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Neurogenic Urinary Tract Dysfunction
is severely compromised, incontinent urinary diversion, e.g. ileal not successful or not well tolerated, botulinum A toxin injections in the
conduit, is the method of choice. detrusor are helpful. Only if none of the mentioned conservative or
minimally invasive treatment options is successful do we perform
Reduction of Leak Point Pressure sphincterotomy or sacral deafferentation in patients with complete
In male patients with impaired dexterity, lesion of the upper motoric spinal cord injury, whereas sacral neuromodulation and bladder
neuron and resulting DSD, incision of the external urethral sphincter augmentation are mainly used in patients with incomplete lesions.
(sphincterotomy) is an established treatment option. It frequently
leads to urinary incontinence. Therefore, the use of condom catheters Urinary Tract Infection
is required. As there is no equally effective incontinence aid in Urinary tract infections are the most common complication in patients
women, this technique is not helpful in female patients. If the leak with spinal cord lesions. They can occur as nosocomial infections or
point pressure is sufficiently lowered by this technique, the can be a sign of an inadequate bladder management. There is broad
complication rate is low. According to a recent meta- analysis, in consensus that asymptomatic urinary tract infections should not be
the long term follow-up elevated intravesical pressures, autonomic treated. Signs of symptomatic urinary tract infections in spinal cord
dysreflexia and urinary tract infections may persist or recur in a injury patients are a significant leukocyturia and/or leukocyturia
subset of patients.
34
Insertion of a intrasphincteric stent
35
or botulinum combined with clinical symptoms (pain, increased spasticity,
toxin-A injections in the sphincter are alternative treatment option if haematuria, incontinence, fever, autonomic dysreflexia). Antibiotic
a reversible treatment is required. Whereas the effect of botulinum treatment should be limited to symptomatic urinary tract infections
toxin-A lasts for three to six months,
36
thermosensitive stents can and be initiated after sensitivity testing. Empirical use of antibiotics
easily be removed at any time. must be limited to highly symptomatic infections until the results of
sensitivity testing are available.
40
Bladder Evacuation
The so-called Crédé manoeuvre, i.e. manual expression of the In patients with recurrent urinary tract infections, morphological
bladder, can lead to incontinence and renal impairment and should abnormalities should be ruled out and bladder management should be
therefore no longer be used. Triggered voiding should only be used if checked. In patients with recurrent urinary tract infections, all handling
a sufficiently lowered leak point pressure has been proven by errors should be corrected.
urodynamic examination.
There is no consensus about the optimal method of prophylaxis. In
Intermittent Catheterisation idiopathic recurrent urinary tract infections, urine acidification (pH 5–6)
Today, intermittent catheterisation is regarded as the method of is suggested.
41
However, L-methionine is known to influence
choice. It can be performed either as self-catheterisation or by a third homocysteine levels, which in turn are associated with an increased
party. By these techniques, complete bladder evacuation without risk of arteriosclerosis.
42
Other options are intake of cranberry extracts,
elevated intravesical pressure can be achieved. The volume stored in which are known to prevent bacterial adhesion to the bladder
the bladder should not exceed 500cc. Catheterisation should be urothelium,
43
phytotherapeutics, vaccination or antibiotic prophylaxis.
performed aseptically, with sterile catheters. Today, there is no
consensus about the ‘ideal’ type of catheter.
37
Basically, only single- Long-term Rehabilitation
use catheters should be used, either hydrophilic catheters or A retrospective study including 235 patients with spinal cord injury
uncoated catheters combined with lubricant jelly. The preferred sizes with a median follow-up of 24.1 years demonstrated that bladder
are 12–14 French. management had to be changed rather frequently over time.
44
Bladder management was least frequently altered in patients that
Suprapubic Catheter were initially using intermittent catheterisation. In a retrospective
Suprapubic drainage can be established with 12–14 French silicone study it was shown that nearly all patients had to modify their
catheters. Larger diameters are hardly ever justified. The catheters bladder management at least once during a five-year evaluation
should be exchanged when necessary, approximately every six weeks. period. As alterations in bladder dysfunction became symptomatic
in merely 30%, a long-term urodynamic follow-up of these patients
Transurethral Indwelling Catheter is mandatory.
5
They should merely be used if no other option exists. In these cases,
silicone catheters, size 14–18 French, should be used. The catheters Perspectives
should be exchanged in relation to the degree of incrustation.
37
As Initial promising results of surgical techniques creating a somatic-
long-term indwelling catheters are associated with renal damage
38
autonomic reflex pathway for lower urinary tract reinnervation
45,46
or
and bladder tumours, this technique should not be used as a long- stimulation techniques by implanted devices
47,48
are preliminary and
term solution.
39
need to be further confirmed.
Treatment Algorithm Neurogenic Bladder Dysfunction
In summary, we suggest the following treatment algorithm for patients Due to Other Disorders
with neurogenic detrusor hyperactivity due to spinal cord lesions. Several other diseases or disorders, e.g. diabetes mellitus,
Parkinson’s disease, cerebrovascular disorders or herniated discs
Based on the results of the urodynamic testing, oral anticholinergic may well cause NLUTD.
treatment and intermittent catheterisation are established as first-
line treatment. When intermittent catheterisation cannot be established, The finding with the most severe negative impact on renal function
sphincterotomy is a possible treatment option. If this treatment is either is the combination of detrusor overactivity with DSD. DSD,
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