NICE clinical guidelines
Issued: August 2012
CG148

Urinary incontinence in neurological disease: Management of lower urinary tract dysfunction in neurological disease

This is an extract from the guidance. The complete guidance is available at guidance.nice.org.uk/cg148

Introduction

The lower urinary tract consists of the urinary bladder and the urethra. Its function is to store and expel urine in a coordinated and controlled manner. The central and peripheral nervous systems regulate this activity. Urinary symptoms can arise due to neurological disease in the brain, the suprasacral spinal cord, the sacral spinal cord or the peripheral nervous system. Damage within each of these areas tends to produce characteristic patterns of bladder and sphincter dysfunction. The nature of the damage to the nervous system is also important. In children the neurological damage is often the result of congenital defects such as spina bifida or sacral agenesis. Conditions may produce a relatively fixed or stable injury to the nervous system (for example, stroke, spinal cord injury and cauda equina compression) or progressive damage (for example, dementia, Parkinson's disease, multiple sclerosis and peripheral neuropathy). Table 1 groups neurological conditions based on the anatomical site of the resulting neurological lesion with the likelihood of disease progression.

Table 1 Examples of neurological conditions that can affect lower urinary tract function

Congenital and perinatal conditions

Acquired, stable conditions

Acquired, progressive or degenerative conditions

Brain conditions

Cerebral palsy

Stroke

Head injury

Multiple sclerosis

Parkinson's disease

Dementia

Multiple system atrophy

Suprasacral spinal cord conditions

Spinal dysraphism (such as myelomeningocoele)

Spinal cord injury

Multiple sclerosis

Cervical spondylosis with myelopathy

Sacral spinal cord or peripheral nerve conditions

Spinal dysraphism

Sacral agenesis

Anorectal anomalies

Cauda equina syndrome

Spinal cord injury

Peripheral nerve injury from radical pelvic surgery

Peripheral neuropathy

The proximity of the neurological centres controlling bowel and sexual functions to those involved in lower urinary tract function means that many people with neurological disease will have a combination of urinary, bowel and sexual dysfunction. The clinical team should not treat lower urinary tract problems in isolation but should address associated problems in other systems using a holistic approach.

Symptoms of neurogenic lower urinary tract dysfunction may relate to impaired urine storage and/or bladder emptying difficulties. Symptoms of impaired storage include increased frequency of urination and urinary incontinence. Urinary tract symptoms have a significant impact on quality of life, for example, they can cause embarrassment, lead to social isolation and impair activities of daily living. Incontinence is particularly problematic and can arise as a result of an overactive bladder, dysfunction of the urethral sphincters or a combination of the two.

Secondary effects can also arise as a result of neurogenic lower urinary tract dysfunction. For example, there is a marked increase in the risk of urinary tract infection in people with neurogenic lower urinary tract dysfunction and kidney function can be lost as a result of abnormally high pressures within the bladder, from the effects of urinary tract infection and as a result of kidney stones.

Medical interventions often do not restore normal urinary function, and quality of life may be affected by the medical management of neurogenic lower urinary tract dysfunction. Many patients will have to cope with the side effects of medication, the social and psychological consequences of using intermittent self-catheterisation, the impact of indwelling catheterisation and the continuing use of pads or appliances. These may also have an impact on quality of life for family members and carers, and there may be issues related to the physical demands of caring for a person with neurological disease and urinary problems, as well as psychological, relationship and social pressures.

The economic cost of managing neurogenic lower urinary tract dysfunction is considerable. There are major costs associated with the use of pads, appliances, catheters, drug treatments and surgical interventions. A further financial burden arises from the person's requirements for carer, nursing and medical support. A person's ability to work can be affected by their neurogenic lower urinary tract dysfunction. Further significant expenditure is associated with the follow-up of patients, some of whom are placed on long-term urinary tract surveillance.

An overview of the clinical approach that is used when dealing with neurogenic lower urinary tract dysfunction is provided in three algorithms that are included in the full guideline. The recommendations have also been added to the NICE pathway.

The guideline will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.

This guideline recommends some drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the GMC's Good practice in prescribing medicines – guidance for doctors for further information. Where recommendations have been made for the use of drugs outside their licensed indications ('off-label use'), these drugs are marked with a footnote in the recommendations.