Guideline sources The following summarized guidelines for the evaluation and management of neurogenic bladder are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2022), the American Urological Association (AUA/SUFU 2021), and the International Society of Urology (SIU/ICUD 2018). 1 2 3 Guidelines 1. Classification and risk stratification Risk assessment: Classify patients at initial evaluation as low-risk or unknown risk requiring further evaluation to allow for complete risk stratification. B https://web.pathway.md/diseases/recq8EKcVE7i1DnIE 1/6 6/30/23, 1:16 AM Neurogenic bladder Pathway Obtain risk stratification in patients with an acute neurological event resulting in neurogenic lower urinary tract dysfunction once the neurological condition has stabilized. B 2. Diagnostic investigations Initial evaluation: Include the following in the initial evaluation of all patients with neurogenic lower urinary tract dysfunction: detailed history and physical examination urinalysis post-void residual measurement (in patients who spontaneously void). B Show 3 more Urinalysis and culture: obtain urinalysis and urine culture in patients with neurogenic lower urinary tract dysfunction with signs and symptoms suggestive of a UTI. B Show 2 more Urinary tract imaging: Obtain upper urinary tract imaging in patients with neurogenic lower urinary tract dysfunction with a febrile UTI if the patient does not respond appropriately to antibiotic therapy or is at moderate- or high-risk and is not up to date with routine upper urinary tract imaging, regardless of their response to therapy. B Obtain upper and lower urinary tract imaging in patients with neurogenic lower urinary tract dysfunction with recurrent UTIs. B Urodynamic testing: consider obtaining urodynamic testing in patients with neurogenic lower urinary tract dysfunction with recurrent UTIs and an unremarkable upper and lower urinary tract evaluation. C Show 2 more 3. Diagnostic procedures Cystoscopy: do not perform routine cystoscopy in the initial evaluation of patients with neurogenic lower urinary tract dysfunction. D Show 3 more 4. Medical management Antibiotic prophylaxis: As per AUA 2021 guidelines, do not use daily antibiotic prophylaxis for the prevention of UTI in patients with neurogenic lower urinary tract dysfunction with an indwelling catheter. D Show 2 more As per SIU 2018 guidelines, do not treat asymptomatic bacteriuria except when the patient must undergo surgical or endoscopic manipulations. D https://web.pathway.md/diseases/recq8EKcVE7i1DnIE 2/6 6/30/23, 1:16 AM Neurogenic bladder Pathway Management of autonomic dysreflexia: Terminate urodynamic testing and/or cystoscopic procedure, immediately drain the bladder and continue hemodynamic monitoring in patients with neurogenic lower urinary tract dysfunction developing autonomic dysreflexia during testing. B Initiate pharmacologic management and/or escalate care in patients with neurogenic lower urinary tract dysfunction with ongoing autonomic dysreflexia following bladder drainage. B General principles: Prescribe medications, particularly combination therapy, with care due to the risk of polypharmacy and cognitive impairment in patients with spinal cord injury. B Avoid offering drug "cycling" in patients with spinal cord injury if oral medical therapy fails. Consider offering alternative treatment such as botulinum neurotoxin or surgical reconstruction. D Anticholinergics: consider administering anticholinergics in all patients with spinal cord injury with neurogenic bladder symptoms or worrisome urodynamic findings. B Beta-3 adrenergic receptor agonists: consider administering mirabegron as an alternative or in combination with anticholinergics in patients with spinal cord injury failing anticholinergics. C Alpha-adrenergic receptor antagonists: consider administering tamsulosin or other adrenergic blockers in combination with anticholinergics to improve capacity and compliance in patients with spinal cord injury. C Tricyclic antidepressants: consider administering TCAs in specific scenarios and in combination therapy in patients with spinal cord injury. C 5. Nonpharmacologic interventions Bladder expression: Do not offer bladder expression or triggered bladder voiding in patients with spinal cord injury if any of the following video-urodynamic findings are present: small bladder capacity high leak point pressure low compliance vesicoureteral reflux at any point of the study closed bladder neck during voiding or high voiding pressure. D Show 4 more 6. Therapeutic procedures Intermittent catheterization: offer intermittent catheterization over bladder expression or triggered bladder voiding B as the preferred method of bladder management in patients with urinary retention after spinal cord injury. B Show 2 more https://web.pathway.md/diseases/recq8EKcVE7i1DnIE 3/6 6/30/23, 1:16 AM Neurogenic bladder Pathway Indwelling catheterization: consider offering indwelling urethral catheterization as a last resort option due to a higher rate of complications in patients with spinal cord injury unable or unwilling to perform intermittent catheterization or decline suprapubic tube. C Condom catheterization: consider offering condom catheter drainage in patients with spinal cord injury unable or unwilling to perform intermittent catheterization, if willing to undergo sphincterotomy. C Botulinum toxin injections: consider administering botulinum neurotoxin A bladder injection in patients with spinal cord injury and neurogenic detrusor overactivity if anticholinergic medications are ineffective or not tolerated. B Show 5 more 7. Specific circumstances Pediatric patients (evaluation): obtain urodynamic testing in all patients with spina bifida, and with a high suspicion of neurogenic bladder to estimate the risk for the upper urinary tract and to evaluate the function of the detrusor and the sphincter. B Pediatric patients (intermittent catheterization): perform intermittent catheterization soon after birth in all newborns with spina bifida and neurogenic bladder. B Show 2 more Pediatric patients (medical management): recognize that the main goals of treatment are the prevention of urinary tract deterioration and the achievement of continence at an appropriate age. B Show 4 more Pediatric patients (botulinum toxin injections): consider administering botulinum toxin injection into the detrusor muscle to improve clinical and urodynamic variables in pediatric patients refractory to anticholinergics/muscarinergics. C Pediatric patients (surgical management): consider performing ileal or colonic bladder augmentation in patients with therapy-resistant overactivity of the detrusor, small capacity and poor compliance, which may cause upper urinary tract damage and incontinence. B Show 2 more Pediatric patients (follow-up): Monitor pediatric patients with neurogenic bladder for bowel and urinary function disturbances and offer management accordingly. B Offer lifelong follow-up of upper and lower urinary tract function in all patients and address sexuality and fertility starting before/during puberty. B 8. Patient education https://web.pathway.md/diseases/recq8EKcVE7i1DnIE 4/6 6/30/23, 1:16 AM Neurogenic bladder Pathway Patient education: educate patients with neurogenic lower urinary tract dysfunction about the symptoms and signs warranting additional assessment. B 9. Follow-up and surveillance Follow-up (general principles): do not obtain surveillance upper urinary tract imaging, renal function assessment, or multichannel urodynamic testing in patients with low-risk neurogenic lower urinary tract dysfunction and stable urinary signs and symptoms. D Show 3 more Follow-up, patients with indwelling catheter: As per SUFU/AUA 2021 guidelines, perform interval physical examination of the catheter and the catheter site (suprapubic or urethral) in patients with neurogenic lower urinary tract dysfunction with indwelling catheters. B Show 2 more As per ICUD/SIU 2018 guidelines, obtain ongoing urological follow-up in patients with spinal cord injury using indwelling catheter drainage since upper tract deterioration, urolithiasis and other urinary complications are not rare. B Re-evaluation of patients with new symptoms: As per AUA 2021 guidelines: Obtain reevaluation and repeated risk stratification in patients with low-risk neurogenic lower urinary tract dysfunction presenting with any of the following: new onset signs and symptoms new complications (such as autonomic dysreflexia, UTIs, stones) upper tract or renal function deterioration. B Consider obtaining multichannel urodynamic testing in patients with moderate- or high-risk neurogenic lower urinary tract dysfunction with any of the following: change in signs and symptoms new complications (such as autonomic dysreflexia, UTIs, stones) upper tract or renal function deterioration. C As per SIU 2018 guidelines, do not ignore the following non-specific signs and symptoms of UTIs in patients with spinal cord injury, which may suggest presence of urinary infections: exacerbation of spasticity difficulty to insert the catheter into the urethra due to the spasms of the pelvic floor worsening of incontinence fever abdominal and back pain. D Follow-up (patients with condom catheter): monitor patients with spinal cord injury using condom drainage with routine physical examination of the penis, assessment of post-void residuals, bladder pressure monitoring and upper tract imaging. B https://web.pathway.md/diseases/recq8EKcVE7i1DnIE 5/6 6/30/23, 1:16 AM Neurogenic bladder Pathway Clinical findings Symptoms Past medical history Dysuria Alzheimer's disease Urinary frequency Cerebral palsy Urinary incontinence Diabetes Urinary retention Guillain-barr syndrome Urinary urgency Kidney stones Weak urine stream Lumbar spinal stenosis Multiple sclerosis Neurological exam Parkinson's disease Spina bifida Cauda equina syndrome Spinal cord injury Stroke UTI References 1. Lisette A 't Hoen, Guy Bogaert, Christian Radmayr et al. EAU guidelines on Paediatric Urology. EAU. 2022 Mar. Open 2. David A Ginsberg, Timothy B Boone, Anne P Cameron et al. The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Diagnosis and Evaluation. J Urol. 2021 Nov;206 5 1097 1105. Open 3. Paholo G Barboglio Romo, Christopher P Smith, Ashley Cox et al. Non-surgical urologic management of neurogenic bladder after spinal cord injury. World J Urol. 2018 Oct;36 10 1555 1568. Open 4. Stein R, Bogaert G, Dogan HS et al. EAU/ESPU guidelines on the management of neurogenic bladder in children and adolescent part I diagnostics and conservative treatment. Neurourol Urodyn. 2019 Nov 13. Open 5. Raimund Stein, Guy Bogaert, Hasan S Dogan et al. EAU/ESPU guidelines on the management of neurogenic bladder in children and adolescent part II operative management. Neurourol Urodyn. 2020 Feb;39 2 498 506. Open 6. Expert Panel on Urologic Imaging, Jade J Wong-You-Cheong, Paul Nikolaidis et al. ACR Appropriateness Criteria Renal Failure. J Am Coll Radiol. 2021 May;18 5S S174 S188. Open https://web.pathway.md/diseases/recq8EKcVE7i1DnIE 6/6