THE NEUROUROLOGIC EVALUATION

Neurourologic Evaluation

History Bladder diary
Quality of life assessment
Physical examination
Neurologic examination
Urine bacteriologic studies
Renal function studies
Radiologic evaluation
- Upper tract
- Lower tract Urodynamic/video-urodynamic study
Endoscopic examination

• History
  • Symptomatology
    • Abnormality of storage, emptying, or both
    • History of the symptoms and their onset, duration, time course, and relationship to neurologic
    • Disease or other neurologic symptoms
• Physical and Neurologic Evaluation
  • General physical examination
  • Focused physical examination
    • Lower abdomen, genitalia, and rectum in men and women
    • A careful pelvic examination in women is necessary to detect the presence and degree of: pelvic organ prolapse: apical/uterine, anterior and posterior vaginal prolapse.
  • Neurologic examination
    • Neurologic lesion
      • Localizes it in an attempt to corroborate and explain a given voiding dysfunction
    • Mental status
      • Level of consciousness, orientation, speech, comprehension, and memory
        • Senile and presenile dementia, brain tumors, and normal pressure hydrocephalus
    • Motor function and coordination
      • Sensory examination - touch, pain, temperature, vibration, and position
      • Deep tendon reflexes
        • Lower motor neuron (LMN) lesion
        • Upper motor neuron (UMN) lesion
• Radiologic Evaluation
  • Upper tracts
    • Ultrasonography
      • Hydronephrosis
      • Hydroureter

        Upper tract imaging is generally recommended only in specific situations in the adult:

        • Decreased bladder compliance
        • Neurogenic incontinence
        • Severe urethral obstruction
        • Incontinence associated with significant post void residual
        • Coexisting loin and flank pain
        • Severe untreated pelvic organ prolapse
        • Suspected extra-urethral urinary incontinence

  • Lower tracts
    • Cystogram
      • Cystourethrographic patterns caused by neuromuscular disease
• Endoscopic Evaluation
  • Recommended in specific situations in the adult:
    • When initial testing suggests other types of pathology
      • Microscopic gross hematuria
      • Pain
      • Discomfort
      • Persistent or severe symptoms of bladder overactivity
      • Suspected extra-urethral incontinence
    • In patients who have previously undergone bladder, prostate, or other pelvic surgery
• Urodynamic/Video Urodynamic Evaluation
  • Urodynamics Simplified
    

    

    ^{1, 2}Total bladder (P_ves) and detrusor (P_det) pressures during a filling cystometrogram (FCMG)
    ³Filling cystometrogram
    ⁴Detrusor leak point pressure
    ⁵Urethral pressure profilometry
    ⁶Valsalva leak point pressure
    ⁷Fluoroscopy of outlet during filling/storage
    ^{1a, 2a}Total bladder and detrusor pressures during a voiding cystometrogram (VCMG)
    ⁸Voiding cystometrogram
    ⁹Micturitional urethral pressure profilometry
    ¹⁰Fluoroscopy of outlet during emptying
    ¹¹Electromyography of periurethral striated musculature
    ¹²Flowmetry
    ¹³Residual urine

   

  • General
  • Flowmetry
  • Residual urine volume
    • Measured directly
    • Estimated by cystography or ultrasonography
  • Filling cystometry
  • Voiding cystometry, combined pressure studies, video urodynamic studies
  • Electromyography
  • Urethral profilometry
  • Valsalva leak point pressure
  • Ambulatory urodynamics

   

• Voiding Dysfunction in Neurologic Injury and Disease
  • Neurourologic evaluation
    • History
      • Current urological symptoms
        • Enuresis, F, U, UI, BOO, UTI, etc.
      • Past GU, Med, Surg Hx
        • Similar past symptomatology
        • Prior neurologic, pelvic surgery
        • Prior bladder or urethral surgery
        • Associated bowel/sexual symptoms
        • Medications
      • Limitations
        • Hands/dexterity
        • Mobility
        • Environment: Supportive care, caregivers, etc
        • Other medical issues: PROGNOSIS from neuro dz
    • Physical examination
      • Neurologic examination
    • PVR
    • Creatinine/renal fxn studies
    • Urine bacteriologic studies
    • Upper tract study
    • Urodynamic evaluation
      • Utility in prognosis and treatment
        • Presenting LUTS do not correlate well with of type, extent or level of injury/disease…..or UDS findings
        • Severity of symptoms and PE do not correlate well with prognosis or "danger" to upper tracts…..or UDS findings
        • In SCI, level of injury not always predictive of UDS*
          • Correlation of imaging and UDS not exact
      • Therefore management often dictated by UDS
      • Detrusor leak point pressure
        • Measurement of the resistance of the urethral outlet (sphincter) to detrusor pressure as an expulsive force
        • THIS IS NOT (AND SHOULD BE CLEARLY DIFFERENTIATED FROM) A VALSALVA LEAK POINT PRESSURE OR VLPP
        • Assessing risk to upper tracts
          • Poor compliance
          • Myelo, XRT, s/p APR, etc.
    • +/- VCUG
    • +/- Endoscopic evaluation

References

• Abrams P: Urodynamics, 2nd ed. London, Springer, 1997.
• Andersson K-E, Appell R, Cardozo L, et al: Pharmacological treatment of urinary incontinence. In: Abrams P, Khoury S, Wein A, eds. Incontinence. 1st International Consultation on Incontinence, June 28-July 1, 1998, Monaco. Co-sponsored by World Health Organization and International Union Against Cancer. Health Publications Ltd., 1999, pp 449-486, distributed by Plymbridge Distributors, Ltd.
• Brading AF, Fry CA, Maggi M, et al: Cellular biology. In: Abrams P, Khoury S, Wein A, eds. Incontinence. 1st International Consultation on Incontinence, June 28-July 1, 1998, Monaco. Co-sponsored by World Health Organization and International Union Against Cancer. Health Publications Ltd., 1999, pp 59-103, distributed by Plymbridge Distributors, Ltd.
• deGroat WC, Downie JW, Levin RM, et al: Basic neurophysiology and neuropharmacology. In: Abrams P, Khoury S, Wein A, eds. Incontinence. 1st International Consultation on Incontinence, June 28-July 1, 1998, Monaco. Co-sponsored by World Health Organization and International Union Against Cancer. Health Publications Ltd., 1999, pp 107-154, distributed by Plymbridge Distributors, Ltd.
• Nitti V: Practical Urodynamics. Philadelphia, Saunders, 1998.
• Rovner ES, Wein AJ: Pharmacologic treatment for non-BPH induced voiding dysfunction: Facilitation of bladder emptying, part 1. AUA Update Series. Houston, American Urological Association, Inc., vol. 17, lesson 33, pp 258-265, 1998.
• Rovner ES, Wein AJ: Pharmacologic treatment for non-BPH induced voiding dysfunction: facilitation of urine storage, part II. AUA Update Series. Houston, American Urological Association, Inc., vol. 17, lesson 34, pp 266-272, 1998. Steers WD: Physiology and pharmacology of the bladder and urethra. In: Walsh P, Retik A, Vaughan ED, Jr., Wein AJ, eds. Campbell's Urology, 7th ed. Philadelphia, Saunders, 1997, pp 870-916.
• Steers WD, Barrett DM, Wein AJ: Voiding dysfunction: Diagnosis, classification, and management. In: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW, eds. Adult and Pediatric Urology. St. Louis, Mosby-Yearbook, Inc., 1996, pp 1220-1326.
• Wein AJ: Pathophysiology and categorization of voiding dysfunction. In: Walsh P, Retik A, Vaughan ED, Jr., Wein AJ, eds. Campbell's Urology, 7th ed. Philadelphia, Saunders, 1997, pp 917-926.
• Wein AJ: Neuromuscular dysfunction of the lower urinary tract and its treatment. In: Walsh P, Retik A, Vaughan ED, Jr., Wein AJ, eds. Campbell's Urology, 7th ed. Philadelphia, Saunders, 1997, pp 953-1006. li
• Wein AJ, Barrett DM: Voiding Function and Dysfunction: A Logical and Practical Approach. New York, Year Book Medical Publishers, Inc., 1988. Wein AJ, Rovner, ES: Adult voiding dysfunction secondary to neurologic disease or injury. AUA Update Series. Houston, American Urological Association, Inc., vol. 18, lesson 6, 1999, pp 42-27.
• Wilson PD, Bo K, Bourcier A, et al: Conservative management in women. In: Abrams P, Khoury S, Wein A, eds. Incontinence. 1 st International Consultation on Incontinence, June 28-July 1, 1998, Monaco. Co-sponsored by World Health Organization and International Union Against Cancer. Health Publications Ltd., 1999, pp 581-636, distributed by Plymbridge Distributors, Ltd.
• Zderic SA, Levin RM, Wein AJ: Voiding function: Relevant anatomy, physiology, pharmacology and molecular aspects. In: Gillenwater JY, Grayhack JT,
• Howards SS, Duckett JW, eds. Adult and Pediatric Urology. St. Louis, Mosby-Yearbook, Inc., 1996, pp 1159-1219.

SELF-ASSESSMENT QUESTIONS

1. Regardless of differences regarding physiologic and pharmacologic details, what would most experts agree are the requirements for normal bladder filling and storage? Discuss the main points relating to the anatomy, neurophysiology, and neuropharmacology of each of these factors.
2. Regardless of differences regarding physiologic and pharmacologic details, what would most experts agree are the requirements for normal bladder emptying and voiding? Discuss the main points relating to the anatomy, neurophysiology, and neuropharmacology of each of these factors.
3. Broadly generalize the differences between the autonomic and somatic nervous systems. Discuss the terms parasympathetic and sympathetic.
4. What are the primary neurotransmitters released at postganglionic, parasympathetic, and sympathetic effector sites in the lower urinary tract? Discuss the distribution and the results of activation of the cholinergic and adrenergic receptors in lower urinary tract smooth muscle.
5. Discuss the differences in organization of the micturition reflex in a normal adult and in an adult with a T10 spinal cord transection following spinal shock.
6. Categorize each urodynamic study (flowmetry, residual urine, filling and voiding cystometry, detrusor and abdominal [Valsalva] leak point pressures, urethral profilometry, and electromyography) as to what they characterize with respect to bladder and outlet activity during the filling and storage and emptying and voiding phases of micturition.
7. Characterize the most common types of voiding dysfunction seen with the following neurologic injury(ies) and disease(s) in terms of sensation, bladder activity, smooth sphincter activity, striated sphincter activity: (1) cerebrovascular accident; (2) Parkinson's disease; (3) multiple sclerosis; (4) suprasacral spinal cord injury; (5) sacral spinal cord injury; (6) radical pelvic surgery; and (7) diabetes.
8. Discuss the usual types of management employed in the treatment of the voiding dysfunctions in question 7.
9. Describe and discuss the use of pressure flow urodynamic studies and video urodynamic studies.
10. Excluding extraurethral incontinence and incontinence due to lack of concern or to cognitive dysfunction, discuss the basic pathophysiology of urinary incontinence in the adult.
11. Discuss the classic differentiation between genuine stress urinary incontinence and intrinsic sphincter deficiency and the therapeutic implications of each.
12. Discuss the normal support mechanism(s) of the bladder neck and proximal urethra in the female and the various theories of pathophysiology of hypermobility related stress incontinence.
13. Discuss the possibilities and practicalities of pharmacologic therapy for (1) bladder overactivity; (2) decreased outlet resistance; (3) increased outlet resistance; and (4) decreased bladder contractility.
14. Discuss the theory(ies) behind the use of peripheral and central electrical stimulation in the treatment of bladder overactivity.
15. Discuss the surgical options for treating sphincteric incontinence in adult men.

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