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Neurogenic bladder

Key sources
The following summarized guidelines for the evaluation and management of neurogenic bladder are prepared by our editorial team based on guidelines from the European Association of Urology (EAU/ESPU 2023), the American Urological Association (AUA/SUFU 2021), and the International Society of Urology (SIU/ICUD 2018).
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Guidelines

1.Classification and risk stratification

Risk assessment
Classify patients at initial evaluation as low-risk or unknown risk requiring further evaluation to allow for complete risk stratification.
B
Obtain risk stratification in patients with an acute neurological event resulting in neurogenic lower urinary tract dysfunction once the neurological condition has stabilized.
B
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2.Diagnostic investigations

History and physical examination: include the following in the initial evaluation of all patients with neurogenic lower urinary tract dysfunction:
detailed history and physical examination
urinalysis
post-void residual measurement (in patients who spontaneously void)
B
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  • Urinalysis and culture

  • Urinary tract imaging

  • Urodynamic studies

3.Diagnostic procedures

Cystoscopy: do not perform routine cystoscopy in the initial evaluation of patients with neurogenic lower urinary tract dysfunction.
D
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4.Medical management

General principles
Prescribe medications, particularly combination therapy, with care due to the risk of polypharmacy and cognitive impairment in patients with spinal cord injury.
B
Avoid offering drug "cycling" in patients with spinal cord injury if oral medical therapy fails. Consider offering alternative treatment such as botulinum neurotoxin or surgical reconstruction.
D

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  • Anticholinergics

  • Alpha-blockers

  • Beta-3 agonists

  • TCAs

  • Antibiotic prophylaxis

  • Management of autonomic dysreflexia

5.Nonpharmacologic interventions

Bladder expression: do not offer bladder expression or triggered bladder voiding in patients with spinal cord injury if any of the following video-urodynamic findings are present:
small bladder capacity
high leak point pressure
low compliance
vesicoureteral reflux at any point of the study
closed bladder neck during voiding or high voiding pressure
D
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6.Therapeutic procedures

Intermittent catheterization: offer intermittent catheterization over bladder expression or triggered bladder voiding
B
as the preferred method of bladder management in patients with urinary retention after spinal cord injury.
B
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  • Indwelling catheterization

  • Condom catheterization

  • Botulinum toxin injections

7.Specific circumstances

Pediatric patients, evaluation: obtain urodynamic testing in all patients with spina bifida, and with a high suspicion of neurogenic bladder to estimate the risk for the upper urinary tract and to evaluate the function of the detrusor and the sphincter.
B

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  • Pediatric patients (intermittent catheterization)

  • Pediatric patients (medical management)

  • Pediatric patients (botulinum toxin injections)

  • Pediatric patients (surgical management)

  • Pediatric patients (follow-up)

8.Patient education

Patient education: educate patients with neurogenic lower urinary tract dysfunction about the symptoms and signs warranting additional assessment.
B

9.Follow-up and surveillance

Follow-up, general principles: do not obtain surveillance upper urinary tract imaging, renal function assessment, or multichannel urodynamic testing in patients with low-risk neurogenic lower urinary tract dysfunction and stable urinary signs and symptoms.
D
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  • Follow-up (patients with indwelling catheter)

  • Re-evaluation of patients with new symptoms

  • Follow-up (patients with condom catheter)