Abstract
Objective:
Neuropathic bladder and urinary system pathology, such as incontinence and stone formation, are the most frequently encountered complications of spinal cord injury (SCI) and neurological disease. This study assesses the patient population and current practice at a tertiary UK neurourology service following dedicated clinic restructuring in 2017.
Methods:
A retrospective database was created to assess all patients attending the neurourology clinic over an 8-month period. The database recorded patient demographics, pathologies and subsequent investigations and management. Clinical innovations such as dedicated patient questionnaires and the formation of a dedicated multidisciplinary team, and their subsequent impacts on service improvement, were also assessed.
Results:
A total of 99 patients attended the clinic during the study. The most common pathology was SCI (51.5% (51)). The most common complaints were continence and catheter issues (61.6% (61)). Urinary symptoms such as frequency (15.2% (15)), infection (13.1% (13)) and urinary tract stones (9.1% (9)) accounted for the remainder of presenting complaints. Operative intervention was required in 25.3% (25) of cases.
Conclusion:
Patients with SCI and neurological disease experience a range of urinary symptoms with significant morbidity. Ensuring upper tract integrity, safe bladder management and intervening when necessary to improve quality of life are important concerns for the neurourologist. The redesigning of a dedicated neurourology clinic has permitted the treatment of such patients with a systematic approach ensuring safe bladder monitoring and upper tract surveillance. The introduction of a validated patient-reported symptom score has helped objective monitoring of symptoms before and after specific interventions. Patient concerns regarding sexual function and fertility are increasingly being encountered and addressed in the clinic.
Level of evidence: 4
Introduction
The prevalence of spinal cord injury (SCI) in the UK is ~35,000. 1 These patients experience significant urological problems as a result of their primary injury; genitourinary disease was previously the most common cause of death for SCI patients 1 and still accounts for 13% of SCI-related mortality, second only to respiratory system disease. 2 It is paramount for urologists working in the field of neurourology to be aware of the complex urological problems that these patients develop. The level of SCI is a predictor of urinary disease: patients with tetraplegia and paraplegia are 4.35 and 2.20 times more likely, respectively, to suffer from urinary disease. 3 Up to 95% of SCI patients will have neuropathic detrusor overactivity or detrusor sphincter dyssynergia, and up to 83% may have detrusor underactivity depending on the level of the lesion. 4
The prevalence of urinary symptoms in multiple sclerosis (MS) patients is between 44–100%, and urgency and incontinence have been shown to be independent determinants for lower quality of life scores in MS patients. 5 The urological consequences impact significantly on patients’ quality of life, with up to 80% of males experiencing sexual dysfunction, and up to 79% of patients experiencing neurogenic detrusor overactivity and urge incontinence.6–8
Neurogenic bladder also affects > 95% of spina bifida patients 9 and renal failure was historically a significant cause of mortality, but improvements in bladder management has led to an increase in life expectancy. 10
The advent of more advanced surgical techniques and a greater understanding of patient issues has broadened the role of the neurourologist, so that concerns such as sexual function and fertility are now routinely addressed alongside issues such as continence, urinary tract infection and stone disease. 11
Methods
In 2017, the neurourology service at Southport District General Hospital was redesigned following a retirement and the subsequent appointment of two consultant urologists with an interest in neurourology. An 8-month prospective study was performed examining all patients referred to the weekly, dedicated neurourology clinic. Several new initiatives were introduced to improve the service, including joint clinics, the use of specific questionnaires, standardised letter and video urodynamic reporting, and the introduction of a dedicated multidisciplinary team (MDT) with input from the SCI physicians.
The purpose of this study was to examine the workload, referral base and patient characteristics of the restructured clinic over 8 months. A database was established and recorded the following categories: patient demographics, primary pathology, level of injury in SCI referrals, date of injury, symptoms, investigations requested, baseline Qualiveen score, MDT discussion, referral source and operative intervention.
Results
During the 8-month study, a total of 99 patients were seen in the weekly neurourology clinic (Table 1). The median age was 52.6 years of age (range 18–83 years) and 51.5% (51) were male. The most common pathology was traumatic SCI 51.5% (51) and the most common level of injury was cervical spine 19.2% (19), followed by lumbar spine 15.2% (15) and thoracic spine 13.1% (13) (Figure 1). Median time elapsed since SCI was 5.5 years (range 6 months to 51 years).
Total number of referrals and aetiology.
Distribution of spinal cord injury level.
Neurological disease was the primary pathology in 47.5% (47) of patients: 16.2% (16) of patients had MS, 11.1% (11) had congenital defects including spina bifida and 6.1% (6) had infectious complications (meningitis/unspecified myelitis). The median time since onset of neurological disease was 48 years (range 1–73 years) with the longer time frame representing that some patients, such as those with spina bifida, had stable neurological disease since birth.
A total of two patients had been inherited from the previous service with artificial urinary sphincters and one underwent several operative interventions during the study period for symptomatic urethral erosion.
The most common complaints were continence and catheter issues in 61.6% (61) of patients (Table 2). Catheter-related problems included recurrent blockages, bypassing, expulsion and advice regarding alternative methods of containment. A total of 15.2% (15) of patients reported lower urinary tract symptoms, most commonly urinary frequency, whereas 13.1% (13) reported recurrent urinary tract infection and 9.1% (9) presented with urinary tract stones.
Most common symptoms reported by patients.
Renal tract ultrasonography was the most common investigation requested in 40.4% (40) of patients, followed by cystoscopy 39.4% (39) and videourodynamics 37.4% (37) (Table 3). MDT discussion was carried out in 44.4% (44) of cases. Routine bladder stones, scrotal pathology and catheter-related issues were excluded from the MDT. The mean baseline short form (SF)-Qualiveen score was 2.57.
Specialist investigations requested.
Operative intervention was undertaken in 25.3% (25) of patients (Table 4). The most common procedures were suprapubic catheterisation, stone-related procedures and intravesical botox injection. Only one patient was referred externally for a urinary diversion procedure and one patient was referred externally for sacral neuromodulation. Two patients with artificial urinary sphincters were inherited from the previous consultant: one developed urethral erosions during follow-up and required sphincter removal. Due to age and comorbidities, he elected not to undergo sphincter reinsertion initially and opted for long-term catheter placement, but was subsequently listed for suprapubic catheter placement. The three patients recorded as receiving intravesical botox were all SCI patients who had injections on an inpatient theatre list due to the risk of autonomic dysreflexia, which they had previously developed.
Operative intervention.
Referred externally.
Only two SCI patients underwent surgical sperm retrieval in the form of testicular sperm extraction.
Discussion
Life expectancy for both SCI and MS patients has increased significantly over the last 50 years, with an ongoing incidence of SCI injury of 15/1,000,000 and an estimated incidence of neurological disease of 0.6 % in the general population.3,12–14 Consequently, a large patient population with urinary side effects of neurological disease are now enjoying a better quality of life with increased life expectancy. Neurogenic bladder presents a multitude of diagnostic challenges for the urologist due to the heterogeneity of symptoms that occur, in addition to the fact that the pattern of bladder dysfunction may evolve over time. 15 Appropriate bladder management is paramount to improve quality of life, and prevent the morbidity and mortality associated with improper bladder monitoring. 16 Issues such as fertility for the spinal cord-injured male are now being addressed frequently by those urologists working in the area of SCI. 17
This study assessed changes made to a regional tertiary neurourology clinic. Specific alterations included the introduction of an MDT meeting including surgeons, spinal cord physicians, physiotherapists and nurse practitioners. This allowed other practitioners to highlight patients that were not already known to urology and allowed the Urology team to raise issues relevant to other specialties such as orthotic equipment impeding urological management. The role of the MDT has been shown to have a positive effect in this setting, and has been associated with shorter lengths of stay and more effective use of resources. 18 However, it is accepted that there remains a paucity of data regarding the role of the neurourology MDT.
Additionally, we introduced a specific letter template for all new referrals so that injury level, bowel, and bladder function and baseline symptom score were recorded at initial assessment, and ensuring that the treating neurourologist or SCI Physician was included in the correspondence.
The SF-Qualiveen score is a tool that records urinary-specific quality of life in patients with neurological disease.19,20 It is the abbreviated short form of the Qualiveen-30, which has been used and validated in European units for patients with MS and SCI.21,22 It has helped objectively quantify the effect of urinary symptoms in neurological patients with bladder concerns and now is used routinely at baseline assessment in our unit. 23 With time, it will also have an increased value in the measurement of symptoms, allowing urologists to assess the impacts of interventions and responses to treatment.
The desire and ability of patients with neurological disease to maintain sexual activity has been historically underestimated, and recognising this has assisted us in further improving our patient’s quality of life. 24 Male MS patients are highly likely to experience erectile dysfunction (60%), and there is also a higher incidence of orgasmic and ejaculatory dysfunction, and loss of libido. 25 For men with SCI, the level and severity of injury will influence the nature of symptoms. 26 The management of sexual health is more complex in neurological patients than in the general population and the neurourologist needs to recognise the impact of other neurological symptoms such as continence, poor mobility and stoma management on sexual function. 25
We now routinely enquire about sexual function and fertility in each new clinic appointment, and liase with gynaecology colleagues when fertility services are required. In this 8-month study, only two testicular sperm extractions were performed in SCI patients seeking assisted conception techniques, but we expect this number to increase as referrals to the unit rise.
One of the drawbacks of this study was that only patients who had intravesical botox under general anaesthetic on a theatre list were captured. Patients with MS and other neurological disease who received intravesical botox on a day case flexible cystoscopy list were not included.
This study demonstrates the significant needs of patients with urinary symptoms as a consequence of traumatic, congenital and acquired neurological disease. The patient population was reflective of a tertiary neurourology clinic with a mix of traumatic and organic neurological disease. The commonest level of injury in our cohort was the cervical spine and previous studies indicate that this is most likely to be associated with significant urinary symptoms. 3 The relatively high rate of operative intervention of 25.3% (25) in this cohort demonstrates the need for a urologist to be involved in the multidisciplinary assessment and care of these patients from an early stage, as their needs cannot be managed by neurologists and rehabilitation specialists alone. The development of the clinic has led to an increasing volume of referrals from outside the hospital’s catchment area as more general urologists seek specialist intervention for their patients. In this period, 42.6.% of patients were from the local population, 28.7% from Greater Merseyside and 28.7% from elsewhere in the country. As demonstrated, the majority of the urological surgery required is not unique to this population; however, the nature of the conditions can make surgery more challenging for a variety of reasons (e.g. contractures, respiratory compromise and risk of dysreflexia) and urologists will require the support of other team members, such as anaesthetists and nursing staff.
Conclusion
This study illustrates the important role of the urologist in the care of the patient with any neurourological disorder, and highlights how the formation and redesign of a tertiary, specialist clinic has altered patient management. Over 8 months, a total of 99 patients were seen with 14 different neurological disorders in a weekly clinic. Traditional issues such as catheter care and urinary tract infections continue to be the most frequently encountered problems in clinic, but we increasingly encounter consultations related to reproductive and sexual health. The redesign of our services has allowed urologists to work more closely alongside other practitioners in the spinal injuries unit and provide a more holistic standard of care. The specialist MDT and validated questionnaire use has facilitated decision making for complex cases, and assisted in patient management and response to treatment. Despite changing SCI demographics, operative requirements remain significant as illustrated by this study. It is imperative that all SCI patients are managed by a urologist with a dedicated interest in neurourology with links to an SCI centre. For those working in the field of SCI and neurogenic bladder, we acknowledge the paucity of guidelines available to the neurourologist27,28 and the limited training opportunities available to those currently training at registrar level. Alongside urology registrars, other specialty trainees, including in neurology and gynaecology, are now attending clinics and videourodynamic lists to develop their understanding of neurourology and continence assessment.
As the service develops, operative procedures will increase and referrals will continue to expand. Specifically, we expect an increase in referrals related to surgical sperm retrieval at the clinic and links with the obstetric unit to mature. We intended to introduce sacral neuromodulation and reintroduce complex continence surgery to our unit, in addition to continuous audit of our service to monitor improvement.
Footnotes
Acknowledgements
None.
Conflicting interests
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Ethical approval
Our centre does not require ethical approval for reporting individual case studies or case series
Informed consent
Not required.
Guarantor
MSF
Contributorship
HG: data collection and interpretation, and wrote the manuscript. JD: assisted in data collection. RNK: reviewed and approved final draft. MSF: Derived the idea for the paper, assisted in the writing at all stages, analysed it for intellectual content and approved the final draft.
