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David A. Ginsberg, MD; Timothy B. Boone, MD; Anne P. Kennelly, MD; Gary E. Lemack, MD; Eric S. Rovner, MD; Lesley H. Kraus, MD. With the understanding that this is not just an issue confined to the bladder, NLUTD is now the preferred way to describe the various voiding issues seen in patient with a neurologic disorder.
The clinician treating patients with NLUTD needs to balance a variety of factors when making treatment decisions. This Guideline allows the clinician to understand the options available to treat patients, understand the findings that can be seen in NLUTD, and appreciate which options are best for each individual patient.
NLUTD is a broad term in several respects. A wide array of potential neurologic etiologies can lead to lower urinary dysfunction.
For example, some patients can have urinary incontinence UI while others may have urinary retention requiring intermittent catherization CIC. In addition, NLUTD is not necessarily confined to only one of these categories and is often a mixture of several issues; for example, patients could have both UI and urinary retention. For example, patients with NLUTD secondary to diabetes may initially be asymptomatic, then progress to overactive bladder OAB -type symptoms and ultimately evolve to a bladder with incomplete emptying and possible overflow incontinence.
NLUTD is often categorized by the neuroanatomic location suprapontine, suprasacral spinal cord, or sacral of the neurologic deficit contributing to the abnormal lower urinary tract function. Depending on the location of the neurological lesion, common pathophysiological patterns of NLUTD manifest.
The most common of these diseases is CVA. The estimated prevalence of MS in in the United States, culminated over ten years, ranged from to per ,, which corresponds to a total of , to , cases of MS. Common causes of NLUTD at the peripheral nerve level include diabetes and iatrogenic injuries from surgeries such as abdominoperineal resection and radical hysterectomy.
It is estimated that This speaks to one of the main goals for the clinician caring for patients with NLUTD: understanding risk of upper urinary tract damage and managing the patient in such a way that risk is minimized. However, there are often a variety of other issues that the clinician caring for the patient with NLUTD may need to address.
Non-urinary conditions such as sexual dysfunction, male infertility, and bowel dysfunction are also common in patients with NLUTD but are not within the scope of this Guideline. The initial urologic evaluation and subsequent surveillance of the NLUTD patient differs depending on the etiology and severity of the neurologic injury or disease.
In addition to the standard history, physical examination, and urinalysis UA , there are a variety of tools that are used in the evaluation of NLUTD patients. These may include evaluations and tests such as voiding diaries, questionnaires e. This Guideline will help clinicians caring for patients with NLUTD understand what the appropriate initial evaluation should entail.
Once that is done, the patient is then placed into one of the three levels of risk: low; medium; high Figure 1. The level of risk then determines what would be the appropriate surveillance over time. This Guideline allows the clinician to understand the options available to treat patients with various types of LUTS, understand the findings that can be seen in NLUTD, and appreciate which options are best for each individual patient.
Additionally, the Panel included patient representation. Funding of the Panel was provided by the AUA; panel members received no remuneration for their work. The search was rerun in February to identify systematic reviews published from October through Where no existing systematic reviews were identified, or when identified reviews were incomplete in some fashion, PubMed MEDLINE and Embase databases were systematically searched using standardized vocabulary and keywords derived using the a priori developed PICO population, interventions, comparisons, and outcomes elements.
Control articles, which were deemed important and relevant by the Panel, were compared with the literature search strategy output and the strategy was updated as necessary to capture all control articles. Databases were searched for studies published from January through October and the search was rerun in February to capture the newer literature. All hits from the literature search were input into reference management software EndNote X7 , where duplicate citations were removed. Abstracts were reviewed by the methodologist to determine if the study addressed the Key Questions and if the study met study design inclusion criteria.
For all research questions, randomized controlled trials, observational studies, and case-control studies were considered for inclusion in the evidence base.
Although studies of any sample size were included, where data was available, only studies that enrolled at least 30 patients were used to inform recommendation statements. Case series, letters, editorials, in vitro studies, studies conducted in animal models, and studies not published in English were excluded from the evidence base a priori. Full-text review was conducted on studies that passed the abstract screening phase. Studies that met the PICO criteria were chosen for inclusion in the evidence base.
Figure 1 summarizes the study selection process. Individual Study Quality and Potential for Bias Quality assessment for all retained studies was conducted. Using this method, studies deemed to be of low quality would not be excluded from the systematic review, but would be retained, and their methodological strengths and weaknesses discussed where relevant.
To define an overall study quality rating for each included study, risk of bias as determined by validated study-type specific tools, was paired with additional important quality features.
Additional important quality features, such as study design, comparison type, power of statistical analysis, and sources of funding were extracted for each study.
GRADE defines a body of evidence in relation to how confident guideline developers can be that the estimate of effects as reported by that body of evidence is correct. Evidence is categorized as high, moderate, low and very low, and assessment is based on the aggregate risk of bias for the evidence base, plus limitations introduced as a consequence of inconsistency, indirectness, imprecision and publication bias across the studies.
The AUA employs a 3-tiered strength of evidence system to underpin evidence-based guideline statements. All three statement types may be supported by any body of evidence strength grade. Body of evidence strength Grade A in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances and that future research is unlikely to change confidence. Body of evidence strength Grade B in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances but that better evidence could change confidence.
Body of evidence strength Grade C in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances but that better evidence is likely to change confidence. Conditional Recommendations also can be supported by any evidence strength. Where gaps in the evidence existed, the Panel provides guidance in the form of Clinical Principles or Expert Opinions with consensus achieved using a modified Delphi technique if differences of opinion emerged.
Expert Opinion refers to a statement, achieved by consensus of the Panel, that is based on members’ clinical training, experience, knowledge, and judgment for which there may or may not be evidence. Search for Existing Systematic Reviews The search for existing systematic reviews identified 45 possible reviews on evaluation, surveillance, management, or follow-up of patients with NLUTD.
Twenty-five were chosen for inclusion in the evidence base. When multiple systematic reviews reported on the same outcome and included the same primary literature, only the most complete systematic review was retained. All 20 excluded systematic reviews were excluded based on overlapping primary literature when compared to the systematic reviews chosen for inclusion in the evidence base. Search for Primary Literature The primary literature systematic review was used to address all outcomes not covered by the included systematic reviews.
It was anticipated that primary literature would report on outcomes in addition to what was pooled in the 24 included systematic reviews. As such, the literature search for primary literature was not altered following selection of the systematic review into the evidence base. Instead, where overlap was recognized between studies included in the identified systematic reviews and identified primary studies, primary studies were either removed from the evidence base, or when primary literature reported on additional outcomes, overlapping outcomes were not extracted in the primary literature.
This methodology ensured that data were not included twice in the evidence base, as this may result in an overestimate of effect. Literature Search Results The primary search returned 20, unique citations. Following a title and abstract screen, full texts were obtained for 3, studies. One hundred eight-four primary literature studies met the inclusion criteria and were included in the evidence base Figure 1. An integral part of the guideline development process at the AUA is external peer review.
Additionally, a call for reviewers was placed on the AUA website from May 26 — June 7, to allow any additional interested parties to request a copy of the document for review.
The guideline was also sent to the Urology Care Foundation to open the document further to the patient perspective. The draft guideline document was distributed to 34 peer reviewers. All peer review comments were blinded and sent to the Panel for review. In total, 23 reviewers provided comments, including 3 external reviewers.
At the end of the peer review process, a total of comments were received. Following comment discussion, the Panel revised the draft as needed. At initial evaluation, clinicians should identify patients as either: a. Clinical Principle. In addition to treating bothersome symptoms associated with NLUTD, the clinician needs to be aware of the various parameters that place patients at future risk for damage to the upper urinary tract.
This can be a challenge when managing NLUTD patients as there are a variety of neurologic diseases and insults that can result in NLUTD and, even within specific neurologic diagnoses, there is a spectrum of disease severity. The Panel strongly feels that clinicians who treat patients with NLUTD are able to assess their potential for risk and damage to the upper urinary tract and follow these patients accordingly based on this risk stratification Figure 2.
To a certain degree stratification can be done based on location of the neurologic disease or insult. For example, patients with suprapontine lesions e. However, elevated PVRs could be seen in certain patients after CVA or in patients with cerebral palsy and pseudodyssynergia; placing them in the moderate-risk category.
In addition, lesions distal to the spinal cord tend to have low bladder storage pressures; however, poor contractility could result in elevated PVRs and over time loss of bladder compliance can be seen in this patient population as well, another example of how lesion location can cross over into several risk stratification categories.
These patients would be placed in the unknown-risk category until further evaluation UDS, upper tract imaging, assessment of renal function is performed allowing for more specific stratification. These studies allow for evaluation for kidney abnormalities such as hydronephrosis or renal scarring, assessment of renal function and the presence of potentially concerning urodynamics findings such as poor bladder compliance, DO and DESD.
Once patients are appropriately stratified based on their evaluation Table 3 , the Panel has provided recommendations within the Guideline as to how these patients should undergo regular urologic surveillance. Patients are categorized into the highest risk strata they meet e. At initial evaluation, all patients with NLUTD should undergo a detailed history, physical exam, and urinalysis.
NLUTD represents a broad spectrum of medical conditions and illnesses which result in variable effects to the lower urinary tract. Although, to some degree, the individual clinical findings can be predicted by the neurological condition or illness, there are several factors which may preclude accuracy in the initial assessment. Potential limitations of cognition, as well as motor and sensory deficits in some individuals with NLUTD, can make information gathering and physical examination challenging and time consuming.
Such limitations also may reduce the diagnostic and prognostic accuracy of the initial evaluation prompting additional studies. A thorough initial assessment including a comprehensive history, directed physical examination, and UA is critical in directing subsequent evaluation and management.
Such an initial assessment will guide the clinician in forgoing, or pursuing, further studies such as imaging and multichannel UDS.