Patients with neurological causes of AUR tend to present either acutely, at the same time as their neurological insult, e.g., cerebrovascular event (CVE) or with AUR as a new component of a progressive neurological condition such as multiple sklerosis (MS). In either case, the initial management is the same as previously, namely urethral or suprapubic catheterization.
The majority of neurological causes of UR relate to loss of detrusor function rather than excess sympathetic activity, and because of this the UR may not always be painful, especially on a background of progressive LUTS or difficulty voiding. The most commonly associated neurological abnormalities associated with void ing dysfunction include CVEs, cauda equina syndrome or spinal cord compression, Parkinson's disease, Shy-Drager syndrome (multisystem atrophy), multiple sclerosis (MS), and motor neuron disease (MND). Spinal cord injury also causes long-term voiding dysfunction, but rarely AUR. Most patients are, however, managed with an in-dwelling catheter after the initial injury, until the period of spinal shock has passed when a better idea of long-term bladder function can be ascertained.
On presentation of patients in UR with neurological disease, it is important to ascertain not only the diagnosis of the neurological impairment, but how this is likely to affect their urinary tract function. Some patients with acute conditions such as CVE may fully recover normal urinary tract function, so may only need catheterization for a short period of time. Others are more likely to need definitive longer-term management to be in place once the initial event is treated.
On examination of these patients, it is imperative to perform a full neurological examination paying specific attention to the sacral dermatomes and myotomes and their associated reflexes. Assessment of anal tone and sensation can be performed at the same time as DRE. In patients with symptoms suggestive of cauda equina compression, such as back pain and saddle anesthesia, urgent magnetic resonance imaging (MRI) scanning should be performed with a view to urgent neurosurgical intervention where appropriate. Some patients in this group may have known metastatic bone disease, in which case MRI followed by urgent radiotherapy may be required. Both of these events will not effect the immediate management of AUR, i.e., cathe-terization. If treated early, normal neurological function should return after a period of time, but any delays to treatment are associated with worse long-term recovery.
In cases caused by progression of chronic neurological disease, those patients with reasonable motor function, specifically with reference to the hands and upper limbs, and normal cognitive function, CISC is the best option for long-term bladder management. Some patients, however, may not be able to manage this independently, and long-term management of these individuals needs to be decided on a case-by-case basis to ensure all parties involved in the patient's on-going care are informed and capable of whatever is needed. Some patients may require long-term suprapubic cath-eterization as a less intensive method of long-term bladder management.
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