Adult Neurogenic Lower Urinary Tract Dysfunction: Diagnosis and Evaluation

At initial evaluation, clinicians should identify patients as either:
a. low-risk, or
b. unknown risk, who will require further evaluation to allow for complete risk stratification.
(Clinical Principle)


At initial evaluation, all patients with NLUTD should undergo a detailed history, physical exam, and urinalysis.
(Clinical Principle)


At initial evaluation, patients with NLUTD who spontaneously void should undergo post-void residual measurement.
(Clinical Principle)


At initial evaluation, optional studies in patients with NLUTD include a voiding/catheterization diary, pad test, and non-invasive uroflow.
(Expert Opinion)


At initial evaluation, in patients with low-risk NLUTD, the clinician should not routinely obtain upper tract imaging, renal function assessment, or multichannel urodynamics.
(Moderate Recommendation; Evidence Level: Grade C)


At initial evaluation, in patients with unknown-risk NLUTD, the clinician should obtain upper tract imaging, renal function assessment, and multichannel urodynamics.
(Moderate Recommendation; Evidence Level: Grade C)


In the patient with an acute neurological event resulting in NLUTD, the clinician should perform risk stratification once the neurological condition has stabilized.
(Clinical Principle)


Clinicians should not perform routine cystoscopy in the initial evaluation of the NLUTD patient.
(Clinical Principle)

During urodynamic testing and/or cystoscopic procedures, clinicians must hemodynamically monitor NLUTD patients at risk for autonomic dysreflexia.
(Clinical Principle)


For the NLUTD patient who develops autonomic dysreflexia during urodynamic testing and/or cystoscopic procedures, clinicians must terminate the study, immediately drain the bladder, and continue hemodynamic monitoring.
(Clinical Principle)


For the NLUTD patient with ongoing autonomic dysreflexia following bladder drainage, clinicians should initiate pharmacologic management and/or escalate care.
(Clinical Principle)

The clinician must educate patients with NLUTD on the signs and symptoms that would warrant additional assessment.
(Clinical Principle)


In patients with low-risk NLUTD and stable urinary signs and symptoms, the clinician should not obtain surveillance upper tract imaging, renal function assessment, or multichannel urodynamics.
(Moderate Recommendation; Evidence Level: Grade C)


In patients with moderate-risk NLUTD and stable urinary signs and symptoms, the clinician should assess the patient with:
a. annual focused history, physical exam, and symptom assessment.
b. annual renal function assessment.
c. upper tract imaging every 1-2 years.
(Moderate Recommendation; Evidence Level: Grade C)


In patients with high-risk NLUTD and stable urinary signs and symptoms, the clinician should assess the patient with:
a. annual focused history, physical exam, and symptom assessment.
b. annual renal function assessment.
c. annual upper tract imaging.
d. multichannel urodynamic studies, with or without fluoroscopy, which may be repeated when clinically indicated.
(Moderate Recommendation; Evidence Level: Grade C)


In patients with low-risk NLUTD who present with new onset signs and symptoms, new complications (eg, autonomic dysreflexia, urinary tract infections, stones), and/or upper tract or renal function deterioration, the clinician should re-evaluate and repeat risk stratification.
(Clinical Principle)


In patients with the moderate- or high-risk NLUTD who experience a change in signs and symptoms, new complications (eg, autonomic dysreflexia, urinary tract infections, stones), or upper tract or renal function deterioration, the clinician may perform multichannel urodynamics.
(Clinical Principle)


In the NLUTD patient with concomitant hematuria, recurrent urinary tract infections, or suspected anatomic anomaly (eg, strictures, false passage), clinicians should perform cystoscopy.
(Moderate Recommendation; Evidence Level: Grade B)


In NLUTD patients, clinicians should not perform screening/surveillance cystoscopy.
(Strong Recommendation; Evidence Level: Grade B)


In NLUTD patients with a chronic indwelling catheter, clinicians should not perform screening/surveillance cystoscopy.
(Strong Recommendation; Evidence Level: Grade B)


In NLUTD patients with indwelling catheters, clinicians should perform interval physical examination of the catheter and the catheter site (suprapubic or urethral).
(Moderate Recommendation; Evidence Level: Grade C)


In NLUTD patients with indwelling catheters who are at risk for upper and lower urinary tract calculi (eg, patients with spinal cord injury, recurrent urinary tract infection, immobilization, hypercalciuria), clinicians should perform urinary tract imaging every 1-2 years.
(Moderate Recommendation; Evidence Level: Grade C)

In asymptomatic NLUTD patients, clinicians should not perform surveillance/screening urine testing, including urine culture. (Moderate Recommendation; Evidence Level: Grade C)


Clinicians should not treat asymptomatic bacteriuria in patients with NLUTD.
(Moderate Recommendation; Evidence Level: Grade C)


In NLUTD patients with signs and symptoms suggestive of a urinary tract infection, clinicians should obtain a urinalysis and urine culture.
(Moderate Recommendation; Evidence Level: Grade C)


In NLUTD patients with a febrile urinary tract infection, clinicians should order upper tract imaging if:
a. the patient does not respond appropriately to antibiotic therapy.
b. the patient is moderate- or high-risk and is not up to date with routine upper tract imaging, regardless of their response to therapy.
(Clinical Principle)


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.
(Clinical Principle)



In NLUTD patients with recurrent urinary tract infections, clinicians should evaluate the upper and lower urinary tracts with imaging and cystoscopy.
(Clinical Principle)


In NLUTD patients with recurrent urinary tract infections and an unremarkable evaluation of the upper and lower urinary tract, clinicians may perform urodynamic evaluation.
(Conditional Recommendation; Evidence Level: Grade C)


In NLUTD patients who manage their bladder with an indwelling catheter, clinicians should not use daily antibiotic prophylaxis to prevent urinary tract infection.
(Strong Recommendation; Evidence Level: Grade B)


In NLUTD patients who manage their bladders with clean intermittent catheterization and do not have recurrent urinary tract infections, clinicians should not use daily antibiotic prophylaxis.
(Moderate Recommendation; Evidence Level: Grade B)