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Page 4 of 13 Alsulihem et al. Neuroimmunol Neuroinflammation 2019;6:13 I http://dx.doi.org/10.20517/2347-8659.2019.007
[6]
conducting a urodynamic study had been considered of limited clinical value . Recent evidence has
shown the presence of adverse urodynamic findings in those patients in the early phase (within 40 days of
[12]
the injury) . The best management at this phase is to ensure complete bladder drainage by intermittent
catheterization (IC) or an indwelling urethral catheter [6-12] . Once the patient is stabilized medically, a trial of
spontaneous voiding along with post-void residual measurement or self-intermittent catheterization, if the
patient cannot void spontaneously, should be tried, while admitted in a rehabilitation facility .
[12]
Initial urological evaluation
This will take place at the first consultation and includes: detailed history, physical examination, bladder
diary (often catheterization record), post-void residual, urinalysis and culture, renal function assessment,
and upper urinary tract imaging [6,8,12] . Urodynamic assessment and cystoscopy may be indicated at the first
evaluation, depending on the stage of evolution of the neurogenic bladder dysfunction.

History
Complete medical and surgical history is essential for further evaluation and potential management options
and consideration of personalized treatment and follow up. Information about initial trauma and level and
completeness of SCI (ASIA score), associated trauma to the urinary tract, and previous lower urinary tract
diseases and treatments before spinal cord injury should be documented. The patient’s mental and physical
capacity should also be noted. History should also include the history of urinary tract infection frequency,
symptoms, and treatments. Social history and social support, history of alcoholism or drug abuse are also
important for long-term management. History of bowel management, past medical history of acute angle
glaucoma, uncontrolled hypertension, and myasthenia gravis should be elicited as it might be a potential
contraindication for medications that can be used for the treatment of NDO [6,12] .

Physical examination
General physical examination is warranted, including a focused examination of the abdomen and genitalia.
The ability to perform self-intermittent catheterization should be noted, along with previous abdominal
scars or any contraindications that might complicate the insertion of suprapubic catheter insertion. If
the clinician is in doubt regarding the patient’s capability of performing IC, a consultation in ergotherapy
could be very helpful. A focused neurologic exam is required, including anal tone, perineal sensation, and
[12]
bulbocavernosus reflex .

Bladder diary
A bladder diary is highly recommended but not well studied . It can add further information about
[13]
how frequent the patient is urinating or catheterizing, the amount of urine drained, and the post-void
residual. It can add further value in the monitoring of the treatment effect. Components of bladder diary
recommended by ICS include voiding time, voided volume, incontinence episodes/use of pads, amount of
fluids ingested, urgency, and incontinence degree, along with the method of emptying the bladder [12,14] .

Urinalysis and culture
Urinalysis and microscopy are recommended in the initial visit and in follow up [8,12] to investigate the
possibility of UTI in the presence of symptoms with subsequent urine cluture, and it can also detect
microscopic hematuria, pyuria, or proteinuria, which might warrant further investigations. The presence of
asymptomatic bacteriuria, which is frequent in patients performing IC, is not an indication of antibiotics in
the majority of cases.

Post-void residual
Post void residual measurement is recommended in patients who void spontaneously, or uses valsalva
voiding, reflexive voiding/crede voiding and/or condom catheter. The presence of elevated residual might