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These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc. Advertisement Advertisement. This statement is informed by two systematic reviews Averbeck , Cameron and seven observational studies Cameron , Edokpolo , Guzelkucuk , Gao , Katsumi , Chen , Bartel reporting on detection of new or worsening symptoms.
The studies carried a very serious aggregate risk of bias but evidence was not further downgraded for any domain. An annual focused history, physical exam, and symptom assessment, with or without applicable questionnaires, provides the opportunity to screen for complications and worsening or new symptoms that may require investigation or a change in medical management Figure 1. Patients who catheterize can be assessed for adherence to their recommended schedule or for difficulties in passage of their catheter.
Renal function with serum creatinine, although a weak predictor of renal deterioration for many patients in this population with low muscle mass, 61 is a simple test and often is performed with other routine lab work obtained by other providers. Serum creatinine levels in SCI patients have been shown to be significantly lower than age and gender matched ambulatory individuals; levels below the normal range are expected.
A significant rise in serum creatinine from baseline, even within the normal range, should prompt careful assessment. Alternatively, a creatinine clearance measure by hour urine collections is more sensitive, but time consuming. Due to changes in sensation from their neurological disorder, renal calculi are often asymptomatic in moderate-risk NLUTD patients and symptoms of ureteral obstruction may present differently.
In addition, because these patients are at a higher risk of UTI, staghorn calculi and infectious stones are prevalent and can lead to serious complications if discovered late or when of substantial size.
Renal US is a low morbidity imaging modality that assesses both the kidneys and bladder with better sensitivity for calculi than a kidney, ureter, and bladder X-ray KUB 61 and without the risk of ionizing radiation from CT scans.
If a patient has undergone cross sectional or other equivalent upper tract imaging for other purposes during the interval between visits, it would be adequate to reference this imaging. Nuclear medicine renal scans are a more sensitive assessment of renal obstruction than serum creatinine, intravenous pyelogram, or voiding cystourethrogram 61 and provide information on renal function; however, in studies on serial renal nuclear scans on individuals with SCI, there was no advantage over renal US, particularly if the renal US was normal.
A renal scan, which is more time-intensive than a renal US, is best reserved for investigating renal function deterioration based on serum creatinine, evaluating obstruction, or as a secondary imaging study if abnormalities are seen on renal US. Also, renal scans are poor at identifying renal stones and cannot be used as an alternative imaging to renal US.
Several systematic reviews support this surveillance schedule, particularly the use of routine renal US, 61 although actual clinical practice may differ. Various systematic reviews and guidelines suggest different schedules. While some advocate imaging as often as every six months, 69 most recommend US annually 61 or every years. Edokpolo and Foster 55 assessed the impact of routine surveillance with annual renal US.
This follow up strategy was deemed safe and effective. A trabeculated bladder was seen in Longer time since injury, bladder management with indwelling catheter, and higher level of injury were other risk factors for these complications, further emphasizing the need for long term surveillance since risk of complications appears to increase over time.
Flexibility in the schedule of US imaging is at the discretion of the provider who may space out imaging to every two years in those patients who have been stable for longer periods of time and who are reliable at seeking care when they have complications or symptoms. In patients with high-risk NLUTD and stable urinary signs and symptoms , the clinician should assess the patient with:. The evidence base for this statement is comprised of three systematic reviews Cameron , Averbeck , Kavanagh and two observational studies Elmelund , Fletcher Across the studies evaluating the surveillance modalities and reporting on the outcomes of interest, the aggregate risk of bias was very serious.
Evidence was not further downgraded in any domain for any reported outcome. This group of patients is at substantial risk of renal deterioration, worsening bladder parameters, and urinary infections. An annual clinical assessment with their urological provider is the minimum clinical follow-up recommendation for this high-risk group, and they will likely require more care than this surveillance schedule for management of complications or medical treatment.
In contrast to moderate-risk patients, high-risk patients require upper tract imaging annually given their risk of new stones, increasing stone burden, or renal parenchymal loss in a potentially already compromised upper tract Figure 1.
Close surveillance is particularly important in these patients who manage their bladder with such high-risk bladder methods. UDS may need to be repeated in high-risk patients, even in those with stable symptoms. The timing of repeat UDS is left to the discretion of the urological provider since not all patients in this group will benefit from routine UDS.
Some patients who are high-risk because of upper tract findings but have prior favorable UDS parameters and have their incontinence well managed with medical or surgical treatment of the bladder, are unlikely to have unexpected findings on UDS study. On the other hand, a patient with prior dangerous bladder storage parameters and continued symptoms can easily have deterioration prompting more aggressive therapy. Existing guidelines and systematic reviews are varied in their recommendations.
Most guidelines advocate for UDS in the event of new symptoms or a more regular basis in high-risk patients with prior poor bladder compliance. A systematic review of 28 studies including patients found that evidence supporting the timing of UDS was lacking. UDS was found to modify treatment and often had findings even in the absence of symptoms or changes on upper tract imaging; 74 however, UDS is costly and not without risk to the patient.
The Panel recommends that clinician take these morbidities into account as well as the time and travel burden to this vulnerable population. A patient can change from high- to moderate-risk after receiving appropriate treatment and undergoing subsequent evaluation, post-treatment, repeat UDS, upper tract imaging, or renal function studies.
If this occurs, then follow-up should be based on their new risk category. There are essentially two pathways for patients to initially enter the low-risk stratification. This can occur at initial presentation with a neurological condition that is at low-risk for upper tract deterioration, with the identification of good bladder emptying, with stable urological symptoms, and with no recurrent UTIs or complications.
This can also occur in patients who were initially classified as unknown-risk who subsequently underwent risk stratification with upper tract imaging, UDS, and renal function and showed normal renal function and upper tracts and synergistic voiding on UDS.
This would subsequently classify these patients as low-risk Table 3. If they do not require further urological management for LUTS, these patients may be under the care of their primary care physician and do not require routine urological care. Despite their initial risk categorization as low-risk, they are not at zero risk of urological manifestations of NLUTD.
If their urinary tract condition has changed over time, and a clinical assessment changes their risk stratification, they should be followed up according to their new category. In patients with the moderate- or high-risk NLUTD who experience a change in signs and symptoms, new complications e.
The data is mixed on the utility of routine UDS in patients with NLUTD who have stable urinary symptoms and no urological complications; however, the data is very consistent that UDS performed for specific symptoms or cause often yield important urodynamic findings that may result in treatment changes.
In multiple studies following NLUTD patients with sign or symptom changes such as increased incontinence, recurrent UTIs, changes in renal function or new hydronephrosis, UDS revealed changes in bladder function such as loss of bladder compliance, high storage pressure, VUR, or worsening DO that required a change in bladder management method or medical or surgical therapy. In the NLUTD patient with concomitant hematuria, recurrent urinary tract infections, or suspected anatomic anomaly e.
This statement is supported by a systematic review Ismail with a serious risk of bias. Any patient with painless gross hematuria requires upper tract imaging i. SCI patients have a slightly elevated risk of bladder cancer which is especially pronounced after 20 years of disease. In a systematic review of 15 studies encompassing , SCI patients, the only patient factor correlating with bladder cancer was the presence of gross hematuria. Patients with indwelling catheters or those who perform CIC are at risk of urinary tract irritation or catheter trauma as the source of bleeding, but this cannot be determined without cystoscopic investigation.
Benign bladder lesions, urethral strictures, or calculi can also be the cause of bleeding and will be effectively diagnosed with a cystoscopy and receive the correct treatment. Recurrent UTIs are not rare in NLUTD patients, but in this population they can be the result of anatomic defects in the bladder such as foreign bodies or bladder diverticula that can be diagnosed with cystoscopy. NLUTD patients with difficult urethral catheter passage or hematuria with catheterization can have urethral strictures or a false passage from catheter trauma, particularly in those patients with external sphincter spasm during catheter passage.
Cystoscopy can effectively diagnose these conditions and may prompt treatment of a stricture or a change in catheterization technique after careful observation of the patient performing CIC. Alternatively, in the case that a urethral stricture is highly suspected as the cause of difficult catheter passage, a retrograde urethrogram can make the diagnosis of urethral strictures in male patients.
The evidence base supporting statements nineteen and twenty are shared based on identified studies enrolling NLUTD patients using different bladder management strategies with subgroup analyses for those using indwelling catheters in several studies.
The evidence base is comprised of two systematic reviews Ismail , Cameron and four observational studies El-Masri , Hamid , Sammer , Hamid , which were limited only by a serious risk of bias. Patients with SCI are at higher risk than the general population for developing bladder cancer; however, this overall risk is only 0.
Half of the patients utilized indwelling catheters as a bladder management method making it a significant risk factor, along with smoking and recurrent UTIs. It has been suggested that surveillance cystoscopy in this population might be beneficial in the early detection of bladder cancer, given their higher risk, and might reduce overall morbidity and mortality. However, although conceptually attractive, this notion has not yet been proven.
A systematic review of nine studies has shown that cystoscopy and cytology are poor screening tests for bladder cancer in NLUTD patient. Only one malignancy was found on screening, but many patients had benign inflammatory or metaplastic lesions that led to surgical biopsy and other investigations. None of these studies deemed routine cystoscopy as useful in the detection of bladder cancer. The difficulty in this population, who have more UTIs and catheter burden, is that the bladder is subject to irritation and subsequent inflammatory lesion e.
Routine cystoscopy leads to over detection of these benign lesions, which in turn leads to surgical biopsy and its inherent risk. In studies that looked closely at annual surveillance, patients were found to develop advanced symptomatic cancer between surveillance cystoscopy episodes making it a poor screening study. This argument also applies to patients who underwent prior augmentation cystoplasty. Routine cystoscopy was performed on 92 patients who were at least ten years status-post prior bladder augmentation.
Screening cystoscopy did not identify any tumors and the only malignancy was diagnosed after cystoscopy was done for gross hematuria after a previously normal screening cystoscopy. In NLUTD patients with indwelling catheters, clinicians should perform interval physical examination of the catheter and the catheter site suprapubic or urethral. This statement is informed by three observational studies Katsumi , Gao , Lavelle with a very serious risk of bias, plus evidence was downgraded for indirectness.
Indwelling catheters are chronic foreign bodies present in the urinary tract and their site of entry is inherently at risk for complications. The urethra is at risk for catheter hypospadias i. The catheter itself can cause pressure necrosis of the tissue of the urethra or even the pubic bone over prolonged periods of time. Risk factors for this complication include individuals with decreased sensation in the perineal area, impaired cognition, larger catheter size, and patients who are seated for prolonged periods of time.
In women, the relatively short urethra and bladder neck gradually dilate over time, which can lead to urine leakage around the catheter. A temporary solution is often to increase the catheter size, which only increases the pressure on the urethra, further exacerbating the problem.
The urethra can become so dilated that the catheter balloon is expelled and a larger mL balloon is often employed. As with catheter upsizing, balloon upsizing also exacerbates the problem long-term. A larger balloon causes more bladder stimulation and spasms, often resulting in the larger balloon to be expelled as well.
Hence, neither increasing the size of the catheter nor balloon are recommended and rather an investigation of the cause of leakage is indicated. These urethral injuries can be repaired with urethroplasty if the tissue is amenable.
Suprapubic catheters avoid urethral complications but can also erode through the abdominal wall if improperly secured. Granulation tissue can often occur around the suprapubic catheter site and can bleed and make tube changes more difficult. This can be easily identified and treated in the office with topical silver nitrate application. In NLUTD patients with indwelling catheters who are at risk for upper and lower urinary tract calculi e.
The evidence base for this statement is comprised of four observational studies Guzelkucuk , Katsumi , Lavelle , Gao The studies were limited by an aggregate very serious risk of bias, plus evidence was downgraded for indirectness. NLUTD patients with indwelling catheters are at unique risk for stones because of the chronic presence of a foreign body in their urinary tract.
The catheter increases the risk of UTIs 90 and is a source of chronic bacteriuria, both of which are risk factors for bladder and upper tract calculi. The catheter itself can serve as a nidus for biofilm and crystal formation. When the balloon is deflated for catheter changes, these shells of calculi are often left in the bladder to serve as a seed for bladder calculi formation. In addition, UTIs and bacteriuria from urease splitting organism can result in high urine pH, which precipitates urinary crystals.
The advantage of detecting these stones when small is that very small stones can be irrigated in clinic, while those that are slightly larger can be managed with a simple cystolithalopaxy. Cystoscopy only allows for assessment of the bladder and KUB is less sensitive for bladder stones compared to US.
Any patient with an indwelling catheter falls under the moderate- or high-risk NLUTD category for long-term surveillance and requires surveillance based on their particular risk level Statement 14 and Statement This statement is supported by three observational studies Skelton , Tornic , Weglinski all reporting on the prevalence of asymptomatic bacteriuria and symptomatic UTI.
The studies carried an aggregate very serious risk of bias but evidence was not further downgraded. The rationale to screen asymptomatic NLUTD patients is to treat those with positive urine cultures with antibiotics, to reduce bacteriuria, and to prevent the development of a future symptomatic UTI. However, the risk of developing a UTI in this patient population appears to be low enough to not justify treatment, thus eliminating the need for screening in the asymptomatic NLUTD population.
Tornic et al. The statement is supported by four observational studies Tornic , Weglinki , Skelton , Waites with a very serious risk of bias but no further limitations. Antibiotic resistance is a significant problem in patients with NLUTD, given the high frequency of antibiotic use. The unnecessary use of antibiotics, such as for treating asymptomatic bacteriuria, should be avoided at all costs. Treatment of asymptomatic bacteriuria in catheter-free patients with SCI is followed by early recurrence of the bacteriuria with more resistant strains.
The exception to treating asymptomatic bacteriuria in NLUTD patients is in patients who are pregnant and prior to urologic procedures, in which urothelial disruption or upper tract manipulation is anticipated. Perioperative antimicrobial treatment or prophylaxis for contaminated or clean-contaminated procedures is a best practice.
In NLUTD patients with signs and symptoms suggestive of a urinary tract infection, clinicians should obtain a urinalysis and urine culture. The evidence base is comprised of five observational studies Linsenmeyer , Massa , Ronco , Togan , Clark reporting on outcomes informing this statement. Across the outcomes, studies carried a very serious risk of bias plus for evidence was downgraded in the inconsistency domain for studies reporting on accuracy of predicting a UTI based on symptoms.
The classic symptoms of UTI seen in able-bodied patients such as dysuria, urgency, and frequency may be seen in NLUTD patients with intact lower urinary sensation; however, these symptoms are often not applicable to many patients with NLUTD due to changes in lower urinary tract sensation and altered modes of bladder management.
In addition, the signs and symptoms suggestive of UTI can be impacted by the specific neurologic disorder causing NLUTD, the severity of the neurologic disorder, the degree of alteration of bladder sensation and type of bladder management volitional void versus IC versus indwelling catheter.
Due to these many variables, there are no signs and symptoms alone that are adequately specific and sensitive enough to predict the presence of a UTI in all patients with NLUTD. Due to these challenges, the Panel recommends that patients with signs and symptoms suggestive of a UTI should have a UA and urine culture, allowing for optimal diagnosis and the ability to use culture-specific antibiotics when treating a UTI in NLUTD patients.
Linsenmayer and Oakley evaluated the accuracy of predicting UTI based on symptoms in a prospective case series of consecutive SCI patients male; at T6 or higher. Patients presented to the urology clinic with complaints of a UTI over a nine-month period.
UTI was defined as a new onset of clinical signs and symptoms e. In addition, the authors found that the type of bladder management had no impact on whether patients with SCI were able to predict the presence of a UTI based on symptoms alone. Massa et al. This study was part of a larger trial evaluating the effectiveness of hydrophilic catheters in patients with chronic SCI injured for at least six months and recurrent UTI. During the three-month period, participants completed a monthly UTI signs and symptoms questionnaire i.
The authors found that patients were much better at predicting when they did not have a UTI versus when they did have a UTI. The authors also evaluated individual signs and symptoms to identify their predictive values alone.
The presence of urinary leukocytes had the highest sensitivity Cloudy urine had the second highest positive predictive value Ronco et al. Patients were divided into two groups: symptomatic UTI episodes; patients and asymptomatic UTI episodes; patients. Asymptomatic UTI had the same culture criteria without any of the above signs and symptoms. There was no clinical sign or symptom that was diagnostic of UTI.
Their conclusion was that these signs and symptoms, in isolation, were not optimal for a diagnosis of UTI. They also found that fever was not associated with more concerning urinary findings and speculated this could be related to various other causes of infection leading to fever. This data illustrates the challenges of diagnosing UTI with symptoms alone in the NLUTD population, especially in those patients with altered and decreased sensation.
Without standard normal UTI symptoms, clinicians often rely on non-specific symptoms such as increased spasticity, abdominal discomfort, malaise, and increased symptoms of AD.
All these symptoms can be secondary to UTI; however, these symptoms can also be caused by a variety of other conditions not related to UTI. However, AD symptoms could also be secondary to bladder distention, bladder or kidney stones, constipation, hemorrhoids, and pressure ulcers. Thus, it is very important to obtain a UA and urine culture to optimally obtain a diagnosis of UTI in this patient population. However, it can also be unclear as to how to interpret culture results in patients with NLUTD who manage their bladder by a variety of methods.
In addition, the IDSA did not advocate using pyuria to determine whether antibiotics should be administered; however, they did state that if pyuria was absent another cause of symptoms, other than UTI, should be sought. Finally, another argument for obtaining a urine culture is the ability to treat a UTI with culture-specific antibiotics and the importance of antibiotic stewardship. This is especially applicable to patients with NLUTD who may be at greater risk of harboring resistant organisms.
Changes included positive to negative culture, negative to positive culture, and a change in organism in a positive culture.
Clark and Welk reviewed urine culture results over a two-year period of patients with NLUTD at a tertiary care urology clinic. Of the 81 individuals with at least two positive cultures, there was Interestingly, antibiotic sensitivity concordance was higher than what was seen for the specific bacterial organism ciprofloxacin: This illustrates the importance of checking prior culture results if empiric antibiotics are to be started once a UA and culture have been obtained, but not yet resulted, in NLUTD patients with signs and symptoms of a UTI.
In NLUTD patients with a febrile urinary tract infection, clinicians should order upper tract imaging if:. In addition, the potential alteration of normal sensation may impact signs and symptoms, such as flank or abdominal pain, that would normally inform the caregiver of a potentially more dangerous condition.
If there is a high degree of suspicion for a UTI then empiric antibiotics should be initiated with the antibiotic changed, if needed, based on the culture result. The clinician may choose an antibiotic based on a recent, prior culture, if available. The need for appropriate radiographic assessment in these patients is still required, even if they have an appropriate response to antibiotics. Therefore, it is imperative that patients continue to be risk stratified see Table 3 and evaluated appropriately based on their level of risk.
In NLUTD patients with a suspected urinary tract infection and an indwelling catheter, clinicians should obtain the urine culture specimen after changing the catheter and after allowing for urine accumulation while plugging the catheter. Urine should not be obtained from the extension tubing or collection bag. IDSA recommends obtaining urine specimens aseptically through the catheter port in patients with short-term indwelling catheterization and suspected UTI.
Due to concerns related to biofilm possibly impacting the adequate assessment of the urine, the recommendation from the IDSA is to obtain urine for culture from a freshly placed catheter. In addition, it is specifically stated that urine should not be obtained from the drainage bag.
The studies that support this statement are older and primarily evaluated elderly patients who managed their bladder with chronic indwelling catheters for a variety of reasons; these were not studies that specifically evaluated the topic in NLUTD patients. Bergqvist et al. Fourteen of the specimens were negative, which correlated between both techniques. However, when bacteriuria was identified, there was a lack of agreement in 12 of 36 specimens.
The concern was that specimens obtained via a chronically placed catheter were not optimal and the authors recommended suprapubic bladder aspiration when obtaining urine in patients with a chronic indwelling catheter. While suprapubic aspiration is not the recommendation of the Panel, this does speak to the potential benefit of obtaining urine for culture from a newly placed catheter over one that has not been changed. Two other studies focused on the concept of placement of a new catheter to obtain urine in patients with chronic indwelling catheters which reflects present day practice.
Grahn et al. A catheter specimen was obtained via needle aspiration from the distal end of the catheter that had not been changed for at least 30 days; the bladder specimen was obtained from the end of a freshly placed catheter that was clamped for 30 minutes. There was a difference in 22 of 41 isolated bacterial strains in 17 of 20 patients.
There were 17 instances where the CFU count from the catheter exceeded the quantity of the same strain in the bladder by at least tenfold. Tenney et al. In NLUTD patients with recurrent urinary tract infections, clinicians should evaluate the upper and lower urinary tracts with imaging and cystoscopy.
Similar to the evaluation of hematuria, it is considered good clinical practice to evaluate both the upper and lower urinary tracts for sources of recurrent UTI. Imaging is needed for examining the upper urinary tracts. The risks of direct visualization via ureteroscopy far outweighs the benefit in this situation and is not recommended. Contrast studies are not required in the initial evaluation.
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