4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 urinary incontinence, prevent urinary tract infections and urolithiasis, and avoid autonomic dysreflexia. 5 Initial urologic evaluation Initial evaluation includes a detailed history and physical examination, urinalysis, and bladder or catheterization diary. Patients who spontaneously void should be carefully evaluated. A post void residual should be obtained in nearly all who spontaneously void. Further evaluation can be tailored based on stratification of risk for lower and upper urinary tract complications. Initial evaluation of patients at high risk for urologic complications would generally include upper tract imaging, assessment of renal function, and urodynamic evaluation. It is important to recognize that an acute neurologic event such as SCI often is followed by a phase of spinal shock. Therefore, urodynamic evaluation should be deferred until the neurologic condition is stabilized and spinal shock has resolved. Conservative management Behavioral interventions for the management of urinary incontinence secondary to NDO may be effective in selected cases. For patients who void spontaneously and have no bladder emptying deficits, timed voiding may effectively minimize or eliminate incontinence related to involuntary detrusor contractions. Adapting drinking habits to spread fluid intake throughout the course of the day, and in some cases fluid restriction, is often employed in patients with NDO to minimize incontinence and lengthen intervals between catheterization. These management options need to be carefully individualized to each patient as this population often suffers from neurogenic bowel and chronic constipation which can be exacerbated by low fluid intake. Another method to lessen detrusor overactivity and improve storage is through activation of detrusor inhibitory reflexes stimulated by activity in pelvic floor musculature. 6 Pelvic floor exercises may be offered in carefully selected patients with less severe neurologic deficits and although it may have a role in management of patients with NLUTD with multiple sclerosis or CVA, it is rarely useful in patients with SCI. Oral pharmacologic treatment of NDO Systemic pharmacotherapy has long been utilized in the management of urinary incontinence secondary to NDO event though many of the commonly used agents have not been widely studied in neurogenic populations. These agents are commonly used in patients with overactive bladder (OAB) to improve symptoms of urinary urgency, frequency, and urge incontinence. The objective of pharmacologic therapy in patients with neurogenic bladder is to minimize episodes of incontinence resulting from detrusor overactivity and to lower detrusor pressures, particularly during the storage phase in order to minimize the risk of upper tract complications. The most commonly used oral systemic agents are antimuscarinics and beta-3 agonists. These are often used adjunctively with intermittent catheterization in patients who have deficits in bladder emptying. Antimuscarinic agents, also known as anticholinergics, have been consistently shown to improve clinical and urodynamic parameters in patients with NDO. They inhibit the binding of acetylcholine at M2 and M3 muscarinic receptors on detrusor smooth muscle, allowing for relaxation of the detrusor muscle. 7 TheM3 receptors appear to be the most important for detrusor contraction in the healthy state, but M2 receptors may play an important role in detrusor contractions in patients with neurogenic bladder dysfunction. 8 Antimuscarinic treatment should be considered not only in patients with symptomatic bother from NDO, but also in those withworrisome urodynamic findings. Published studies on the use of antimuscarinics are characterized by the lack of validated and standardized reported outcomes, lack of long term follow up, and absence of sufficient evidence in particular groups of patients with NDO. Most studies primarily include patients with SCI, and to a lesser extent, patients with multiple sclerosis. A systematic review and meta- analysis of 16 randomized controlled trials published between 1966 and 2011 involving 960 patients treated with antimuscarinic medications found a significant improvement in maximum cystometric capacity, and lower detrusor pressure compared to placebo. 9 In a review including other non-randomized control trials of treatment with oxybutynin, propiverine, and trospium, maximum detrusor pressure decreased by 30%-40% and bladder capacity increased by over 30%- 40%. Urodynamic improvements appear to be dosed related with further decreases in detrusor pressures at higher doses. 10 Flexible dosing, in which patients self- select different doses of antimuscarinics, may improve efficacy without diminishing tolerability. These antimuscarinic agents are inherently non- selective and bind to smoothmuscle receptors of other organs resulting in the commonly reported side effects such as drymouth, constipation, and pupillary dilation with blurred vision. These side effects are mediated by Clark ET AL. 34