4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 Management of neurogenic detrusor overactivity Cassra B. Clark, MD, Radhika Ragam, MD, Akhil K. Das, MD, Patrick J. Shenot, MD Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA CLARK CB, RAGAM R, DAS AK, SHENOT PJ. Management of neurogenic detrusor overactivity. Can J Urol 2021;28(Suppl 2):33-37. Introduction: Neurogenic lower urinary tract dysfunction (NLUTD) refers to altered function of the urinary bladder, bladder outlet, and external urinary sphincter related to a confirmed neurologic disorder. Neurogenic detrusor overactivity (NDO) is a subset of NLUTD that frequently results in incontinence and may be associated with elevated bladder storage and voiding pressures resulting in upper urinary tract damage. Materials andmethods: This article provides an update on the evaluation and management of patients with NDO. Basic bladder physiology as well as classification of NLUTD, initial urologic evaluation, and management options ranging from the most conservative to surgical interventions will be covered. Results: NDO may be managed by conservative, pharmacologic, and surgical methods. Untreated or inadequately managed NDO may result in significant urologic morbidity and mortality, making careful evaluation and lifelong management necessary to optimize quality of life and prevent secondary complications. Conclusions: Patients with NDO should have life- long urologic surveillance and follow up. The extent of regular evaluation and testing should be based on the principal of risk stratification. Treatment for NDO should be considered not only for clinical symptoms such as incontinence, but also aimed at preserving renal function. Key Words: bladder augmentation, neurogenic bladder, urinary incontinence Address correspondence to Dr. Cassra B. Clark, Department of Urology, Thomas Jefferson University, 1025Walnut Street, Suite 1100, Philadelphia, PA 19107 USA Introduction Neurogenic lower urinary tract dysfunction (NLUTD) refers to altered function of the urinary bladder, bladder outlet, and external urinary sphincter related to a confirmed neurologic disorder. Common causes of NLUTD include spinal cord injury (SCI), multiple sclerosis (MS), myelomeningocele, Parkinson’s disease, and cerebrovascular accident (CVA). While CVA is a most common of these conditions, multiple sclerosis and spinal cord injury/dysfunction are the most common neurologic disorders to result in clinically significant NLUTD. 1,2 The vast majority of patients with SCI have NLUTD, and about 85% of patients with MS have lower urinary tract symptoms (LUTS). 3 Neurogenic detrusor overactivity (NDO) is a subset of NLUTD that frequently results in urinary frequency, urgency, and urge incontinence. It may be associated with elevated bladder storage and voiding pressures. Elevated bladder pressures, can lead not only loss of urinary control, but to upper urinary tract damage and renal failure. Classification of neurogenic lower urinary tract dysfunction The functional system for classification of NLUTD is simple, intuitive, and widely accepted. The function of the bladder is to store urine at appropriate pressures and volumes without incontinence, and empty completely at the appropriate place and time. This system divides lower urinary tract dysfunction into two broad categories: 1) failure to store and 2) failure to empty. Failure to store urine can result from either bladder dysfunction such as NDO or impaired bladder compliance, or outlet dysfunction such as intrinsic sphincter deficiency. Failure to empty may result from bladder dysfunction such as impaired bladder contractility. Outlet obstruction, such as detrusor external sphincter dyssynergia, may also lead to failure of bladder emptying. Historically, sequela of poorly managed lower urinary tract dysfunction has been a significant cause of morbidity and mortality in patients with NDO, particularly those with SCI. Mortality rates from genitourinary complications in SCI patients have declined significantly, from approximately 50% in the 1950s to less than 3% today. 4 The goal of NLUTD management, in general, and NDO specifically, is to prevent upper urinary tract deterioration, minimize 33