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Scope of the guidelines.

These guidelines deals with the diagnosis and management of patients with NLUTD. Extensive history taking, thorough examination together with laboratory, radiological and urodynamic investigations should be done in every NLUTD patient. Accordingly, tailoring and individualizing the plan of management follows.

Recommendations.

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

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

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

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

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

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

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

12. Perform uroflowmetry in NLUTD patients who can void (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 (STRONG)

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

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

16. 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 (STRONG)

17. 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 (STRONG)

18. Prescribe anticholinergics as the first-line medical therapy for NDO (STRONG)

19. Offer combination therapy of antimuscarinics and Beta 3 agonists to maximise outcomes for NDO (STRONG)

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

21. 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 of 12-16 Fr. Bladder volume should not exceed 400-500 mL at catheterization time (STRONG)

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

23. Avoid use of indwelling transurethral and suprapubic catheterisation whenever possible (STRONG)

24. 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 (STRONG)

25. Offer bladder neck incision in a fibrotic sclerotic bladder neck (STRONG)

26. Offer botulinum toxin A 100 IU intrasphincteric in cases of DSD (STRONG)

27. Offer pubovaginal sling in neuro-urological females with decreased outlet resistance who can do self-catheterization (STRONG)

28. Offer TOT and TVT to neuro-urological females with decreased outlet resistance(STRONG)

29. Insert an AUS in male patients with neurogenic stress urinary incontinence (STRONG)

30. Offer bladder augmentation as an alternative to treat refractory NDO and/or impaired bladder compliance (STRONG)

31. Recommend urinary diversion when no other therapy is successful for NDO and/or impaired bladder compliance (STRONG)

32. Do not perform screening for asymptomatic bacteriuria nor treat it in NLUTD patients (STRONG)

33. Avoid the prescription of long-term antibiotics for recurrent UTIs (STRONG)

34. Prescribe oral PDE5I as first-line medical treatment in neurogenic ED(STRONG)

35. Offer intracavernous injections of vasoactive drugs as second-line medical treatment in neurogenic ED (STRONG)

36. Offer penile prostheses for selected NLUTD patients when all other treatments have failed (STRONG)

37. Perform vibrostimulation and transrectal electroejaculation for sperm retrieval in men with SCI (STRONG)

38. Do not offer medical therapy for the treatment of neurogenic sexual dysfunction in women (STRONG)

39. Assess the upper urinary tract every six months in high-risk patients (those with high Pdet/hypocompliant bladders/DSD) by ultrasonography (STRONG)

40. Perform a physical examination and urine analysis and culture every year in high-risk patients (those with high Pdet/hypocompliant bladders/DSD) (STRONG)

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