Should patients with neurogenic bladder undergo urodynamic testing to assess bladder functions?

From the Guidelines

Patients with neurogenic bladder should undergo urodynamic testing to assess bladder functions, particularly those with high-risk NLUTD, as it is essential for properly diagnosing and managing the condition, and for monitoring disease progression over time. The most recent and highest quality study, 1, recommends that high-risk NLUTD patients should undergo multichannel urodynamic studies, with or without fluoroscopy, which may be repeated when clinically indicated. This is because high-risk NLUTD patients are at substantial risk of renal deterioration, worsening bladder parameters, and UTIs.

Key Points to Consider

• Urodynamic testing, including cystometry, uroflowmetry, and post-void residual measurement, helps healthcare providers understand the specific type of neurogenic bladder dysfunction and determine appropriate treatment strategies.
• Additional tests, such as electromyography and videourodynamics, may be necessary to assess sphincter function and combine imaging with pressure measurements.
• The results of urodynamic testing directly inform treatment decisions, including medication choices, catheterization schedules, and whether surgical interventions might be necessary.
• Patients with low-risk NLUTD do not require routine upper tract imaging, renal function assessment, or urodynamic studies, but may need re-evaluation and repeat risk stratification if they develop new onset signs and symptoms or complications, as stated in 1.

Important Considerations

• The American Urological Association (AUA) and the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) guideline on adult neurogenic lower urinary tract dysfunction, 1 and 1, provides recommendations for the diagnosis and evaluation of NLUTD.
• The guideline emphasizes the importance of post-void residual measurement and urodynamic testing in the diagnosis and management of NLUTD.
• Healthcare providers should educate patients with NLUTD on the signs and symptoms that would warrant additional assessment, as stated in 1.

From the Research

Urodynamic Testing for Neurogenic Bladder

• Urodynamic testing is considered the definitive test for diagnosis and management of neurogenic bladder dysfunction 2.
• The test is performed by neurourologists or other specially trained providers to assess bladder functions and prevent severe complications, including renal damage 2.
• Follow-up urodynamics is necessary to ascertain the safety of bladder pressures and identify patients at risk of secondary upper urinary tract damage 3.

Importance of Urodynamic Testing

• Symptoms are unreliable, and follow-up urodynamics is the only method to ensure the safety of bladder pressures 3.
• Urodynamic testing can document efficacy and identify the need for escalation of therapy in patients on intermittent catheterization and antimuscarinics 3.
• The test can help identify patients suitable for intravesical botulinum and mark those destined for failure 3.

Guidelines and Recommendations

• The EAU/ESPU guideline panel advocates a proactive approach, including urodynamic studies, for the management of neurogenic bladder in children and adolescents 4.
• Close follow-up, including ultrasound, bladder diary, urinalysis, and urodynamics, is necessary within the first 6 years and after that, the time intervals can be prolonged, depending on the individual risk and clinical course 4.
• Urodynamic testing is recommended for patients with spinal injury, spinal dysraphism, and anorectal malformations, who are at higher risk for upper tract damage 3, 4.

Treatment and Management

• Urodynamic testing can help guide treatment decisions, including the use of anticholinergic medication, botulinum toxin, and augmentation cystoplasty 2, 5.
• Intermittent bladder catheterization is often necessary to obtain complete evacuation of the bladder, and urodynamic testing can help determine the best treatment approach 5.
• Botulinum toxin type A has been shown to be a safe and effective treatment for neurogenic urinary incontinence, with significant improvements in bladder function and quality of life 6.