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Alsulihem et al. Neuroimmunol Neuroinflammation 2019;6:13 I http://dx.doi.org/10.20517/2347-8659.2019.007 Page 3 of 13

[5]
Figure 2. Expected lower urinary tract dysfunction based on the level of neurologic insult (adopted from Panicker et al. )

THE SEQUELAE OF UNTREATED LOWER URINARY TRACT DYSFUNCTION
The primary functions of the lower urinary tract are: (1) storage of urine under low vesical pressure
without leakage; and (2) periodic complete expulsion of urine in socially acceptable time and location.
[7]
Intact central and peripheral nervous systems are required to achieve these functions . SCI and other
neurologic disorders frequently affect the functions of the lower urinary tract. Untreated or poorly
managed neurogenic lower urinary tract dysfunction may result in: (1) upper urinary tract deterioration
resulting in end-stage renal disease; (2) urinary incontinence and urethral damage; (3) recurrent urinary
[8]
tract infections and urolithiasis; and (4) autonomic dysreflexia . In the last half-century, advancement
in the management of neurogenic lower urinary tract dysfunction has led to decreased mortality caused
by chronic kidney disease, from 50% in the 1950s and 1960s to less than 0.5% in the 1980s [9,10] . This
emphasized the importance of prompt management of the neurogenic lower urinary tract dysfunction to
prevent its sequelae. The 2019 report of the national SCI statistical center has reported a 2.9% mortality rate
[11]
secondary to genitourinary diseases in SCI patients .

INITIAL EVALUATION AND MANAGEMENT AFTER ACUTE SCI
Early phase after SCI (the spinal shock)
After acute traumatic SCI, a spinal shock phase occurs. The bladder is hypotonic, and urinary retention
and overflow incontinence happen in the absence of management. This phase resolves as early as 2 weeks,
[6]
with an average of 8 weeks, and can be prolonged up to a year . The extent and duration of this phase
are variable and depend on the extension and the completeness of the spinal injury . During this phase,
[12]