Iatrogenic urological triggers of autonomic dysreflexia: a systematic review

Autonomic dysreflexia in urological practice: pathophysiology, prevention and treatment considerations

PURPOSE

Spinal cord injury (SCI) leads to sensorimotor impairments; however, it can also be complicated by significant autonomic dysfunction, including cardiovascular and lower urinary tract (LUT) dysfunctions. Autonomic dysreflexia (AD) is a dangerous cardiovascular complication of SCI often overlooked by healthcare professionals. AD is characterized by a sudden increase in blood pressure (BP) that can result in severe cardiovascular and cerebrovascular complications. In this review, we provide an overview on the clinical manifestations, risk factors, underlying mechanisms, and current approaches in prevention and management of AD.

METHODS

After conducting a literature research, we summarized relevant information regarding the clinical and pathophysiological aspects in the context of urological clinical practice CONCLUSIONS: The most common triggers of AD are those arising from LUT, such as bladder distention and urinary tract infections. Furthermore, AD is commonly observed in individuals with SCI during urological procedures, including catheterization, cystoscopy and urodynamics. Although significant progress in the clinical assessment of AD has been made in recent decades, effective approaches for its prevention and treatment are currently lacking.

From Toxin to Treatment: A Narrative Review on the Use of Botulinum Toxin for Autonomic Dysfunction

Since its regulatory approval over a half-century ago, botulinum toxin has evolved from one of the most potent neurotoxins known to becoming routinely adopted in clinical practice. Botulinum toxin, a highly potent neurotoxin produced by Clostridium botulinum, can cause botulism illness, characterized by widespread muscle weakness due to inhibition of acetylcholine transmission at neuromuscular junctions. The observation of botulinum toxin's anticholinergic properties led to the investigation of its potential benefits for conditions with an underlying etiology of cholinergic transmission, including autonomic nervous system dysfunction. These conditions range from disorders of the integument to gastrointestinal and urinary systems. Several formulations of botulinum toxin have been developed and tested over time, significantly increasing the availability of this treatment for appropriate clinical use. Despite the accelerated and expanded use of botulinum toxin, there lacks an updated comprehensive review on its therapeutic use, particularly to treat autonomic dysfunction. This narrative review provides an overview of the effect of botulinum toxin in the treatment of autonomic dysfunction and summarizes the different formulations and dosages most widely studied, while highlighting reported outcomes and the occurrence of any adverse events.

Automatic detection of the mental state in responses towards relaxation

Nowadays, considering society's highly demanding lifestyles, it is important to consider the usefulness of relaxation from the perspective of both psychology and clinical practice. The response towards relaxation (RResp) is a mind-body interaction that relaxes the organism or compensates for the physiological effects caused by stress. This work aims to automatically detect the different mental states (relaxation, rest and stress) in which RResps may occur so that complete feedback about the quality of the relaxation can be given to the subject itself, the psychologist or the doctor. To this end, an experiment was conducted to induce both states of stress and relaxation in a sample of 20 university students (average age of 25.76 ± 3.7 years old). The electrocardiographic and electrodermal activity signals collected from the participants produced a dataset with 1641 episodes or instances in which the previously mentioned mental states take place. This data was used to extract up to 50 features and train several supervised learning algorithms (rule-based, trees, probabilistic, ensemble classifiers, etc.) using and not using feature selection techniques. Besides, the authors synthesised the cardiac activity information into a single new feature and discretised it down to three levels. The experimentation revealed which features were most discriminating, reaching a classification average accuracy of up to 94.01 ± 1.73 % with the 6 most relevant features for the own-collected dataset. Finally, being restrictive, the same solution/subspace was tested with a dataset referenced in the bibliography (WESAD) and scored an average accuracy of 90.36 ± 1.62 %.

Are local analgesics effective in reducing autonomic dysreflexia in individuals with spinal cord injury? A systematic review

STUDY DESIGN

Systematic review.

OBJECTIVES

To systematically review the evidence on the use of local analgesics, specifically lidocaine or bupivacaine, to prevent autonomic dysreflexia (AD) during iatrogenic procedures or bowel and bladder care routines in individuals with spinal cord injury (SCI).

METHODS

A keyword search of MEDLINE, CINAHL, CENTRAL, Cochrane Reviews, PsycInfo, Embase, and Web of Science databases identified all English-language studies evaluating the efficacy of local analgesics in reducing AD. Included studies were either randomized controlled trials (RCTs) or quasi-experimental studies. Participants were adults with chronic SCI who received local analgesics prior to AD-triggering procedures or routines. Additionally, studies were required to report blood pressure values as an outcome. The methodology of this review followed the PRISMA checklist and was registered with PROSPERO (CRD42021219506).

RESULTS

Four RCTs and two quasi-experimental studies met inclusion criteria. Results were narratively synthesized as meta-analysis was not possible due to heterogeneity across studies included in the review. All six studies administered lidocaine. Lidocaine was found to have a beneficial effect on AD in three studies, no effect in two studies and a detrimental effect in one study.

CONCLUSIONS

Presently, RCTs and quasi-experimental studies on the use of lidocaine for reducing AD in individuals with SCI had small sample sizes and opposing findings. There is a strong need for definitive, well-monitored clinical trials with adequate sample sizes. Presently there is not enough compelling evidence to support or refute recommendations for the use of lidocaine from the AD management clinical practice guidelines.

Targeting bladder function with network-specific epidural stimulation after chronic spinal cord injury

Profound dysfunctional reorganization of spinal networks and extensive loss of functional continuity after spinal cord injury (SCI) has not precluded individuals from achieving coordinated voluntary activity and gaining multi-systemic autonomic control. Bladder function is enhanced by approaches, such as spinal cord epidural stimulation (scES) that modulates and strengthens spared circuitry, even in cases of clinically complete SCI. It is unknown whether scES parameters specifically configured for modulating the activity of the lower urinary tract (LUT) could improve both bladder storage and emptying. Functional bladder mapping studies, conducted during filling cystometry, identified specific scES parameters that improved bladder compliance, while maintaining stable blood pressure, and enabled the initiation of voiding in seven individuals with motor complete SCI. Using high-resolution magnetic resonance imaging and finite element modeling, specific neuroanatomical structures responsible for modulating bladder function were identified and plotted as heat maps. Data from this pilot clinical trial indicate that scES neuromodulation that targets bladder compliance reduces incidences of urinary incontinence and provides a means for mitigating autonomic dysreflexia associated with bladder distention. The ability to initiate voiding with targeted scES is a key step towards regaining volitional control of LUT function, advancing the application and adaptability of scES for autonomic function.

Perioperative Complications and Anesthesia Practices in Managing Patients With Quadriplegia Undergoing Surgery: A Systematic Review

Quadriplegia is associated with a multitude of health complications affecting numerous organ systems. Complications during the perioperative periods are not uncommon in this patient population due to abnormal responses to surgical stressors. Such complications include autonomic dysreflexia, cardiac ischemia, and respiratory compromise. Currently, there is no clear consensus on the ideal technique for perioperative anesthesia management in this population. In addition, the relationship between the perioperative complications and anesthesia practices have not been explored in-depth. Therefore, we aimed to investigate perioperative complications in the context of anesthesia that are associated with patients with quadriplegia undergoing various surgical procedures. Our PRISMA compliant systematic review included 12 articles covering the literature from inception to January 12, 2021. The review showed complications being pulmonary, cerebral, but most importantly and commonly cardiac in nature, with many patients suffering hypertension, and many others hypotension. In addition, our review showed that autonomic dysreflexia is common and in majority of patients, it was managed successfully with good recovery. Based on our findings, the use of anesthesia, either general or spinal, can be considered. Future studies are needed to elucidate the exact mechanisms involved in perioperative complications and anesthetic management that are associated with patients with quadriplegia. This review will aid in developing general recommendations based on the information available in the literature to guide perioperative management of this vulnerable patient population.

[Urinary Bladder Cancer as a Long-term Sequela of Spinal Cord Injury - Relevance to Practice]

Urinary bladder cancer is the second most common tumour disease after lung cancer leading to death in people with a spinal cord injury. This paper provides a comprehensive overview of the differences relevant to urologists between urinary bladder tumours in this population compared with urinary bladder tumours in the general population.People with a spinal cord injury are 1 to 2 decades younger on average at the time of tumour diagnosis than patients without a spinal cord injury. Histopathologic findings at the initial diagnosis of urinary bladder cancer in people with a spinal cord injury are much less favourable than for urinary bladder cancers in the general population. Muscle-invasive tumours and tumours with poor differentiation are much more common, and the proportion of squamous cell carcinomas is significantly higher. The incidence rises after more than 10 years of paralysis. Urinary bladder cancer mortality is significantly elevated and increases with the duration of paralysis. In diagnostic procedures and, in particular, in radical cystectomy, clinically important features have to be considered. For example, urodynamic examinations or cystoscopy may trigger autonomic dysreflexia with hypertensive crises and the risk of life-threatening bradycardia.In the case of radical cystectomy, frequent adhesions and callosities of the urinary bladder, among other things, must be taken into account intraoperatively. Severe paralysis, prolonged intestinal atony and other conditions are frequently observed after the surgical procedure due to neurogenic bowel dysfunction. Correct positioning of the patient immediately after surgery to avoid decubitus and to support breathing, as well as bowel management specific to spinal cord injury, must be strictly observed.Other special features of paraplegic patients with urinary bladder cancer that should also be considered in clinical practice, as well as considerations for screening for urinary bladder tumors, are presented in the article.

A Hierarchical Machine Learning Solution for the Non-Invasive Diagnostic of Autonomic Dysreflexia

More than half of patients with high spinal cord injury (SCI) suffer from episodes of autonomic dysreflexia (AD), a condition that can lead to lethal situations, such as cerebral haemorrhage, if not treated correctly. Clinicians assess AD using clinical variables obtained from the patient’s history and physiological variables obtained invasively and non-invasively. This work aims to design a machine learning-based system to assist in the initial diagnosis of AD. For this purpose, 29 patients with SCI participated in a test at Cruces University Hospital in which data were collected using both invasive and non-invasive methods. The system proposed in this article is based on a two-level hierarchical classification to diagnose AD and only uses 35 features extracted from the non-invasive stages of the experiment (clinical and physiological features). The system achieved a 93.10% accuracy with a zero false negative rate for the class of having the disease, an essential condition for treating patients according to medical criteria.

Special surgical aspects of radical cystectomy in spinal cord injury patients with bladder cancer

PURPOSE

Radical cystectomy in people with spinal cord injury (SCI) provides numerous additional difficulties, compared to able-bodied people. Therefore, it is important to obtain information from an experienced team about optimally managing these patients.

METHODS

Surgical procedures, based on the experience of 12 radical cystectomies in SCI patients with bladder cancer between January 1st, 2001, and December 31st, 2020, were recorded and the operative and perioperative clinical data were evaluated. Surgery was performed in a high-volume center by the surgeon most experienced in radical cystectomies, assisted by the neuro-urologist, involved in the care of the patient from the spinal cord center. Furthermore, a checklist based on the experience of the surgeon and the assisting neuro-urologist was developed.

RESULTS

SCI patients mostly suffered from an advanced disease and were always operated by the same team. The hospital stays ranged from 23 to 134 days (median 42 days). Four of the patients suffered from a postoperative paralytic ileus. Otherwise, both the operation time and the intraoperative blood loss as well as intraoperative and postoperative complications were basically comparable with those in able-bodied patients. The special features of radical cystectomy in SCI bladder cancer patients are described. Furthermore, a checklist addressing preoperative red flags, intra-operative challenges and post-operative challenges is presented.

CONCLUSION

Radical cystectomy in SCI patients should be performed in a high-volume department by the most experienced surgical team. The inclusion of the urologist caring for the patient from the spinal cord injury center is highly recommended.

Long-term neurogenic lower urinary tract dysfunction: A case of cardiovascular nightmares

CONTEXT

Individuals with spinal cord injury (SCI) suffering from autonomic dysreflexia (AD) due to neurogenic detrusor overactivity (NDO) can effectively be treated with intradetrusor onabotulinumtoxinA. We present a complex case to highlight the treatment's potential limitations to ameliorate AD and improve lower urinary tract (LUT) function in this population.

FINDINGS

A 46-year old man, who was relying on an indwelling urethral catheter for bladder emptying due to severely impaired hand function following a SCI (C5, AIS B) sustained 30 years ago, underwent intradetrusor onabotulinumtoxinA injections for treatment of refractory NDO and associated AD. Although LUT function slightly improved (i.e. cystometric capacity increased while detrusor pressure was reduced), severe bladder-related AD persisted post-treatment.

CONCLUSIONS

This case raises awareness of serious considerations when treating NDO-related AD in individuals with longstanding neurogenic LUT dysfunction and compromised dexterity following SCI. Given the limited improvement in LUT function and persisting bladder-related AD following treatment, urinary diversion as advocated in the wider literature should be considered to protect an individual's urinary tract from further deterioration and thus eliminate bladder-related AD consequences long-term. Early treatment and management of NDO and AD is crucial to minimize complications associated with these two major health risks in this population.

Safety and preliminary efficacy of functional electrical stimulation cycling in an individual with cervical cord injury, autonomic dysreflexia, and a pacemaker: Case report

Context: Functional electric stimulation (FES) cycling is a commonly used therapeutic exercise modality after spinal cord injury (SCI); however, additional precautions must be taken in certain situations. The purpose of this study was to develop and apply a safety monitoring protocol for autonomic dysreflexia (AD) during FES cycling and to determine if an interval-FES cycling program can be safe and beneficial to an individual with cervical SCI, a history of AD, and a non-dependent cardiac pacemaker.The participant was a 36-year-old male with C6 AIS-C SCI sustained 9 years earlier, intermittent AD, and implanted cardiac pacemaker. Ten sessions of interval-FES cycling were performed twice weekly for 5 weeks. Rating of perceived exertion (RPE), blood pressure (BP), oxygen saturation (O2sat), and heart rate (HR) were monitored before, after, and every 5 min during cycling. ECG and cardiac pacemaker were evaluated by a cardiologist after ending the program.Findings: The participant reported self-limited chills 27 times over 10 sessions (19 "light", 3 "moderate", 5 "sharp"). Chills coincided with BP increases 59% of the time and their magnitudes moderately correlated (r = 0.32). The ECG was determined to be normal and the pacemaker fully functional at the end of the study, while blood glucose decreased (111-105 mg/dl), HbA1c levels increased (5.5-5.9%), and resting BP decreased (118/84-108/66 mmHg).Conclusion/Clinical Relevance: A person with cervical SCI, symptomatic AD, and a non-dependent pacemaker can safely participate and benefit from the interval-FES cycling program provided adequate monitoring of symptoms and vital signs.

Quantitative analysis of dysautonomia in patients with autonomic dysreflexia

Autonomic dysreflexia (AD) is a life-threatening condition for individuals with cervical or high-thoracic spinal cord injury (SCI). The profile of autonomic dysfunction in AD using validated clinical autonomic tests has not been described so far, although it could be useful to identify SCI patients at greater risk of developing AD non-invasively. With this objective, 37 SCI patients (27% female) were recruited, and hemodynamic and cardiac parameters were continuously monitored to determine the presence of AD, defined as an increase of systolic blood pressure of 20 mmHg or higher after bladder filling with saline. Then, standard autonomic function testing was performed, including Deep Breathing, Valsalva Manoeuvre and Tilt Table Test. Finally, baroreflex sensitivity (BRS), and spectral analysis of heart rate and blood pressure variability were measured at rest. Catecholamines and vasopressin levels were also measured at supine and upright positions. The severity of SCI was assessed through clinical and radiological examinations. AD was observed in 73.3% of SCI patients, being 63.6% of them asymptomatic during the dysreflexive episode. AD patients displayed a drop in sympathetic outflow, as determined by decreased noradrenalin plasma levels, reduced sympathovagal balance and increased BRS. In line with decreased sympathetic activity, the incidence of neurogenic orthostatic hypotension was higher in AD patients. Our results provide novel evidence regarding the autonomic dysfunction in SCI patients with AD compared to non-AD patients, posing non-invasively measured autonomic parameters as a powerful clinical tool to predict AD in SCI patients.

Guideline for the management of pre-, intra-, and postpartum care of women with a spinal cord injury

The German Association of the Scientific Medical Societies guideline for pregnancy, childbirth, and puerperium in women with a spinal cord injury (SCI) addresses a range of topics from the desire to have a child to different stages of pregnancy and birth. Given that a generally accessible and evidence-based presentation of this complex issue does not yet exist, this new guideline contributes to the standardization of gynecological, obstetric, and maternal care of women with SCI. This guideline aims to provide practice-oriented support for the care and counseling of women in the pre-, intra-, and postpartum periods; to close identified gaps in medical care; foster collaboration among clinicians of relevant disciplines; and inspire research.

Autonomic Dysreflexia in Patients With Spinal Cord Injury: What the Radiologist Needs to Know

OBJECTIVE. Autonomic dysreflexia (AD) is a potentially life-threatening condition that occurs in patients with cervical and high thoracic spinal cord injury (SCI). AD is not completely understood and has a high incidence that increases proportional to the level and severity of the SCI. The signs and symptoms can vary, but severe hypertension is a dominant feature and may be fatal. This condition can be precipitated by a wide range of triggers occurring below the level of the injury, several of which are common to both diagnostic and interventional radiology, such as manipulation or distention of the genitourinary or gastrointestinal tract, patient positioning, or the use of certain anesthetic techniques. There is little guidance in the radiology literature specific to risk stratification or the use of premedication in this population. The incidence and pathophysiology of AD are discussed, along with pragmatic tips to aid the radiologist in selecting patients who may require a higher level of care or anesthesiologist involvement, with instructions for the conservative and medical management of acute episodes of AD. CONCLUSION. Awareness of AD is essential for all health care practitioners involved in the care of patients with SCI. A variety of procedures in the radiology department, both diagnostic and interventional, may precipitate AD. Planning, monitoring procedures, knowledge of the relevant pathophysiology and pharmacology, and communication with clinical colleagues are essential to ensure safe practice. Clinicians ordering procedures and radiologists selecting protocols for those procedures should identify at-risk patients before booking a procedure to ensure appropriate supervision and anesthesiology support. Education of radiologists, interventional nursing staff, and technical staff can assist in prevention, early recognition, and successful management of AD.

A custom made interface to integrate recording of pulse rate and blood pressure during urodynamics investigations

Patients with a spinal cord injury above the 6th thoracic vertebrae may be prone to autonomic dysreflexia (AD) in response to bladder stimulus associated with a urodynamics investigation. It is essential that these patients are managed carefully in the urodynamics clinic in order to prevent life-threatening hypertension and bradycardia. Part of this management is the measurement and manual recording of pulse rate (PR) and non-invasive blood pressure (NIBP), alongside the standard urodynamics data set. The purpose of recording these additional data is to identify the characteristic drop in PR and rise in NIBP that indicates the onset of AD. This technical note describes the development of a novel, in-house constructed interface that allows PR and NIBP to be recorded alongside the standard urodynamics data set, using a commonly available vital signs monitor and urodynamics workstation.

Early neurological care of patients with spinal cord injury

PURPOSE

Considering the major clinical challenges of managing patients with spinal cord injury (SCI), we summarized the relevant aspects of the early (within 1 year after SCI) neurological care emphasizing common standards.

METHODS

This review was performed according to the methodology recommended by the Joint SIU-ICUD International Consultation. Embase and Medline databases were used to identify literature relevant to the early neurological care of SCI patients. Recommendations were developed by consensus and graded using a modified Oxford system which identifies level of evidence (LOE) and grade of recommendation (GOR).

RESULTS

Emergency health care providers must address altered mental status, evidence of intoxication, suspected extremity fracture/distracting injury, focal neurological deficit and spinal pain/tenderness to determine the risk of SCI in a trauma patient [LOE 1, GOR A]. Neurogenic shock must be recognized and treated [LOE 3, GOR A]. Spine surgeons should consider early decompression and spine fixation/stabilization, where indicated, and should promote early active rehabilitation to improve functional recovery [LOE 2, GOR B]. Clinicians should refer SCI patients to specialized SCI rehabilitation centers [LOE 4, GOR B], must apply interventions to prevent venous thromboembolism (i.e., compression devices and low-molecular weight heparin/unfractionated heparin) after acute SCI respecting contraindications [LOE 1, GOR A]. Contemporary guidelines to manage pain must be employed [LOE 1, GOR A] and methods to reduce the risk of pressure ulcers should be used [LOE 3, GOR B].

CONCLUSIONS

Early treatment, prevention of associated complications and individualized patient-targeted rehabilitation programs provided by a specialized interdisciplinary team are crucial to optimize the outcome after SCI.

Prediction of autonomic dysreflexia during urodynamics: a prospective cohort study

BACKGROUND

Autonomic dysreflexia is a severe and potentially life-threatening condition in patients with spinal cord injury, as it can lead to myocardial ischemia, brain hemorrhage, or even death. Urodynamic investigation is the gold standard to assess neurogenic lower urinary tract dysfunction due to spinal cord injury and reveal crucial pathological findings, such as neurogenic detrusor overactivity. However, neurogenic detrusor overactivity and urodynamic investigation are known to be leading triggers of autonomic dysreflexia. Therefore, we aimed to determine predictors of autonomic dysreflexia in individuals with spinal cord injury during urodynamic investigation.

METHODS

This prospective cohort study included 300 patients with spinal cord injuries and complete datasets of continuous non-invasive cardiovascular monitoring, recorded during same session repeat urodynamic investigation. We used logistic regression to reveal predictors of autonomic dysreflexia during urodynamic investigation.

RESULTS

We found that level of injury and presence of neurogenic detrusor overactivity were the only two independent significant predictors for autonomic dysreflexia during urodynamic investigation. A lesion at spinal segment T6 or above (odds ratio (OR) 5.5, 95% CI 3.2-9.4) compared to one at T7 or below, and presence of neurogenic detrusor overactivity (OR 2.7, 95% confidence interval (CI) 1.4-4.9) were associated with a significant increased odds of autonomic dysreflexia during urodynamic investigation. Both odds persisted after adjustment for age, sex, and completeness and stage of injury (adjusted OR (AOR) 6.6, 95% CI 3.8-11.7, and AOR 2.2, 95% CI 1.1-4.5, respectively). Further stratification by lesion level showed level-dependent significantly increased adjusted odds of autonomic dysreflexia, i.e., from C1-C4 (AOR 16.2, 95% CI 5.9-57.9) to T4-T6 (AOR 2.6, 95% CI 1.3-5.2), compared to lesions at T7 or below.

CONCLUSIONS

In patients with neurogenic lower urinary tract dysfunction due to spinal cord injury, autonomic dysreflexia is independently predicted by lesion level and presence of neurogenic detrusor overactivity. Considering the health risks associated with autonomic dysreflexia, such as seizures, stroke, retinal bleeding, or even death, we recommend both continuous cardiovascular monitoring during urodynamic investigation in all spinal cord-injured patients with emphasis on those with cervical lesions, and appropriate neurogenic detrusor overactivity treatment to reduce the probability of potentially life-threatening complications.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01293110 .

Intracerebral haemorrhage following uncontrolled autonomic dysreflexia post suprapubic catheter placement surgery

INTRODUCTION

We describe a case of intracerebral haemorrhage (ICH) following uncontrolled episodes of autonomic dysreflexia (AD) within 24 h of a minor urological procedure.

CASE PRESENTATION

A 33-year-old active paraplegic patient T1 Association Impairment Scale A underwent an elective suprapubic catheter (SPC) placement for bladder management. The surgery was done under general anaesthesia and was uneventful. Four hours after surgery, he developed haematuria and multiple blood clots in the urine, which eventually caused blockage of the SPC and resulted in symptomatic AD. The clots and blockage persisted, which continued to trigger repeated episodes of increased blood pressure (BP) and AD. Despite medical treatment with sublingual nitrate to lower the increased BP, the patient subsequently developed massive left ICH presenting with right upper limb weakness, facial asymmetry and inability to speak. He continued to have fluctuating BP measurements for 11 days post event with severe hypertensive and hypotensive episodes. This presented a challenge in the BP management as well as post-ICH management. He underwent an intensive neurorehabilitation programme as soon as the BP had stabilized.

DISCUSSION

Severe neurological complications of AD are rare. In this case report, we highlight the importance of close monitoring of BP and AD symptoms after an SPC procedure, the challenges in BP management and the subsequent importance of an early rehabilitation programme after ICH secondary to uncontrolled AD.

[Neuro-urological diagnosis and therapy of lower urinary tract dysfunction in patients with spinal cord injury : S2k Guideline of the German-Speaking Medical Society of Paraplegia (DMGP), AWMF register no. 179/001]

BACKGROUND

Most patients with spinal cord injury (SCI) suffer from neurogenic lower urinary tract dysfunction (NLUTD), bowel dysfunction and sexual dysfunction. If these remain untreated, severe medical complications and serious limitations (restrictions) in quality of life are imminent.

OBJECTIVES

In the long term, there are considerable differences in the treatment results of highly specialized centers versus other treatment facilities.

MATERIALS AND METHODS

Against this background, a consensus-based guideline, according to the AWMF (Association of the Scientific Medical Societies in Germany) criteria (S2k), was developed by the neuro-urology working group of the DMPG (German-Speaking Medical Society of Paraplegia).

RESULTS

The guideline defines the principles and objectives of the neuro-urological care of patients with SCI and discusses in detail the principles of diagnosis and therapy of NLUTD. The need for video-urodynamic studies as a basis for the classification of the NLUTD and as a foundation for the development of a treatment strategy is emphasized. Both conservative and surgical therapy options and their indications are explained in detail. Possible complications and their prevention in the long-term course of SCI are presented with a particular consideration of the specific features of urinary tract infections and autonomic dysreflexia. Finally, the principles of the provision of urological appliances are discussed.

CONCLUSIONS

The presented S2k guideline provides the current standards in the neuro-urological care of patients with NLUTD due to SCI. Their consistent implementation both in the acute and chronic phase as well as in the context of lifelong surveillance of SCI patients should prevent the impending complications of NLUTD.

Detrusor sphincter dyssynergia: a review of physiology, diagnosis, and treatment strategies

Detrusor sphincter dyssynergia (DSD) is the urodynamic description of bladder outlet obstruction from detrusor muscle contraction with concomitant involuntary urethral sphincter activation. DSD is associated with neurologic conditions such as spinal cord injury, multiple sclerosis, and spina bifida and some of these neurogenic bladder patients with DSD may be at risk for autonomic dysreflexia, recurrent urinary tract infections, or upper tract compromise if the condition is not followed and treated appropriately. It is diagnosed most commonly during the voiding phase of urodynamic studies using EMG recordings and voiding cystourethrograms, although urethral pressure monitoring could also potentially be used. DSD can be sub-classified as either continuous or intermittent, although adoption of this terminology is not widespread. There are few validated oral pharmacologic treatment options for this condition but transurethral botulinum toxin injection have shown temporary efficacy in reducing bladder outlet obstruction. Urinary sphincterotomy has also demonstrated reproducible long term benefits in several studies, but the morbidity associated with this procedure can be high.