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

Table 2. Overview of management approach to neurogenic lower urinary tract dysfunction and NDO
Management Lines Options
Assisted bladder drainage Clean intermittent self catheterization, indwelling suprapubic catheters, indwelling
urethral catheters
Systemic medications to reduce intravesical pressure Anticholenergics, beta-3 agonists
Intra-detrusor botulinum toxin A injection Onabotulinum toxin A, abobotulinium toxin A
Sacral nerve stimulation N/A
Surgical treatment Bladder augmentation, urinary diversion
NDO: neurogenic detrusor overactivity

tumor, trabeculation, bladder tumors, and bladder stones. Although the value of cystoscopy at initial
evaluation has been questioned [8,12,13,16] , We recommend doing cystoscopy at initial evaluation, and as
diagnostic tool for patients who present with difficult catheterization to diagnose urethral stricture and
false passage, or when presenting with recurrent urinary tract infection, increased incontinence, bladder
spasticity and/or dysreflexia for possibility of finding a bladder stone. It should be noted that cystoscopy is a
[7]
mandatory investigation for hematuria workup . Screening cystoscopy for patients on a chronic indwelling
catheter is recommended for early diagnosis of bladder cancer, although the value of such an approach has
[17]
not been proven .

Treatment of NDO
The goals of NDO treatment are to reduce its risks on the urinary tract by reducing detrusor storage
pressures, increasing bladder capacity, improving incontinence, and improving patient’s quality of life. Table 2
summarizes management strategies of neurogenic lower urinary tract dysfunction and NDO. Treatment
effect monitoring in a timely fashion (2-3 months) is essential to avoid long term complications of the
[12]
poorly managed bladder .

Adequate bladder drainage using catheterization
[18]
It is estimated that around 75% of SCI injury patients cannot void spontaneously , which mandate assisted
bladder drainage. Types of bladder drainage include: (1) clean intermittent self-catheterization (CISC); (2)
indwelling suprapubic catheterization; and (3) indwelling urethral catheterization.

The patient should be aware of risks and benefits of the several methods of bladder drainage and advised
to avoid indwelling urethral catheters if possible, to reduce risks of urinary tract infections, bladder stone
formation, and urethral erosion [13,19] . It is recommended to keep patients, who cannot empty their bladder
spontaneously, on CISC [8,12,13] . The frequency of CISC depends on many factors, such as fluid intake,
[20]
bladder volume, and urodynamic parameters, and is recommended to do it 4 to 6 times/day . CISC
teaching is preferably done early during the rehabilitation phase, to evaluate the patient ability to perform
[12]
it, and to evaluate for the possibility of spontaneous voiding .

CISC, although considered as the gold standard of assisted bladder drainage mechanism, have several
limitations [Table 3], that treating physician should carefully assess and adjust those limitations if possible
or shift the patient to alternative drainage options [18,21] .

If CISC cannot be performed [Table 3], alternative management options include indwelling suprapubic
catheterization or indwelling urethral catheterization. Suprapubic catheters are generally preferred over
urethral catheters, with some studies supporting that preference. Suprapubic catheters have advantages over
[22]
urethral catheters, which include the elimination of risks of urethral erosions and iatrogenic hypospadias ,
[23]
fewer risks of epididymitis and enable patients to perform sexual activities . Some evidence showed a
decreased risk of urinary tract infection with suprapubic catheters [24-26] . Indwelling catheters (urethral and