Holistic approach, extensive urological assessment are needed for neurogenic patients

The assessment of neurogenic patients is different from other functional disorders. In the latter, quality of life is key and is the starting point. We ask our patients what the main problem or complaint is, why that is bothering them and why they come at this moment. After that we assess the amount of bother and the qualty of life and we perform the diagnostic work-up.

This implies that we combine subjective elements (e.g. questionnaires and VAS scales) with objective or semi-objective findings like voiding diaries and urodynamic investigations. When the diagnosis has been made, we discuss with the patient what can be done. We discuss severity of the disease and findings, whether this can be treated or not, what the treatment options are and what the expected benefits and risks are. Afterwards the patient chooses the best treatment for him, based on well-informed consent.

In oncological diseases this is most often quite different. Someone comes with a suspected disease that can be based on imaging or some abnormal bloodtest. Often there are no complaints at all.

A good example is prostate cancer or a small renal mass suspicious of kidney cancer. Diagnosis is made and staging is done as good as possible. Than the treatment options are discussed, including watchful waiting. A decision is made by the patient, also based on informed consent.

However, the treatment options deal with getting rid of the cancer and survival. Hardly ever quality of life issues play a role, only when discussing the operating technique. The first intention and goal is to cure the cancer.

With this in mind one can cut one’s penis or testicles without protest, because this serves the good cause. It is needless to say that cutting one penis or testicles most often does not improve quality of life and that some degree of subjective bother will be induced by the surgery. So this assessment is quite the oppostie from dealing only with functional problems.

A gray area

Dealing with neurogenic patients is something in between dealing with patients with oncological disorders and those patients with pure symptomatic bothersome disorders. There are many quality of life aspects in people suffering from neurogenic diseases. The degree of bother and the kind of bother is different from patient to patient and very much depending on the kind of neurogenic disease, the severity and the involvement of other organ systems outside the urogenital tract.

However, the aspect that has to be assessed and that is on top of the list is the preservation of kidney function. Every urologists who sees neurogenic patient has listed this goal as top priority.

The reason for this is mainly based on a publication from McGuire et al in 1981 (J Urol 1981:126:205-209). This was an observation in a small study with bifid spine patients. One of the conclusions was that the detrusor leak point pressure should not exceed 40 cm H2O in order te prevent kidney damage.

Although this study is known and the conclusion is often consequently put in clinical practice, everyone who is involved realizes that the outcome might not be representative for every patient suffering from a neurogenic disease.

For clinical practice this means that there is variation in the risks for acquiring top priority disorders like kidney failure, that there is variation in types of neurogenic patients and that there is variation in bother. The rule however is: medical issues come first, quality of life comes second.

In clinical practice, this mean that you have to assess the risk category your patient is in and that you have to look at the individual physical situation and also bother and wishes. The main medical issues that neurogenic patients have to deal with are: kidney failure, urinary tract infection, bladder cancer, urolithiasis, proper bladder emptying, incontinence and sexual dysfunction. Some of these also influence quality of life directly but others don’t.

Medical conditions

Some percentages, although there are many published, can be mentioned here to give some idea of what kind of risks we are talking about (See list in Table 1).

Risk category

The risk category a patient is in depend amongst others on: kind of neurogenic disease, onset of disease and duration of the neurogenic disorder. Another important factor is the urodynamic based classification of lower urinary tract behaviour, which was described very elegantly by Madersbacher (Madersbacher Paraplegia 1990;28(4):217-229).

This handy classification looks at the behaviour of the bladder and the bladder outlet of the lower urinary tract during the long-lasting filling or storage phase and the relatively short voiding phase. If for instance patient A is known with an overactive detrusor in the filling phase and an overactive sphincter in the voiding phase, the risks of developing upper urinary tract disorders is higher than patient B with an overactive bladder and an underactive sphincter in the filling phase.

The last situation means that the bladder outlet functions as a pressure relieve valve. When the pressure goes up because of detrusor overactivity, the bladder outlet opens and the intravesical pressure decreases. This causes incontinence but there is less risk of upper urinary tract deterioration. Therefore, patient A is in a different risk category compared to patient B. This has consequences for treatment as well as follow-up.

As mentioned before, the prevention of medical disorders comes first and quality of life comes second. For treatment, the rule is that one starts with non – invasive measures like life style intervention, physical therapy if appropriate, followed or accompanied by drug treatment.

If that is not enough one can continue with minimally invasive or invasive treatments.

The rules of thumb therefore are:

1. Medical risks come first;
2. Quality of life issues come next;
3. Assess the risk category your patient is in;
4. Assess his personal situation regarding other organ systems (intellectual capacity, social environment, dexterity, transfer possibility, bowel behaviour); and
5. Define the individual treatment and sequence of treatments based on points 1 through 4.

Sequencing of treatment

As listed in the rules of thumb above, generally speaking there is some sequencing of treatment but this very much depends on the personal situation of the patient. An example will make clear why it is not possible to generalize rules of thumb, guidelines, efficacy measures etc.

Suppose we have the next case: A neurogenic patient, suffering from incontinence, weelchairbound, she has good cerebral capacities and she lives in a good social environment within an optimal care-taking system. She works in an office. Urodynamic investigation reveals a cystometric capacity of 250 cc, detrusor overactivity starting at 100 ml of bladder filling.

The detrusor pressures at DO (detrusor overactivity) go up to 100 cm H2O and last for about 30 seconds. Post-void residual is 50 ml. Compliance is slightly deteriorated. Kidney function is normal but renography shows that the efflux from the kidneys is slightly delayed.

Some aspects are obvious for every urologist: 1. something needs to be done to prevent kidney damage. 2. The pressure in the bladder has to be lowered. Everyone will most likely agree that lifestye intervention will not be the solution.

How about drugs? It is known that antimuscarinics will bring down the detrusor pressure (Stöhrer Spinal Cord 1999), but is it enough? We can try to find out what the effect is. However suppose that the patient is suffering from constipation, than this is perhaps not the first option.

The next step would most likely be the intradetrusor application of botulinum toxin A injections. This will bring the detrusor pressure down with about 32 cm H2O (Cruz et al Eur Urol 2012), so we might give it a try. The risk for urinary retention is however 17% of this treatment, and this means that she runs the risk that she has to catheterize to empty her bladder.

If she is a paraplegic spinal cord injury patient this will mean that she will need help to perform CIC and to make transfers. If she is paraplegic with good hand function she might perhaps be able to make transfers and perform CIC, but we also need to know whether this is possible in her working environment.

Another situation is that if she is a MS patient neuromodulation could be tried because there are publications showing good results (Engeler BMC Urol 2015;23(15):105). And another important point is whether her age is 24 or 64 years.

In the last situation a suprapubic catheter could be an option because we also know that with careful control risks for developing bladder cancer are most likely lower than in older days (Feifer, Corcos Neurourol Urodyn 208;27(6):475-479). This could perhaps be combined with anticholinergic instillation or botulinum toxin injections and careful control, which would be out of the question in a young 24-year-old patient.

In conclusion we can say that it is very important to look at all aspects of a neurogenic patient and expand the urological assessment to most other organ systems and also to take the social situation into account when making a decision on treatment and the sequence of treatments.

We can therefore conclude that in neurourology, personalized medicine is put into clinical practice already for a long time to serve both the medical and personal needs of patients.

Table 1:

Author:
Dr. John Heesakkers, Department of Urology Radboud UMC Nijmegen, Nijmegen (NL)