Neuro-Urology

Recommendations

GRADE

Level of certainty

Strength Rating

1. Take extensive general history focusing on past and present symptoms, with special emphasis on four main domains: urinary, sexual, bowel and neurological functions

High (11-17)

Strong

2. Assess Quality of life with validated QoL questionnaires for neuro-urological patients

Moderate (18-26)

Strong

3. Drug, family, past and present history of neurologic and non-neurologic diseases along with history of external and iatrogenic trauma should be properly taken from patients with NLUTD

High(11,14,16)

Strong

4. Special attention should be paid to warning signs such as fever, hematuria, dysuria, leaking around catheter and autonomic dysreflexia, which could alter/change diagnosis and thus affect the current management

High (27,28)

Strong

5. Perineal and genital examination should be performed, including motor and sensory assessment beside specific lumbosacral reflexes

High (29,30)

Strong

6. The anal sphincter activity and pelvic floor muscles should be tested

Moderate(31)

Strong

7. Urine analysis should be performed in the initial evaluation of NLUTD as it has a role in exclusion of UTI in NB patients. It can be also used for following up after antibiotic treatment

High (32,33)

Strong

8. Assessment of renal functions is essential in diagnosis and follow-up of NLUTD patients. GFR can be best measured by Cystatin-C based GFR for assessment of renal function.

Moderate (32,33-35)

Strong

9. Renal ultrasound should be done in primary assessment of NLUTD to evaluate UUT anatomy

Moderate (32,33)

Strong

10. Perform bladder ultrasound with PVR measurement in the primary evaluation of NLUTD patients

High (32,33)

Strong

11. VCUG is recommended in neuro-urological patients to assess the bladder capacity, detect VUR if present and estimate PVR

Moderate (32,33)

Strong

12. Perform uroflowmetry in NLUTD patients who can void

High (36,37)

Strong

13. Perform a urodynamic investigation to detect and specify LUTD, use same session repeat measurement.

Use body-warmed saline, 6 Fr. double lumen urodynamic urethral catheter and filling rate starting at 10 ml/min. If there is no rise in the Pdet, this can be increased to 20 ml/min.

Moderate (12,36-39)

Strong

14. Use VUDS in neuro-urological patients. if not, pressure-flow study may be used instead with VCUG

Moderate (40,41)

Strong

15. EMG, with surface perineal electrodes, could be used if DSD is suspected in NB patients

Low (42)

Conditional

Recommendations

GRADE

Level of certainty

Strength Rating

1. Do not perform assisted bladder emptying techniques (Crede, Valsalva or triggered reflex voiding) as they are hazardous to the upper tract EXCEPT in patients with absent or surgically removed outlet resistance

Moderate (43-46)

Strong

2. Do not offer penile clamps as they are absolutely contraindicated in cases of NDO or low bladder compliance because of the risk of developing high intravesical pressure and pressure sores/necrosis in cases of altered/absent sensations

High (43)

Strong

3. Prescribe anticholinergics as the first-line medical therapy for NDO

High (46-52)

Strong

4. Offer combination therapy of antimuscarinics and Beta 3 agonists to maximise outcomes for NDO

High (53-62)

Strong

5. Prescribe α-blockers to decrease bladder outlet resistance in NLUTD, putting into consideration their off -label in patients with DSD

Low (63-65)

Conditional

6. Use CIC as a standard treatment for patients who are unable to empty their bladder. The average catheterisation schedule is four to six times per day. Use catheter size most of 12-16 Fr. Bladder volume should not exceed 400-500 mL at catheterization time

Moderate (43, 66-69)

Strong

7. Do not use Foley catheters because of the high incidence of latex allergy in the neuro-urological patient population. Use silicone catheters instead

Moderate (70)

Strong

8. Avoid use of indwelling transurethral and suprapubic catheterisation whenever possible

Moderate (71-74)

Strong

9. Offer intradetrusor botulinum toxin injection to reduce NDO when antimuscarinic therapy fails. The recommended dose of intradetrusal botulinum toxin injection in neurogenic bladder is 200 IU, in 30 sites in the bladder, with exclusion of the trigone, for theoretical prevention of VUR

High(75-82)

Strong

10. Offer bladder neck incision in a fibrotic sclerotic bladder neck

High (83-85)

Strong

11. Offer botulinum toxin A 100 IU intrasphincteric in cases of DSD

Moderate(86-89)

Strong

12. Offer pubovaginal sling in neuro-urological females with decreased outlet resistance who can do self-catheterization

Moderate (90-93)

Strong

13. Offer TOT and TVT to neuro-urological females with decreased outlet resistance

High (94-96)

Strong

14. Insert an AUS in male patients with neurogenic stress urinary incontinence (SUI)

Moderate (97-99)

Strong

15. Offer bladder augmentation as an alternative to treat refractory NDO and/or impaired bladder compliance

Moderate (100-104)

Strong

16. Recommend urinary diversion when no other therapy is successful for NDO and/or impaired bladder compliance

Moderate(105-107)

Strong

17. Do not perform screening for asymptomatic bacteriuria nor treat it in NLUTD patients

High (108-110)

Strong

18. Avoid the prescription of long-term antibiotics for recurrent UTIs

High (111-113)

Strong

19. Prescribe oral PDE5I as first-line medical treatment in neurogenic ED

High (114-117)

Strong

20. Offer intracavernous injections of vasoactive drugs as second-line medical treatment in neurogenic ED

Moderate (118-120)

Strong

21. Offer penile prostheses for selected NLUTD patients when all other treatments have failed

Hig (115, 121,122)

Strong

22. Perform vibrostimulation and transrectal electroejaculation for sperm retrieval in men with SCI

Moderate(123-126)

Strong

23. Do not offer medical therapy for the treatment of neurogenic sexual dysfunction in women

Moderate(115, 127,128)

Strong

24. Assess the upper urinary tract every six months in high-risk patients (those with high Pdet/hypocompliance/DSD)by ultrasonography

Moderate(32,129-131)

Strong

25. Perform a physical examination and urine analysis and culture every year in high-risk patients (those with high Pdet/hypocompliance/DSD)

Moderate(32,129-131)

Strong

26. Perform UDS as a mandatory baseline diagnostic intervention. It is recommended yearly in high-risk group, otherwise could be done every two years

Moderate(32,129-131)

Strong