Recommendations for urological follow-up of patients with neurogenic bladder secondary to spinal cord injury

Conservative Bladder Management and Medical Treatment in Chronic Spinal Cord Injury Patients

To review the available data on non-surgical management for neurogenic lower urinary tract dysfunction (NLUTD) in patients with chronic spinal cord injury (SCI) and provide the most updated knowledge for readers. We categorized the bladder management approaches into storage and voiding dysfunction separately; both are minimally invasive, safe, and efficacious procedures. The main goals for NLUTD management are to achieve urinary continence; improve quality of life; prevent urinary tract infections and, last but not least, preserve upper urinary tract function. Annual renal sonography workups and regular video urodynamics examinations are crucial for early detection and further urological management. Despite the extensive data on NLUTD, there are still relatively few novel publications and there is a lack of high-quality evidence. There is a paucity of new minimally invasive and prolonged efficacy treatments for NLUTD, and a partnership between urologists, nephrologists and physiatrists is required to promote and ensure the health of SCI patients in the future.

A survey of clinical practice concerning long-term follow-up of neurogenic lower urinary tract dysfunction due to spinal cord injury in Italy

CONTEXT/OBJECTIVE

This study aimed to assess the clinical practice for long-term follow-up (FU) of neurogenic lower urinary tract dysfunction (NLUTD) due to spinal cord injury (SCI) in Italy and compare this practice with the clinical practice in other countries and with the international guidelines.

DESIGN

Data concerning the long-term urological FU of individuals with SCI were collected using a questionnaire and analyzed by means of descriptive and inferential statistics.

SETTING

Twenty-one Italian centers following SCI patients.

PARTICIPANTS

One physician at each center (either a permanent staff member or chief).

OUTCOME MEASURES

Questions addressed the treatment of urinary tract infections (UTI), frequency of visits, urinary tract imaging examinations and urodynamic tests (UD), distinguishing between suprasacral and sacral SCI.

RESULTS

Nineteen out of 21 centers completed the survey. In most centers, patients were recommended to undergo a visit and an ultrasound examination of urinary tract (UT) at least once a year. While the median interval between FU visits was identical (12 months) for individuals with suprasacral and sacral SCI, the two interval distributions were significantly different (suprasacral SCI: min-max 4-18, IQR = 6; sacral SCI: min-max 6-24; IQR = 8.5; P = 0.02), showing people with suprasacral SCI are followed up more often. Approximately 80% of the surveyed centers performed scheduled UD, with a yearly median frequency of 12 months (range 6-36) for patients with suprasacral SCI, as compared to a median frequency of 18 months for sacral SCI (range 0-36, P = 0.04). VideoUD and antibiotic prophylaxis for recurrent UTIs are carried out only by urologists in 63% and 47.4% of the centers, respectively. Overall, Italian centers share common strategies that compare to standards, including yearly visits, yearly UT examinations and stricter follow-up of people with suprasacral SCI, but may not have standard protocols for antibiotic prophylaxis of UTI, and in few cases control visits and UD are carried out too often.

CONCLUSIONS

Even though most Italian centers follow up patients with NLUTD secondary to SCI according to international guidelines, heterogeneity in frequency of FU examinations still exists. A tailored approach to the SCI patient that minimizes unnecessary examinations and groups different tests in a single access could improve patients' compliance with FU and reduce costs for the Health system.

Efficacy and safety of mirabegron for treatment of neurogenic detrusor overactivity in adults with spinal cord injury or multiple sclerosis: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

To evaluate the efficacy and safety of mirabegron in patients with neurogenic detrusor overactivity due to SCI or MS.

METHODS

A comprehensive search of the Pubmed, Cochrane, Scopus, and Embase databases was performed. Studies evaluating adult patients with neurogenic detrusor overactivity due to SCI or MS were analyzed according to clinical and urodynamic outcome parameters.

RESULTS

A total of 488 patients were included in 11 studies, with sample sizes ranging from 15 to 91. The duration of the treatments varied from 4 weeks to 12 months. Mirabegron was used as a secondline treatment after anticholinergics in most of the studies. While clinical outcome parameters are used in studies involving only MS patients, urodynamic outcome parameters are also used in studies involving patients with SCI. The efficacy of mirabegron was found not to be different than anticholinergics when compared in MS patients. Comprehensive urodynamic evaluation was performed in 2 randomized, double-blind, placebo-controlled studies and no satisfactory results were obtained compared to placebo. In retrospective studies there were some significant improvements in P_det(max), MCC and compliance. The major safety concern with mirabegron is cardiovascular safety. In one study, tachyarrhythmia and palpitations reported in a patient with SCI at C6 level, in another study tachycardia reported in one patient with MS.

CONCLUSIONS

Although mirabegron demonstrates similar clinical efficacy to anticholinergics in MS patients, its effect on urodynamic parameters in patients with SCI cannot be considered satisfactory. It has a good safety profile with mild cardiovascular side effects.

Telmisartan inhibits bladder smooth muscle fibrosis in neurogenic bladder rats

Hypertension is associated with bladder symptoms. The present study investigated whether an angiotensin receptor blocker could improve the symptoms and pathological changes associated with a neurogenic bladder (NB). A Sprague-Dawley rat model of NB was constructed. Rats in the sham and model groups were gavaged with saline, and rats in the treatment group were gavaged with telmisartan. Urodynamic parameters, including maximum cystometric capacity, residual urine volume, bladder wet weight, bladder compliance and detrusor pressure, were detected. Masson and H&E staining were performed to assess bladder fibrosis and histopathological changes. The expression levels of basic fibroblast growth factor (bFGF), TGF-β1, Collagen I, Collagen III, and α-smooth muscle actin (α-SMA) were also measured by reverse transcription-quantitative PCR, western blotting and immunohistochemistry. The model rats exhibited symptoms and pathological changes associated with NB. Treatment with telmisartan reduced maximum cystometric capacity, residual urine volume, bladder compliance and bladder wet weight, and increased detrusor pressure in model rats. The tissue staining results showed that telmisartan exerted an antifibrotic effect. In addition, telmisartan inhibited the expression of bFGF, TGF-β1, Collagen I, Collagen III and α-SMA in model rats. Therefore, the results of the present study indicated that telmisartan may serve as a potential therapeutic agent for NB.

Urinary catheter management: what neurologists need to know

Patients with neurological disorders often have lower urinary tract dysfunction, manifesting as urinary retention or urinary incontinence, and so commonly use catheters. Neurologists should therefore be aware of the different types of catheters and appliances and their risks, benefits and complications. Clean intermittent self-catheterisation is preferable to an indwelling catheter; however, if this is not possible, then a suprapubic indwelling catheter is preferable to a urethral catheter for long-term management. We review the decision-making process when selecting catheters for neurological patients, the evidence base regarding the different options and how neurologists can recognise and address complications. We also discuss alternatives to catheterisation, such as non-invasive containment products and surgical treatments, and the indications for urological referral.

The Stockholm Spinal Cord Uro Study: 3. Urodynamic characteristics in a regional prevalence group of persons with spinal cord injury and indications for improved follow-up

AIMS

Examine the outcome of urodynamic studies in a regional prevalence group of patients with traumatic spinal cord injury (SCI), explore relationships between urodynamic parameters and renal complications/other SCI-related dysfunctions, assess the role of urodynamics in SCI follow-up.

METHODS

In a cross-sectional study, 211 patients were included, who attended a yearly check-up and had urodynamics performed as part of the follow-up in addition to S-creatinine, S-cystatin-C, renal ultrasound, and a questionnaire regarding complications. Relationships between urodynamic parameters and renal complications/other SCI-related dysfunctions were explored by descriptive and comparative statistics.

RESULTS

Neurogenic detrusor overactivity (NDO) was found in 150, underactive/acontractile detrusor in 44, normal detrusor function in 17 patients. Maximum detrusor pressures during filling/voiding in NDO attained mean levels of >40 cm H₂O in 68% of patients and >25 cm H₂O in 83%. Reduced compliance of the bladder wall, cystometric bladder capacity <250 mL, and detrusor overactivity leakage during filling were associated with higher detrusor pressures. Detrusor overactivity during more than one-third of the filling phase was significantly related to signs of renal complications among patients with SCI duration 11-20 years. No significant relationships were found between other urodynamic parameters and renal/other SCI-related complications. Renal complications in underactive/acontractile and normal detrusor function co-varied with evidence of previous NDO and other co-morbidities which may negatively influence kidney function.

CONCLUSIONS

Maximum detrusor pressures during the filling/voiding phases attained high levels in a majority of patients. Detrusor overactivity during more than one-third of the filling phase was significantly related to signs of renal complications.

Population-Based Study of Prevalence, Bother and Behavior Related to Treatment for Lower Urinary Tract Symptoms and Overactive Bladder among Polish Neurogenic Patients

Background: The aim of this study was to perform a cross-sectional study of Polish neurogenic patients to measure, at the population level, the prevalence, bother and behavior associated with treatment for lower urinary tract symptoms (LUTS) and overactive bladder (OAB). Methods: This epidemiological study was based on data from LUTS POLAND, a computer-assisted and population-representative telephone survey. Participants were classified by age, sex and place of residence. Results: LUTS POLAND includes 6005 completed interviews, of which 1166 (19.4%) were for individuals who had ever received any treatment by neurologists and/or neurosurgeons. Among these neurogenic participants, LUTS prevalence was 72.3%, statistically higher than for non-neurogenic respondents. At the population level, neurogenic patients had about a 20% higher risk for LUTS presence than non-neurogenic participants (relative risk: 1.17–1.21). LUTS prevalence did not differ between men and women. Frequency was the most common of the LUTS. Forty percent of neurogenic respondents described having more than one LUTS subtype (i.e., storage, voiding, and/or post-micturition symptom subtype), and more than 50% of respondents reported OAB symptoms. Both storage and voiding symptoms were bothersome, and many neurogenic individuals (42.3–51.0%) expressed anxiety about bladder function affecting quality of life. Only one-third (34.9–36.6%) of neurogenic participants had sought treatment for their LUTS, and the majority of such individuals received and maintained treatment. Conclusions: LUTS and OAB symptoms were highly prevalent and bothersome among Polish neurogenic patients at the population level. Because the scale of seeking treatment for LUTS was low, Polish neurogenic patients may not be adequately informed about multiple effects of LUTS and OAB.

Evaluation and management of neurogenic bladder after spinal cord injury: Current practice among physical medicine and rehabilitation specialists in Turkey

Objectives

This study aims to determine the current trends in evaluation and management of neurogenic bladder secondary to spinal cord injury (SCI) among Physical Medicine and Rehabilitation (PMR) specialists in Turkey.

Materials and methods

Between September 2013 and November 2013, a total of 100 PMR specialists from 18 different provinces of Turkey were included in the study. A 23-item questionnaire was developed to evaluate the current practice on assessment and follow-up of upper and lower urinary tract dysfunction. The questionnaire was delivered via e-mail to the participants routinely providing care for patients with SCI and all responses were obtained electronically.

Results

For surveillance of the upper urinary tract dysfunction, 93% of the participants preferred ultrasonography. A total of 59% of the participants favored an annual assessment and 36% preferred six-month intervals. Multichannel urodynamics, voiding cystourethrography combined with urodynamics, and video-urodynamics were preferred by 62%, 25%, and 10% of the participants, respectively for surveillance of the lower urinary tract. Urodynamic evaluation was performed annually by 51% of the participants. In patients with detrusor overactivity unresponsive to the combination of intermittent catheterization (IC) and anticholinergic agents, 66% preferred to increase the dose and 22% preferred to switch to another medication. For treatment of areflexic bladder, 78% preferred IC and 12% preferred the Credé' or Valsalva maneuvers. Treatment of asymptomatic bacteriuria was not favored in patients on IC and indwelling urethral catheter by 33% and 44% of the participants respectively. Totally, 84% participants preferred to administer antibiotics for 10 to 14 days for the treatment of symptomatic urinary tract infection.

Conclusion

Our study results indicate that there are some differences in the current practice of PMR specialists for surveillance and management of SCI patients with neurogenic bladder. These results also emphasize the need for development of guidelines and implementation of continuous medical education activities in this field.

Botulinum toxin A improves neurogenic bladder fibrosis by suppressing transforming growth factor β1 expression in rats

Background

Intradetrusor botulinum toxin A injection is recommended for the treatment of refractory detrusor overactivity (DO) in patients with neurogenic bladder, however, whether it could inhibit neurogenic bladder fibrosis is uncertain. This study aimed to investigate the effect of botulinum toxin A on neurogenic bladder fibrosis and the underlying mechanism.

Methods

Forty eight Female Wistar rats were evenly randomized into 4 groups: Sham, T10 transection, Early and Late groups. The last three groups were subjected to T10 spinal cord transection, while the Sham group was treated with sham surgery. 0.9% saline was injected into the detrusor in the Sham and T10 transection groups simultaneously with the surgery, while 2 U/rat botulinum toxin A was injected into the detrusor simultaneously with the surgery in the Early group and 4 weeks following the surgery in the Late group. Body/bladder weight, cystometric parameters, bladder Hematoxylin-eosin staining were used to evaluate the bladder fibrosis. Western blot and quantitative Real-time PCR were used to evaluate the expression of bladder transforming growth factor β1.

Results

Compared with the T10 transection group, the bladder/body weight was decreased significantly in the Early and Late groups (P<0.05), along with the significant inhibition of non-voiding contraction (NVC) frequency and amplitude (P<0.05), and the significant increase of bladder volume (P<0.05). The detrusor connective tissue percentage (P<0.05) and the expression of transforming growth factor β1 (P<0.05) also decreased significantly in the Early and Late groups. Those changes were more obviously in the Early group than in the Late group.

Conclusions

Intradetrusor botulinum toxin A injection reduced bladder fibrosis in rats with spinal cord injury (SCI), which was more obviously in the Early group than in the Late group. The mechanisms might be mediated by suppression of transforming growth factor β1 (TGF-β1) expression.

Urological malignancies in neurogenic patients

PURPOSE OF REVIEW

To review recent literature related to urologic malignancies in patients with neurogenic lower urinary tract dysfunction (NLUTD). We performed a literature search of electronic databases (PubMed, ScienceDirect, Scopus, and CIANHL), with a focus on articles published between January 2015 and December 2019.

RECENT FINDINGS

Recent reports demonstrate a lower incidence of bladder cancer in the NLUTD population than previously found, although still significantly higher than the general population. Bladder cancer in patients with NLUTD is usually diagnosed at a younger age, and is associated with higher rates of squamous cell cancer, a higher stage at presentation, and increased mortality. Evidence for screening for bladder cancer in NLUTD is conflicting, with no formal protocols proven for general use. NLUTD has been shown to have a lower rate of prostate cancer, and may be associated with an earlier diagnosis of renal cancer.

SUMMARY

Genitourinary malignancies, although still rare, are an important source of morbidity and mortality in patients with NLUTD. Physicians should recognize that bladder cancer in NLUTD is often a lethal disease. Further research is needed to assist physicians with early recognition of these malignancies to improve patient outcomes.

A Primary Care Provider's Guide to Preventive Health After Spinal Cord Injury

Objective: Provide guidance for preventive health and health maintenance after spinal cord injury (SCI) for primary care providers (PCPs). Main message: Individuals with SCI may not receive the same preventive health care as the general population. Additionally, SCI-related secondary conditions may put their health at risk. SCI is considered a complex condition associated with many barriers to receiving quality primary care. Attention to routine preventive care and the unique health considerations of persons with SCI can improve health and quality of life and may prevent unnecessary health care utilization. Conclusion: PCPs are experts in preventive care and continuity of care, however individuals with SCI may not receive the same preventive care due to numerous barriers. This article serves as a quick reference for PCPs.

Neurogenic bladder symptom score: Polish translation, adaptation and validation of urinary disorder-specific instrument for patients with neurogenic lower urinary tract dysfunction

INTRODUCTION

There is no comprehensive and specific questionnaire translated, adapted and validated in the Polish language for evaluating symptoms, quality of life and complications associated with the neurogenic lower urinary tract dysfunction (NLUTD). The aim of this study was to translate, culturally adapt and validate a Polish version of the Neurogenic Bladder Symptom Score (NBSS) for patients who experience NLUTD.

MATERIAL AND METHODS

Standardised guidelines and well-established methods were used for translation and cross-cultural adaptation of the NBSS. Adult patients with multiple sclerosis and spinal cord injury completed the NBSS, the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), the International Prostate Symptom Score (IPSS) and the SF-Qualiveen. Responses were recorded twice within a 14-day period.

RESULTS

Two hundred seventy-four Polish-speaking patients with NLUTD were included in the study. Content validity was optimal. Significant relationships between NBSS (Incontinence) and ICIQ-SF, NBSS (Storage and Voiding) and IPSS, and NBSS (Quality of Life) and SF-Qualiveen confirmed good construct/criterion validity. An intercorrelation study revealed that internal consistency was good for the total NBSS and specific domains (Cronbach's alpha >0.7). Test-retest reliability (reproducibility) demonstrated strong stability (intra-class correlation coefficients >0.7 for the total NBSS). No ceiling or floor effects were present.

CONCLUSIONS

The Polish NBSS demonstrated good measurement properties for a large cohort of patients with NLUTD. It is a suitable tool to assess NLUTD symptoms, consequences and quality of life. The Polish NBSS will support routine clinical practice of all types of physicians in Poland who care for patients with NLUTD.

MicroRNA expression profile in the spinal cord injured rat neurogenic bladder by next-generation sequencing

Background

An increasing amount of evidence has indicated that microRNAs (miRs) are involved in most biological conditions, including the neurogenic bladder (NB). However, to our knowledge, no studies have investigated these miR expressions in spinal cord-injured (SCI) rat NB. The goal of the study was to explore the miR expression profile in the SCI rat NB by next-generation sequencing (NGS).

Methods

Female Wistar rats underwent spinal cord transection at T9–10 and were randomly divided into the SCI-1, SCI-2 and SCI-3 groups (n=5 for each group) whose bladder tissues were collected 1, 2, and 4 weeks after transection, respectively. The normal rats were used as the normal control (NC) group. MiRs microarray assays were used to detect the differentially expressed miRs between the groups by NGS, which was then verified by quantitative real-time polymerase chain reaction (qRT-PCR). Those significantly differently expressed miRs were analyzed with Gene Ontology categories and Kyoto Encyclopedia of Genes and Genomes bioinformatical analyses.

Results

Compared with the NC group, 96, 28 and 51 miRs were downregulated in the rats’ bladder in the SCI-1, SCI-2, and SCI-3 groups, respectively, and 133, 49, and 76 miRs were upregulated respectively. Specifically, miR-21-5p was the most significantly upregulated miR in all SCI groups. Also, 121 miRs (SCI-1 vs. SCI-2), 98 miRs (SCI-1 vs. SCI-3), and 26 miRs (SCI-2 vs. SCI-3) were of significantly different expression. Furthermore, a large set of genes implicated in essential signaling pathways were targeted by these miRs, including PI3K-Akt, MAPK, Rap1, and cGMP-PKG signaling pathways, along with the tight junction and metabolic pathways.

Conclusions

This is the first demonstration of differentially expressed miRs, which may potentially serve as new molecular targets in the SCI rat NB.

Experience of a tertiary referral center in managing bladder cancer in conjunction with neurogenic bladder

STUDY DESIGN

Case series.

OBJECTIVES

The aim of this study was to present our experience with the management of bladder cancer (BCa) in individuals followed for neurogenic bladder (NB).

SETTING

An Italian tertiary referral center for NB.

METHODS

We retrospectively collected all pre-operative, intra-operative, and post-operative data of our NB cases with BCa, diagnosed from 2004 to 2019.

RESULTS

We included ten cases: eight with acquired spinal cord injury (SCI) and two with myelomeningocele (MMC). Considering individuals with acquired SCI, the median age at BCa diagnosis and time since SCI were 53 and 34 years, respectively. One out of seven cases had positive urine cytology. All cases underwent a radical cystectomy, diagnosing squamous cell carcinoma (SCC) and transitional cell carcinoma in 60 and 40% cases, respectively. Surgical-related complications occurred after 90% procedures. Three out of eight individuals with acquired SCI died 2, 12, and 80 months after the diagnosis. Both individuals with MMC presented no evidence of disease after 24 and 27 months.

CONCLUSIONS

BCa in individuals with NB proved to be associated with a diagnosis at an advanced stage and a high rate of surgical complications. In this population we advocate annual genitourinary ultrasound exam and urine cytology, and cystoscopy in all cases of macrohematuria. Considering the low accuracy of urine cytology and the difficult-to-interpret inflamed bladder walls at cystoscopy in NB, a patient-tailored follow-up schedule based on specific risk factors (e.g., smoking status, indwelling urinary catheter) is mandatory to diagnose and treat BCa at an early stage.

Polish versions of the Qualiveen and the SF-Qualiveen: Translation and validation of urinary disorder-specific instruments in patients with multiple sclerosis

AIMS

No specific questionnaire to date has been available in Polish for evaluating health-related quality of life for urinary dysfunctions associated with multiple sclerosis (MS). The aim of this study was to translate, culturally adapt, and validate Polish versions of the Qualiveen and SF-Qualiveen for use in patients with MS.

METHODS

Cross-cultural adaptation of the original English Qualiveen and SF-Qualiveen into Polish was performed according to international recommended and standard procedures. Adult patients with MS of the Department of Urology at the Jagiellonian University, Krakow, Poland, completed the Qualiveen, SF-Qualiveen, and International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) twice: at baseline and 2 weeks later.

RESULTS

One hundred eighty-nine Polish-speaking patients with MS completed the questionnaires. An intercorrelation study revealed that internal consistency was good for the total Qualiveen and SF-Qualiveen (Cronbach's α >0.8). Test-retest reliability (reproducibility) demonstrated strong stability (intraclass correlation coefficient >0.8). Content validities were optimal. Significant relationships between the Qualiveen and the ICIQ-SF, as well as the SF-Qualiveen and the ICIQ-SF, confirmed good construct/criterion validity.

CONCLUSION

The Polish Qualiveen and SF-Qualiveen are reliable, valid, and consistent measures of urinary disorder-specific quality of life in patients with MS. After years of no appropriate Polish instrument being available for healthcare professionals to evaluate patients with MS, we provide these versions and recommend their use in research and clinical practice in Poland.

The urinary disorder-specific quality of life in patients after spinal cord injury: Polish translation, adaptation and validation of the Qualiveen and SF-Qualiveen

STUDY DESIGN

Prospective cohort validation study.

OBJECTIVES

In spinal cord injury (SCI), neurogenic lower urinary tract dysfunction is associated with a reduced quality of life. No specific questionnaire has been translated, culturally adapted, and validated into Polish language to assess urinary disorder-specific quality of life in people after SCI. In this study, we translated, adapted, and validated the Polish versions of the Qualiveen and SF-Qualiveen in individuals with SCI.

SETTING

University Hospital in Krakow, Poland.

METHODS

Translation and cross-cultural adaptation of the Qualiveen and SF-Qualiveen were done using international recommendations and well-established methods. Adult patients with SCI from the Department of Urology at the University Hospital in Krakow, Poland completed the Polish versions of the Qualiveen, SF-Qualiveen, and International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) at baseline and 2 weeks later. The ICIQ-SF served as the reference instrument. Validity and reliability were determined.

RESULTS

Polish-speaking patients with SCI (n = 178) were included. Content validity/cross-cultural adaptation of the translated questionnaires was investigated during face-to-face interviews. Construct/criterion validity was assessed, and positive correlations were found between the Qualiveen and ICIQ-SF as well as the SF-Qualiveen and ICIQ-SF. A reliability study revealed good internal consistency (Cronbach's alpha > 0.8) and reproducibility (intraclass correlation coefficients > 0.8) for both adapted questionnaires. We did not identify floor or ceiling effect.

CONCLUSIONS

The Polish versions of the Qualiveen and SF-Qualiveen showed good measurement properties. Polish healthcare providers can now reliably and directly assess the urinary disorder-specific quality of life in individuals after SCI.

The reorganisation of a dedicated neurourology service: An interim review

Objective:

Neuropathic bladder and urinary system pathology, such as incontinence and stone formation, are the most frequently encountered complications of spinal cord injury (SCI) and neurological disease. This study assesses the patient population and current practice at a tertiary UK neurourology service following dedicated clinic restructuring in 2017.

Methods:

A retrospective database was created to assess all patients attending the neurourology clinic over an 8-month period. The database recorded patient demographics, pathologies and subsequent investigations and management. Clinical innovations such as dedicated patient questionnaires and the formation of a dedicated multidisciplinary team, and their subsequent impacts on service improvement, were also assessed.

Results:

A total of 99 patients attended the clinic during the study. The most common pathology was SCI (51.5% (51)). The most common complaints were continence and catheter issues (61.6% (61)). Urinary symptoms such as frequency (15.2% (15)), infection (13.1% (13)) and urinary tract stones (9.1% (9)) accounted for the remainder of presenting complaints. Operative intervention was required in 25.3% (25) of cases.

Conclusion:

Patients with SCI and neurological disease experience a range of urinary symptoms with significant morbidity. Ensuring upper tract integrity, safe bladder management and intervening when necessary to improve quality of life are important concerns for the neurourologist. The redesigning of a dedicated neurourology clinic has permitted the treatment of such patients with a systematic approach ensuring safe bladder monitoring and upper tract surveillance. The introduction of a validated patient-reported symptom score has helped objective monitoring of symptoms before and after specific interventions. Patient concerns regarding sexual function and fertility are increasingly being encountered and addressed in the clinic. Level of evidence: 4

Urine retention as the first presentation of congenital absence of the sacrum: A case report of a rare clinical phenomenon

RATIONALE

Congenital absence of either a part of or the entire sacrum is rare, and only a few such cases have been reported until now. Most cases showed vertebral, pelvic, neurological, and visceral abnormalities, and the cases were usually quite serious. Only in rare cases was there urine retention without other symptoms.

PATIENT CONCERNS

We describe the case of a 28-years-old man who presented with urine retention.

DIAGNOSES

Urodynamic study confirmed that he had urinary retention, and magnetic resonance imaging (MRI) showed the absence of the sacrum.

INTERVENTIONS

He was treated with electro-acupuncture and medications to improve nerve function.

OUTCOMES

His symptoms showed clear improvement.

LESSONS

Although this case is rare, it indicates that the spine and pelvis may need to be examined when unexplained urinary retention occurs.