Management of lower urinary tract dysfunction in neurological disease: summary of NICE guidanceBMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e5074 (Published 08 August 2012) Cite this as: BMJ 2012;345:e5074
- Sharon Swain, senior research fellow1,
- Ralph Hughes, health economist1,
- Mark Perry, research fellow1,
- Simon Harrison, consultant urological surgeon2
- on behalf of the Guideline Development Group
- 1National Clinical Guideline Centre, Royal College of Physicians of London, London NW1 4LE, UK
- 2Mid-Yorkshire Hospitals NHS Trust, Department of Urology, Pinderfields Hospital, Wakefield WF1 4DG, UK
- Correspondence to: S Swain
A wide range of neurological conditions can affect the function of the lower urinary tract, potentially causing distressing symptoms and even renal damage. It is important to ask patients with neurological disease about urinary symptoms, as identifying these should lead to appropriate assessment and treatment, improvement in quality of life, and a reduction in long term morbidity. Clinicians can easily overlook urinary tract problems as they focus on other important clinical matters, but a better understanding of how to deal with lower urinary tract problems may increase the confidence of healthcare professionals in this area. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the management of lower urinary tract dysfunction in neurological disease.1
NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.
Patients needing assessment include those with newly diagnosed neurological disease; those with known neurological disease and new or changing symptoms suggesting urinary tract dysfunction; and those requiring periodic reassessment of their urinary tract management. The interval between routine assessments will depend on the person (for example, their age or diagnosis) but should not exceed three years.
Take a clinical history, including information about urinary tract symptoms; neurological symptoms and diagnosis (if known); clinical course of the neurological disease; bowel symptoms; sexual function; comorbidities; use of prescription and other medication and treatments.
Assess the impact of the underlying neurological disease on factors that will affect how lower urinary tract dysfunction can be managed, such as mobility, hand function, cognitive function, social support, and lifestyle.
Do a urine dipstick test using an appropriately collected sample to test for the presence of blood, glucose, protein, leukocytes, and nitrites. Appropriate urine samples include clean-catch midstream samples and samples taken from a freshly inserted intermittent sterile catheter or from a catheter port. Do not take samples from leg bags.
If the result of the dipstick test and the person’s symptoms suggest an infection, arrange a urine bacterial culture and antibiotic sensitivity test before starting antibiotic treatment. Treatment need not be delayed but may be adapted when results are available.
Be aware that bacterial colonisation will be present in people using a catheter and so urine dipstick testing and bacterial culture may be unreliable for diagnosing active infection.
[All the above points are based on the experience and opinion of the Guideline Development Group (GDG)]
Referral for further care
Urodynamic studies (investigations of lower urinary tract function) are needed in some cases to identify causes of incontinence and look for risk factors for renal deterioration. Ultrasound scanning and cystoscopy may sometimes be indicated to look for complicating factors such as urinary tract stones, hydronephrosis, or bladder cancer.
Refer people for urgent investigation (such as ultrasonography, urodynamic investigations, renal scintography) if they have any of the following “red flag” signs and symptoms:
-Recurrent urinary tract infections (for example, three or more infections in six months)
-Recurrent catheter blockages (for example, catheters blocking within six weeks of being changed)
-Hydronephrosis or kidney stones on imaging
-Biochemical evidence of renal deterioration.
Be aware that urinary tract disease can cause changes in neurological symptoms (for example, confusion or worsening spasticity), and consider further urinary tract investigation and treatment if this is suspected.
Assess the impact of lower urinary tract symptoms on the person’s family members and carers and consider ways of reducing any adverse impact, such as stress, that may harm the person. If abuse is suspected, follow local safeguarding procedures.
[All the above points are based on the experience and opinion of the GDG]
Although a urodynamic based understanding of the effects of neurological disease on urinary tract function has underpinned major advances in patient management, effective clinical management doesn’t always require invasive urodynamic investigations.
Do not routinely offer urodynamic investigations (such as filling cystometry and pressure flow studies) to people at low risk of renal complications (for example, most people with multiple sclerosis).
Offer video-urodynamic investigations to people at high risk of renal complications (for example, people with spina bifida, spinal cord injury, or anorectal abnormalities).
[Both points are based on very low quality evidence from observational studies]
Assessment of the patient allows the patient, carers, and clinical team to formulate options for managing the patient’s neurogenic lower urinary tract dysfunction. In some cases, this will be a relatively simple process requiring treatment of a single symptom, such as urinary urgency in a patient with multiple sclerosis who empties their bladder well. In contrast, a person with spina bifida might have to consider options that include the use of intermittent self catheterisation after a surgical lower urinary tract reconstruction or the containment of urinary incontinence with a penile sheath system or pads. The guideline includes recommendations about the treatment of the various abnormalities that might be present.
Impaired bladder storage
Impaired bladder storage is frequently caused by the presence of involuntary contractions (detrusor overactivity) and will typically cause symptoms of urinary frequency, urgency, and incontinence. Possible treatments include the use of various behavioural treatments (such as the timed voiding), the prescription of antimuscarinic drugs, the administration of botulinum toxin type A injections into the bladder wall, and surgical enlargement of the bladder by augmentation cystoplasty. Botulinum toxin type A injections have emerged in recent years as a treatment option in neurogenic incontinence and the guideline includes recommendations about their use in different neurological conditions and in adults and children.
Stress incontinence is caused by weakness of the urethral sphincter mechanism and arises from damage to the sphincter’s nerve supply or through urethral trauma from indwelling urethral catheters. The guideline covers the use of pelvic floor muscle training and surgical procedures such as the use of autologous fascial slings and the artificial urinary sphincter.
Impaired bladder emptying
Impaired bladder emptying will often require the use of intermittent self catheterisation or an indwelling (usually suprapubic) catheter. For people using an indwelling catheter, the guideline supports the use of a catheter valve (a tap-like device that can be switched on or off to drain urine from the bladder or to stop drainage) as an alternative to continuous bladder drainage into a bag. The guideline recommends not using α adrenergic antagonists.
Urinary tract infection is common in people with neurological disease, and the challenge is to balance the reduction of the burden of infections on the individual patient with the need to contain the development of antibiotic resistance.
Do not routinely use antibiotic prophylaxis for urinary tract infections in people with neurogenic lower urinary tract dysfunction.
Consider antibiotic prophylaxis for people who have a recent history of frequent or severe urinary tract infections.
Before prescribing antibiotic prophylaxis for urinary tract infection:
-Investigate the urinary tract for an underlying treatable cause (such as urinary tract stones or incomplete bladder emptying)
-Take into account and discuss with the person the risks and benefits of prophylaxis
-Refer to local protocols approved by a microbiologist or discuss suitable regimens with a microbiologist.
[All the above points are based on moderate to very low quality evidence from randomised controlled trials]
Information and support
Offer specific information and training to people with neurogenic urinary tract dysfunction, their family members, and carers. Ensure that people who are starting to use, or are using, a bladder management system that involves the use of catheters, appliances, or pads:
-Receive training, support, and review from healthcare professionals who are trained to provide support in the relevant bladder management systems and are knowledgeable about the range of products available
-Have access to a range of products that meet their needs
-Have their products reviewed—at the least, every two years.
[Based on very low quality evidence from a randomised controlled trial and observational studies]
Discuss with the person and/or their family members and carers the increased risk of renal complications (such as kidney stones, hydronephrosis, and scarring) in people with neurogenic urinary tract dysfunction (in particular, those with spina bifida or spinal cord injury). Tell them about the symptoms to look out for (such as loin pain, haematuria) and when to see a healthcare professional. [Based on very low quality evidence from a randomised controlled trial and observational studies]
Monitoring and surveillance protocols
Offer lifelong ultrasound surveillance of the kidneys to people at high risk of renal complications (for example, at annual or twice yearly intervals). These include people with spinal cord injury, spina bifida, or adverse features on urodynamic investigations such as impaired bladder compliance, detrusor-sphincter dyssynergia, or vesicoureteric reflux. [Based on very low quality evidence from observational studies and economic evidence with partial applicability and potentially serious limitations]
Healthcare professionals from different disciplines should help patients to access relevant services. This requires the cooperation of commissioners and providers—for example, through better “signposting” of referral pathways. Not all centres currently offer botulinum toxin type A injections, and implementing the recommendations will require service development. However, the health economic model showed that botulinum toxin is more cost effective than standard care when augmentation cystoplasty is not appropriate.
Further information on the guidance
The full guideline provides further guidance on improving bladder storage and stress incontinence, including surgical interventions. It also expands on the provision of information and support for patients and carers and on how to improve access to services (see recommendations below).
Providing information for patients and carers is challenging because of, for example, the need to present complex information in a digestible form and to provide information that is accurate, given the many gaps in our knowledge in this field.
Tailor information and training to the individual’s physical condition and cognitive function to promote their active participation in care and self management. [Based on very low quality evidence from one randomised controlled trial and three observational studies]
When managing the transition of a person from paediatric services to adult services for ongoing care of neurogenic lower urinary tract dysfunction:
-Formulate a clear structured care pathway at an early stage and involve the person and/or their parents and carers
-Involve the person’s parents and carers when preparing transfer documentation with the person’s consent
-Provide a full summary (for the person and the receiving clinician) of the person’s clinical history, investigation results, and details of treatments
-Integrate information from the multidisciplinary health team into the transfer documentation
-Identify and plan the urological services that will need to be continued after the transition of care
-Formally transfer care to a named individual(s).
[Based on high to low quality evidence from qualitative studies]
The guideline was developed according to NICE guideline methods (www.nice.org.uk/aboutnice/howwework/developingniceclinicalguidelines/developing_nice_clinical_guidelines.jsp). The Guideline Development Group (GDG) comprised specialist nurses, a general practitioner, specialists in uroneurology and rehabilitation medicine, a geriatrician, urological surgeons, and patients and carer representatives. This involved systematic searching and critically appraising and summarising the clinical and cost effectiveness evidence. The scope and full guideline was posted on the NICE website as part of a stakeholder consultation. The GDG also conducted new cost effectiveness analysis, for botulinum toxin type A.
NICE has produced four different versions of the guideline: a full version; a quick reference guide; a version known as the “NICE guideline” that summarises the recommendations; and a version for patients and the public. All these versions are available from the NICE website (http://guidance.nice.org.uk/CG148). Updates of the guideline will be published according to the NICE guideline development programme.
The GDG highlighted some important questions that need to be answered:
How do different antimuscarinic drugs compare in this patient population and what are their risks, particularly in relation to central nervous system side effects?
Do repeated intradetrusor injections of botulinum toxin type A have long term efficacy, and can they protect the kidneys from high bladder pressures?
How can the burden of urinary tract infection be reduced and by which strategies?
How do different urinary tract management strategies (such as intermittent self catheterisation, the use of indwelling catheters) differ in terms of complications and quality of life outcomes?
Cite this as: BMJ 2012;345:e5074
This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
The members of the Guideline Development Group were Christine Anderson, Alison Bardsley, Noreen Barker, Amelia Denny, Tamara Diaz, Clare Fowler, Laura Graham, Simon Harrison (chair), Ralph Hughes (health economist), Judith Jesky, Philipp Laramee, Doreen McClurg, Keith McDermott, Susan Orme, Mark Perry (systematic reviewer), Gill Ritchie (guideline lead), Sharon Swain (systematic reviewer), Paul Tophill, Julie Vickerman, Richard Whittome, Alun Williams, Sue Woodward.
Contributors: All authors drafted the article. All authors revised it critically for important intellectual content and approved the final version to be published. All authors are guarantors of this article.
Competing interests: All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no financial support for the submitted work from anyone other than NICE; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.