Management of lower urinary tract symptoms in men with progressive neurological disease

Progressive neurological disease can cause lower urinary tract symptoms similar to those seen in bladder outflow obstruction. Increasingly common with age, these two groups of conditions often coexist. The complex pathophysiology of men with this combination of problems is often poorly understood and suboptimally managed, mostly with long-term indwelling catheters. This review looks at recent diagnostic advances and emerging therapeutic alternatives.

For various neurogenic bladder disorders, urodynamic studies may demonstrate typical constellations of abnormalities, but no pathognomonic features. Other modalities such as sphincter electromyography and central nervous system imaging have been proposed to aid diagnosis. Functional brain imaging has helped to understand the complex nature of bladder storage and micturition control. A new generation of bladder-selective antimuscarinics has graduated through phase-III randomized controlled trials and these are now available for routine use. These agents are as efficacious as oxybutynin but have better side-effect profiles. Modern minimally invasive techniques such as desensitizing bladder instillations or injections of botulinum toxin have safely been used and are achieving excellent results.

Urodynamic studies are important and increasingly regarded as mandatory in all men considered for outflow surgery. Neurogenic bladder and sphincter dysfunction can be managed conservatively or with new minimally invasive techniques. Surgery should be reserved for severely symptomatic treatment failures. A working knowledge of common neurological disease associated with lower urinary tract dysfunction is important for urologists to diagnose these conditions or initiate an appropriate referral. This article gives an overview of recent work that has implications for the diagnosis and management of neurological disorders of micturition.