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NICE Clinical Guideline 148. Urinary Incontinence in Neurological

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NICE Clinical Guideline 148. Urinary Incontinence in Neurological Urinary incontinence in neurological disease: management of lower urinary tract dysfunction in neurological disease F.2 Does the use of urodynamics (filling cystometry, leak point pressure measurements, pressure-flow studies of voiding, video urodynamics) direct treatment or stratify risk of renal complications (such as hydronephrosis)? Higher risk group – children with myelodysplasia Source Study type Number Outcome of Evidence of Length of measures fundin Reference level patients Patient characteristics Intervention Comparison follow-up g Bauer SB, Hallett M, Observation N=36 Consecutive newborns with As soon as possible - Follow-up Urodynamic None Khoshbin S et al. al study myelodysplasia. In each child after the urodynamic findings reporte Predictive value of (prospective) the myelomeningocele was neurosurgical studies d urodynamic evaluation repaired with 24 hrs of birth, operations or when were done in newborns with and, when indicated, the CSF the child’s condition semiannuall myelodysplasia. JAMA. diverted. allowed, serum y in all 1984; 252(5):650-652. creatinine level, urine children Ref ID: BAUER1984 cultures, neurologic with examination, dyssynergic excretory urogram sphincter and urodynamic activity, as studies were increasing performed. If the postvoiding excretory urogram volume of was abnormal or if urine, or an the urodynamic study abnormal 132 Urinary incontinence in neurological disease – appendices Urinary incontinence in neurological disease: management of lower urinary tract dysfunction in neurological disease disclosed urogram. In incoordination of the the detrusor external remainder, urethral sphincter, a urodynamic voiding assessment cystourethrogram was was obtained performed yearly. Follow-up ranged from 18 to 48 months Effect The urodynamic studies showed that 18 (50%) of the 36 children had incoordination of the detrusor-external urethral sphincter. Three of these had hydronephrosis on the initial excretory urogram. Severe hydroureteronephrosis, massive reflux, or an enlarged bladder with a large post voiding volume or urine developed within six months of birth in seven, before 2 yrs of age in two, after two years of age in one. Thirteen (72%) of 18 children with dyssynergia were found to have these abnormalities. The five infants with incoordination of the detrusor-external urethral sphincter who urinary tracts did not deteriorate had milder forms of dyssynergia. Nine newborns had synergic activity of the external uretheral sphincter. In two (22%), dyssynergia and subsequent decompensation of the urinary tract developed. Of the nine neonates with absent electromyographic activity in the external urethral sphincter, only one experienced deterioration of the urinary tract, and this child had elevated urethral resistance. The incidence of urinary tract decompensation was significant different (χ²=19.6, 2 df, p<0.001) among the three groups of newborns differentiated by the nature of electromyographic activity at the time of initial urodynamic study. No correlation could be made between the level of the neurological lesion and the type of activity of the external sphincter or the development of deterioration of the urinary tract. 16/36 (44%) of infants required treatment for deterioration of the urinary tract. Authors conclusion Infants with dyssynergia of the detrusor-external sphincter are at high risk of deterioration of the urinary tract; they should be followed up closely and intermittent catheterisation should be started early. Study type Number Outcome Source Evidence of Length of measures of Reference level patients Patient characteristics Intervention Comparison follow-up funding McGuire EJ, Retrospective N=42 Patients with myelodsplasia Serial radiographic - Mean 7.1 Detrusor response None 133 Urinary incontinence in neurological disease – appendices Urinary incontinence in neurological disease: management of lower urinary tract dysfunction in neurological disease Woodside JR, Borden observational studies that included yrs (range to filling reported TA et al. Prognostic excretory urography 3 to 15 Urodynamic value of urodynamic (IVP) and voiding yrs) findings in relation testing in cystourethrography, to IVP and voiding myelodysplastic all had undergone cystourethrography patients. Journal of urodynamic Urology. 1981; evaluation (urethral 126(2):205-209. Ref pressure ID: MCGUIRE1981 profilometry, cystometrogram) Effect Detrusor response to filling Of the 42 patients 7 (17%) showed reflex detrusor activity in response to bladder filling. In 3 of these 7 patients intravesical pressure at the time of urethral leakage (urethral opening pressure) was higher than maximal resting urethral closing pressure values as determined by the profile technique, while in 4 it was lower. In the former 3 patients discoordinate activity between the detrusuor and external sphincter was present, while in the latter 4 patients coordinate detrusor and sphincter activity occurred. 35/42 (83%) patients showed areflexic detrusor dysfunction. Detrusor pressure response to volume increments varied: 5 patients showed no significant intravescial pressure response to volume increments and demonstrated a large bladder capacity without urethral leakage, while 30 showed a progressive increase in pressure without increasing volume culminating in urethral leakage when intravesical and intraurethral pressures were equal. Urodynamic findings in relation to excretory urography (IVP) and voiding cystourethrography A total of 20 patients showed intravesical pressures ≤ 40 cm water at the time of urethral leakage, while 22 showed pressures greater than this value. No patients in the low pressure group suffered vesicoureteral reflux and only 2 showed evidence of urethral dilation on an IVP. Urethral dilation resulted in resolution of upper urinary tract changes in these 2 patients. In contrast, the patients who demonstrated higher peak urethral closing pressures and, consequently, higher intravesical pressures at the time of urethral leakage had significantly more clinical problems. 15 (68%) had vesicoureteral reflux, 18 (81%) showed uretral dilation on an IVP, 8 underwent an operative procedure to decrease urethral resistance and 7 underwent urinary diversion. One patient ultimately required a renal transplant into an ileal loop diversion. In all, 17 operative procedures were performed, including 2 ureteral reimplantations. Relationship of urethral opening pressure to ureteral complications 134 Urinary incontinence in neurological disease – appendices Urinary incontinence in neurological disease: management of lower urinary tract dysfunction in neurological disease Urethral opening pressure < 40 cm water No. (%) > 40 cm water No. (%) Vesicoureteral reflux 0 15 (68) Ureteral dilation 2 (10%) 18 (81) The major clinical problems were incontinence in patients with low urethral closing pressures and the degree of urinary retention, upper urinary tract deterioration and the development of vesicoureteral reflux in those with higher urethral closing pressures Authors conclusion There is a striking relationship between urethral closure pressure and intravesical pressure at the time of urethral leakage and the clinical course in this group of myelodysplastic patients is demonstrated. Every patient with a normally closed vesical outlet was continent on intermittent catheterisation and an anticholinergic agent, while nly 60% of patients with open bladder outlets similarly treated achieved good urinary control and none was dry. Treatment options for patients with high urethral closed pressures include intermittent catheterisation and anticholinergic medications or a sphincter ablative procedure to decrease the outlet resistance combined with anticholinergic therapy and implantation of an artificial sphincter. However, only longer follow,up will determine if these therapeutic regimens will prevent upper urinary tract deterioration Study type Number Outcome Source Evidence of Length of measures of Reference level patients Patient characteristics Intervention Comparison follow-up funding Seki NA. An analysis of Observational N=39 Patients with myelodysplasia. Basic evaluations for - NA Predictors of None risk factors for upper study (cross- Inclusion criteria included: not inclusion in the study vesico-utereric reported urinary tract sectional) N=63 to have been managed by were excretory reflux (VUR) deterioration in reviewed either intermittent or urogram, a voiding and patients with indwelling catheterisation cysto-urethrogram hydronephrosis myelodysplasia. BJU before being referred to the and a baseline International. 1999; hospital. The basic evaluations urodynamic study 84(6):679-682. Ref ID: for inclusion in the study were which had been SEKI1999 an excretory urogram, a performed within 30 voiding cysto-urethrogram and days after the first a baseline urodynamic study visit which had been performed within 30 days after the first 135 Urinary incontinence in neurological disease – appendices Urinary incontinence in neurological disease: management of lower urinary tract dysfunction in neurological disease visit. None of the patients were managed using anticholinergic agents during the study. Of the 39 patients, 15 (39%) showed some degree of vesico-ureteric reflux (VUR) and hydronephrosis was identified in five patients (13%) at evaluation. The results of the stepwise logistic regression analysis showed that a high level of MUCP and the presence of DSD were selected as having the most effective combination of factors for the incidence of
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