients who are not improved by simple conservative measures.

A retrospective study on female urological surgeries over the 10 years following spinal cord lesion

To evaluate the efficacy and safety over a 10-year period of any urological operations required by female patients with spinal cord lesions (SCLs). Retrospective study of urological surgeries from our database performed on females with SCLs from 2001 to 2002. Surgery efficacy for neurogenic lower urinary tract dysfunctions (N-LUTDs) was evaluated by comparing 7-day voiding diaries pre- and post-surgeries, while individual investigations were done pre- and post-surgery to evaluate urological complications. Drawbacks were assessed. Thirty-eight out of 69 patients underwent one or more urological procedures. Twenty-one out of 42 patients with suprasacral lesions underwent interventions for N-LUTD. The main surgical treatment was endoscopic detrusor infiltration of botulinum-A (Botox 300 UI or Dysport 750 UI) performed 107 times on 15 subjects using aseptic intermittent catheterizations for neurogenic overactive bladder. Mean efficacy duration was 9.2 months. Six females with infrasacral lesions underwent at least one intervention for N-LUTD. Two females in each group underwent tension-free vaginal tape for stress urinary incontinence (SUI), reducing episodes per week of SUI by >90% after 5 years. The most serious urological complication was active vesico-ureteral reflux (VUR) in three patients, treated endoscopically with submucosal injection of Macroplastique. No VUR recurrence was detected during a 6-year follow-up. All bladder stones (five cases) and renal calculi (five cases) were treated with endoscopic transurethrally electrohydraulic lithotripsy and extracorporeal shock-wave lithotripsy, respectively. Overall, no serious drawbacks were observed. Mini-invasive surgeries were exclusively used to address urological issues in chronic SCL patients.

Efficacy of endoscopic subureteral injection for vesicoureteral reflux in adults with decreased bladder compliance

To evaluate the outcome of endoscopic subureteral injection (ESI) in adults with vesicoureteral reflux (VUR) associated with decreased bladder compliance (D-BC). We retrospectively reviewed the medical records of 46 consecutive patients who underwent ESI for VUR at a single tertiary academic center. Fourteen patients (17 ureter units) who had underlying neurological disease with decreased bladder compliance, as determined by filling cystometry, were grouped as D-BC. Thirty-two patients (47 units) who had no signs or symptoms that suggested neurogenic lower urinary tract dysfunctions were grouped as normal bladder compliance (N-BC). We compared the cure rates for ESI between groups, defining cure as complete resolution of reflux on voiding cystourethrogram. In 70.6% of the D-BC group and 70.2% of the N-BC group, VUR resolved completely after the first injection (P = 0.977). One failed unit of D-BC was cured after second ESI, and seven failed units of N-BC were cured after additional treatments (second ESI, two patients; ureteroneocystostomy, five patients). No additional treatments were applied to three units of D-BC or seven units of N-BC without symptoms. No complications related to the ESI were observed. The ESI was found to be effective in adults with VUR regardless of the bladder compliance. As a minimally invasive procedure with a favorable outcome, ESI may represent the first choice for treatment of VUR even in adults with D-BC.

Diagnosis and therapy for neurogenic bladder dysfunctions in multiple sclerosis patients

Neurogenic lower urinary tract dysfunctions are common in patients with multiple sclerosis and for most of them urinary dysfunction has the most negative impact on their social life. No correlation exists between clinical urinary symptoms and urodynamic patterns. Abnormal urodynamic patterns may be present in asymptomatic patients. Both clinical and urodynamic findings may change during the course of the illness. Early diagnostic approach and scheduled follow-ups are mandatory in order to prevent upper urinary tract complications and improve quality of life (QoL).