K - BLADDER FUNCTION
K.1.1
When referred a new patient with neurogenic bladder, a focused history and physical exam relevant to the neurogenic condition should be performed. (CUA 2019, p.161; Level C)
K.1.2
Consider referral for urgent investigation if individuals with SCI have any of the following ‘red flag’ signs and symptoms:
- recurrent catheter blockages (for example, catheters blocking within 6 weeks of being changed)
- hydronephrosis or kidney stones on imaging
- biochemical evidence of renal deterioration (i.e., estimated eGFR-write out all algorithm).
K.1.3
Clinicians should be attentive to any modification of general functioning and on the appearance of any new urological symptoms and alarm signs (e.g., pain, increased spasticity, autonomic dysreflexia, infection, fever, and hematuria). (URO 2017, p.588; Level A)
K.1.4
Clinicians should be aware that unexplained changes in neurological symptoms (for example, confusion or worsening spasticity) can be caused by urinary tract disease and consider further urinary tract investigation and treatment if this is suspected. (NICE 2012, p.51; Level C)
K.1.5
Clinicians should assess the impact of lower urinary tract symptoms on the individual’s quality of life, family members, and caregivers and consider ways of reducing any adverse impact. (NICE 2012, p.51; Level C)
K.2.1
Clinicians should undertake a general physical examination that includes:
- blood pressure management
- abdominal examination
- external genitalia examination
- vaginal or rectal examination (as indicated for evidence of pelvic floor prolapse, fecal loading or alterations in anal tone)
- ISNCSCI assessment, if necessary
- hand function
- mobility
- cognitive assessment
K.3.1
Clinicians should ask individuals with SCI and/or their family members and caregivers to complete a ‘fluid input/urine output chart’ to record fluid intake, frequency of catheterization, urination and volume of urine passed for a minimum of 3 days as a baseline to detect changes in bladder function. (Adapted from NICE 2012, p.50; Level C)
K.4.1
All individuals with SCI and evidence of neurogenic bladders should ideally be assessed using video urodynamic as it is the gold standard to assess neurogenic lower urinary tract in individuals with SCI. (URO 2017, p.589; Level A)
K.4.2
Attending clinicians should not stop medications that may influence lower tract function before video urodynamic; however, their administration should be considered in the interpretation of the data. (URO 2017, p.589; Level B)
K.4.3
Clinicians should not routinely prescribe antibiotic prophylaxis before urodynamics. However, in scenarios where the individual has high-risk factors such as, evidence of vesicoureteral reflux, high voiding pressure, repeated urinary tract infection or prothesis that may be at risk of infection, antibiotic prophylaxis may be considered prior to urodynamics. (Adapted from URO 2017, p.589; Level C)
K.4.4
Urodynamic studies should not be performed when an individual with SCI has a symptomatic UTI or pyuria to avoid worsening of the clinical condition and prevent erroneous interpretation of the urodynamic findings. (Adapted from URO 2017, p.589; Level C)
K.5.1
Clinicians should not treat positive dipstick or culture in asymptomatic patients who catheterize except in the setting of nephrolithiasis and stone-forming bacteria as bacterial colonization will likely be present in individuals using a catheter (indwelling or intermittent), and so urine dipstick testing and bacterial culture may be unreliable for diagnosing active infection. (Adapted from NICE 2012, p.50; Level C)
K.5.2
We recommend clinicians do not screen or treat individuals with asymptomatic bacteriuria with neurogenic lower urinary tract dysfunction (except in pregnancy as it promotes antibiotic resistance and can increase the likelihood of symptomatic urinary tract infection).
Treatment should be limited to individuals with positive urine culture in the presence of clinical symptoms, including leukocyturia, bacteriuria. (Adapted from CUA 2019, p.164; Level B)
K.5.3
Use the presence of leukocyturia, bacteriuria, and clinical symptoms to diagnose UTI in individuals with SCI and neurogenic lower urinary tract dysfunction (except in pregnancy): treatment should be limited to individuals with positive urine culture in the presence of clinical symptoms of UTI. (Adapted from CUA 2019, p.164; Level B)
K.5.4
Urinalysis and urine culture should always be obtained prior to initiating antibiotic therapy due to the increased risk of multidrug-resistant microorganisms. (Adapted from CUA 2019, p.164; Level B)
K.5.5
If an individual is systemically unwell or symptoms are intolerable, collect culture, start antibiotic therapy, and modify or discontinue antibiotic therapy based on culture results. (Adapted from CUA 2019, p.164; Level B)
K.5.6
Clinicians should prescribe individuals with SCI and a culture confirmed UTI with a course of antibiotics for at least 7 days and 10–14 days for those with significant infection or a delayed response. (Adapted from CUA 2019, p.164; Level B)
K.5.7
Clinicians should avoid the provision of routine anti-microbial prophylaxis for individuals with SCI and neurogenic lower urinary tract dysfunction and frequent urinary tract infection. (Adapted from CUA 2019, p.165; Level A)
K.5.8
Consider antibiotic prophylaxis only for individuals who have a recent history of frequent urinary tract infections once reversible causes have been ruled out (such as urolithiasis). (Adapted from NICE 2012, p.271; Level C)
K.6.1
Triggering and Valsalva or Crede´ manoeuvres should be strongly discouraged due to their threat to the upper urinary tract (i.e., kidney and ureter damage) in individuals with SCI. (Adapted from CUA 2019, p.162; Level B)
K.6.2
Selection of an assisted bladder drainage method (clean intermittent catheterization, urethral or suprapubic catheter) based on the individual’s motor functions, anatomic limitations, bladder characteristics, prior urological complications, and quality of life. Clean intermittent catheterization is the preferred method of bladder management after SCI, where possible. (Adapted from CUA 2019, p.166; Level B)
K.7.1
Offer individuals with neurogenic urinary tract dysfunction, their family members, and caregivers specific information and training. Individuals who are starting to use or are using a bladder management system that involves the use of catheters, appliances or pads, should:
- receive training, support and review from healthcare professionals who are trained to provide support in the relevant bladder management systems and are knowledgeable about the range of products available,
- have access to appropriate education on managing the daily and social needs of their bladder,
- have access to a range of products that meet their needs, and
- have their products reviewed at a maximum of 2 yearly intervals. SCI-U Patient Education Link on Bladder: http://sci-u.ca/bladder-2
K.7.2
Patients with indwelling urethral catheters should be offered conversion to a suprapubic catheter in the setting of significant urethral damage (and ideally before the urethra has been irreversibly damaged and there is a risk of stress incontinence). (CUA 2019, p.163; Level B)
K.8.1
For individuals with motor incomplete SCI AIS C/D and some preservation of pelvic floor function, clinicians should consider pelvic floor muscle training. Refer patients for this training after specialist pelvic floor assessment. Consider combining pelvic floor muscle training with biofeedback and/or electrical stimulation of the pelvic floor. (Adapted from NICE 2012, p.211; Level B)
K.8.2
The following conditions must be met before initiating a behavioural management program (e.g., timed voiding, bladder retraining or habit retraining) for those with neurogenic lower urinary tract dysfunction:
- prior assessment by a healthcare professional trained in the assessment of individuals with neurogenic lower urinary tract dysfunction and
- in conjunction with education about lower urinary tract function for the individual and/or their family members and caregivers.
K.8.3
Clinicians should consider choosing a behavioural management program, taking into account that prompted voiding and habit retraining are particularly suitable for individuals with cognitive impairment. (NICE 2012, p.85; Level C)
K.9.1
Oral antimuscarinics with dose-escalation are the first-line pharmacological treatment for patients with neurogenic lower urinary tract dysfunction in order to improve overactive bladder symptoms and neurogenic detrusor overactivity, decrease urgency urinary incontinence and lower detrusor pressures (CUA 2019, p.166; Level A)
K.9.2
Mirabegron may be a useful alternative to antimuscarinics for individuals with symptoms of overactive bladder and neurogenic lower urinary tract dysfunction, but further evidence of urodynamic changes is needed in this population. (CUA 2019, p.167; Level B)
K.9.3
Clinicians should monitor residual urine volume in individuals with SCI who are not using intermittent or indwelling catheterization after starting antimuscarinic treatment. Once therapy is initiated, clinicians should monitor for signs and symptoms of urinary retention. (Adapted from NICE 2012, p.116; Level B)
K.10.1
Clinicians should prescribe oral antimuscarinics with dose-escalation as the first-line pharmacological treatment for patients with neurogenic lower urinary tract dysfunction in order to improve overactive bladder symptoms and neurogenic detrusor overactivity, decrease urgency urinary incontinence and lower detrusor pressures. (CUA 2019, p.166; Level A)
K.10.2
Oral antimuscarinics with dose-escalation are the first-line pharmacological treatment for patients with neurogenic lower urinary tract dysfunction in order to improve overactive bladder symptoms and neurogenic detrusor overactivity, decrease urgency urinary incontinence and lower detrusor pressures. (CUA 2019, p.166; Level A)
K.10.3
Mirabegron may be a useful alternative to antimuscarinic for individuals with symptoms of overactive bladder and neurogenic lower urinary tract dysfunction, but further evidence of urodynamic changes is needed in this population. (CUA 2019, p.167; Level B)
K.10.4
Alpha-blockers can be considered for the treatment of failure to empty the bladder secondary to detrusor sphincter dyssynergia; however, this is supported by weak evidence. (CAN-SCIP 2020; Level C)
K.11.1
Monitor residual urine volume in individuals who are not using a catheterization regimen during treatment with botulinum toxin type A. Monitor for and educate patients on urinary retention as a complication. (Adapted from NICE 2012, p.176; Level A-C)
K.11.2
Before offering an intravesical botulinum toxin type A:
- explain to the individual and/or their family members and caregivers that a catheterization regimen is needed in most individuals with neurogenic lower urinary tract dysfunction after treatment
- ensure that they are able and willing to manage such a regimen should urinary retention develop after the treatment
K.11.3
Antimuscarinic drugs are the first-line treatment for detrusor overactivity. Botulinum toxin type A injections to the bladder wall should be considered when antimuscarinic drugs have proved to be ineffective or poorly tolerated. (Adapted from NICE 2012, p.175; Level A-C)
K.11.4
Clinicians should monitor individuals with SCI, particularly those with cervical SCI, for the risk of generalized weakness (including respiratory weakness and motor weakness) after the injection of intravesical botulinum toxin type A. (CAN-SCIP 2020; Level B)
K.11.5
For individuals receiving intravesicular botox injections should be offered prompt access to repeat injections when symptoms return. (NICE 2012, p.176; Level A-C)
K.11.6
For individuals receiving multiple indication botox (e.g., spasticity, neurogenic bladder, aesthetic purposes), a coordinated plan amongst care providers is required to minimize the risk of adverse reactions. (CAN-SCIP 2020, Level C)
K.12.1
A physiatrist, urologist and/or family physician should conduct regular annual urological assessments of all individuals with SCI and neurogenic lower urinary tract dysfunction. (Adapted from CUA 2019, p.170; Level B)
K.12.2
An annual renal and bladder ultrasound is recommended in individuals with neurogenic lower urinary tract dysfunction. (Adapted from CUA 2019, p.170; Level B)
K.12.3
Routine surveillance cystoscopy for bladder cancer screening is not required in individuals:
- with neurogenic lower urinary tract dysfunction;
- with or without augmentation cystoplasty;
- individuals who have no other signs or symptoms.
K.12.4
Where feasible, video urodynamic studies or a cystogram should be performed in patients where further knowledge of the urinary tract anatomy and physiology is needed. If not feasible, urodynamic studies should be done - in the setting of worsening bladder symptoms or concerning changes in renal function (biochemical or radiologic investigations). (Adapted from CUA 2019, p.171; Level B)
K.12.5
Isotopic creatinine clearance or 24-hour urine for creatinine clearance assessment should be conducted every one to two years to follow renal function.
Note: Do not rely on serum creatinine and estimated glomerular filtration rate in isolation for monitoring renal function in individuals with neurogenic lower urinary tract dysfunction. Creatinine measurement in SCI is not reflective of renal function due to low total muscle mass, causing artificially low serum creatinine. (Adapted from NICE 2012, p.292; Level C)
K.12.6
Consider using isotopic glomerular filtration rate when an accurate measurement of glomerular filtration rate is required (e.g., if imaging of the kidneys suggests that renal function might be compromised). (NICE 2012, p.292; Level C)
K.13.1
Patients should be referred to a urologist when there is persistent and bothersome incontinence, unmitigated urodynamic parameters (such as neurogenic detrusor overactivity or poor compliance), new or worsening hydronephrosis or renal dysfunction that cannot be reversed so that the individual can consider reconstructive surgery options such as bladder augmentation, abdominal continence stoma, or urinary diversion. (CAN-SCIP 2020; Level C)
K.14.1
Clinicians should measure the post-void residual urine volume, preferably by ultrasound with a portable scanner or clean intermittent catheterization, on different occasions to establish how bladder emptying varies at different times and in different circumstances for individuals with SCI and some ability to void. (Adapted from NICE 2012, p.51; Level C)
K.15.1
Clinicians should routinely discuss with individuals with SCI and their family members and caregivers that indwelling catheters (urethral and suprapubic) are associated with a higher incidence of bladder stones compared with other forms of bladder management. (Adapted from NICE 2012, p. 309; Level C)
K.15.2
Clinicians should educate these individuals to look out for signs that suggest that they should consult a healthcare professional (for example, recurrent infection, recurrent catheter blockages or haematuria). (Adapted from NICE 2012, p. 309; Level C)
K.15.3
Clinicians should discuss with the individual with SCI, family members and caregivers the increased risk of renal complications (e.g., kidney stones, hydronephrosis and scarring) in individuals with neurogenic urinary tract dysfunction. (Adapted from NICE 2012, p.308; Level C)
K.16.1
Clinicians should discuss with the individual with SCI, family members and caregivers that there may be an increased risk of bladder cancer in individuals with neurogenic lower urinary tract dysfunction, particularly in those with a long history of neurogenic lower urinary tract dysfunction and complicating factors, such as recurrent urinary tract infections. Clinicians should educate individuals with SCI regarding the symptoms to look out for (for example, recurrent infection, recurrent catheter blockages, or hematuria), which mean they should see a healthcare professional. (Adapted from NICE 2012, p.309; Level C)