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Trauma Spinal Cord Injury
Neurogenic Urinary Tract Dysfunction
Jürgen Pannek
Head, Department of Neuro-Urology, Swiss Paraplegic Centre, Nottwil
Abstract
As lower urinary tract function is co-ordinated by a neural control system comprising brain, spinal cord and peripheral nerves, any
neurological disorder may lead to neurogenic urinary tract dysfunction (NUTD). Due to spinal cord lesions, NUTD can cause low bladder
compliance or detrusor overactivity. Both lead to elevated storage pressures, which are major risk factors for renal deterioration.
Urodynamic assessment is essential to distinguish the different types of NUTD. The primary goal of treatment is to achieve low-pressure
urine storage and voiding. Currently, first-line treatment comprises anticholinergic medication and intermittent catheterisation. Botulinum-
toxin A injections in the detrusor or surgical treatment (sacral neuromodulation, sphincterotomy, sacral deafferentation, bladder
augmentation, artificial sphincter) are second- or third-line options. NUTD due to other neurological disorders often has less impact on renal
function, but can severely impair quality of life. In these cases, treatment strategy should be based on urodynamics, patient compliance,
social situation, medical state and individual preference of the patient.
Keywords
Neurogenic lower urinary tract dysfunction, urodynamics, incontinence, intermittent catheterisation, botulinum-toxin A, spinal cord injury,
diabetes, multiple sclerosis, neuromodulation, deafferentation
Disclosure: The author has no conflicts of interest to declare.
Received: 1 September 2009 Accepted: 27 November 2009
Correspondence: Jürgen Pannek, Chefarzt Neuro-Urologie, Schweizer Paraplegiker Zentrum, Guido A Zäch Strasse 1, CH-6207 Nottwil, Switzerland.
juergen.pannek@paranet.ch
The main functions of the lower urinary tract are urine storage phase (detrusor overactivity or low compliance) combined with
and voiding. To accomplish these tasks, the urinary bladder and detrusor–external sphincter dyssynergia (DSD). The combination of
the bladder outlet act as a functional unit. Their activities are these two findings is mainly caused by suprasacral infrapontine
co-ordinated by a neural control system in the brain, spinal cord spinal lesions. In 1950, complications of bladder dysfunction
and the peripheral ganglia. Afferent signals from the lower urinary (pyelonephritis, septicaemia, renal damage, cerebral haemorrhage
tract (LUT) are controlled by neural circuits in the spinal cord and caused by autonomic dysreflexia) were the leading causes of death
the brain, enabling voluntary control of voiding.
1
Any central in spinal cord injury patients.
4
The severity of the dysfunction may
and peripheral neurological disorders may cause functional not correlate with the severity of the clinical symptoms.
5
disturbances of the LUT, classified as neurogenic lower urinary
tract dysfunction (NLUTD). NLUTDs related to other causes, e.g. multiple sclerosis, diabetes,
Parkinson’s disease, cerebrovascular disorders, Guillain-Barre
Depending on the extent and the location of the disorder, a variety syndrome or herniated discs, are far more frequent. Although the risk
of NLUTDs may occur. These may be symptomatic or asymptomatic. of renal damage is significantly lower, the LUT symptoms can cause
Moreover, NLUTD may cause a variety of long-term complications, significant problems and can severely impair quality of life (QoL).
6
the most dangerous being damage of renal function. As symptoms
and long term complications do not correlate, it is important not Aims
merely to identify patients with NLUTD, but to stratify if they have a The goals of treatment are:
low or a high risk of subsequent complications.
protection of renal function;
According to today’s knowledge, an impaired detrusor compliance rehabilitation of the lower urinary tract;
and elevated storage pressures in the bladder, either alone or avoiding early and late complications; and
combined with vesico-ureteric reflux, are the most important risk preservation of QoL.
factors for renal damage.
2,3
In general, the higher the risk of upper urinary tract damage, the
A sustained elevated storage pressure in the bladder is mainly due more diagnostic procedures are necessary and the more invasive
to a combination of increased detrusor activity during the storage treatment is required.
56 © TOUCH BRIEFINGS 2009
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