The management of complex neuro-urological patients was examined today during the “Functional Urology” session, which was chaired by Prof. Fiona Burkhard (CH) and Prof. Dirk De Ridder (BE). In this Plenary Session, two patient cases were presented by Prof. Dr. Frank Van Der Aa (BE); one case was dedicated to discussing multiple sclerosis (MS) and the other to two different scenarios: a patient with dementia and a patient who has suffered a stroke.
Case 1The patient was a 55-year old female. Careful history and clinical examination suggested the patient had predominant urgency with urgency urinary incontinence (UUI), stress urinary incontinence and hesitancy.
If a patient such as this has no underlying neurological disease, then the EAU Guidelines advise keeping a voiding diary, screening for urinary tract infection (UTI) and measuring post-void residual urine. Urodynamic studies are not mandatory because invasive treatment options are not considered at this stage.
Treatment options for the patient include lifestyle modifications (e.g. reducing caffeine intake), behavioural therapy (e.g. bladder training), and some medical therapy (antimuscarinics/mirabegron).
Multiple sclerosisIf the patient in Case 1 suffered from secondary progressive MS and took no alpha blocking agents or antimuscarinics, Dr. Bartosz Dybowski (PL) said that a urodynamic study would be performed.
In this scenario, the results showed that she had detrusor overactivity in the storage phase and a negative cough test. There was hypocontractility during voiding, detrusor sphincter dyssynergia, and a low post-void residual urine volume (PVR). To treat the urgency, 100 units of Botulinum toxin serotype A (BoNT/A) were injected. The treatment outcomes were resolution of her UUI, a low (PVR), and no need for self-catheterisation.
After two years, the patient’s stress urinary incontinence had progressed but there had only been minor deterioration of her MS-related disability. A urodynamic study showed that the result of the cough test was now positive but excluded the presence of urinary incontinence. Transobturator tape (TOT) was implanted and BoNT/A injections were continued. The treatment was effective and no self-catheterisation was necessary.
Dybowski said: “It is important to stress that aside from neurogenic disorders, there are also non-neurogenic symptoms. Stress incontinence in women and problems related to benign prostatic hyperplasia (BPH) should be diagnosed as well.”
Case 2The patient was a 77-year old male with urgency, frequency and UUI, who was resistant to first-line medical treatment. The patient took tamsulosin (0.4mg), tolterodine (4mg) and donezepil (10mg) daily, and had associated cognitive and mobility problems. Clinical examination showed that he had an enlarged benign prostate.
If a patient such as this has no underlying neurological disease, then transurethral resection of the prostate (TURP) might be considered. Based on the EAU Guidelines, the urologist should use a frequency volume chart (FVC) and apply serum creatinine, as well as performing an ultrasound of the prostate, a kidney ultrasound, urinalysis and possibly, surgical treatment.
DementiaIf the patient in Case 2 suffered from dementia, Dr. Jalesh Narayana Panicker (GB) emphasised that the use of an anticholinergic greater than 3 on the anticholinergic burden (ACB) scale is clinically relevant. This may lead to increased risks in cognitive impairment, impaired functional performance and mortality. He said: “If you have a patient with a high ACB score, you should ask yourself is the medication essential? Are there alternatives? If there are no other options, then you monitor the patient closely.”
For patients with dementia, he suggested trospium chloride and darifenacin as antimuscarinic agents, or mirabegron and tibial nerve simulation as non-antimuscarinic options.
StrokeIf the patient in Case 2 had suffered a stroke within the prior nine months, Prof. Pierre Denys (FR) said this would be too soon to be discussing irreversible treatments such as TURP. “Due to spontaneous recovery, we have to wait and look at the patient after one year,” stated Denys. To assess the patient, non-invasive evaluation should be applied such as urinalysis, targeted history with clinical examination, and PVR screening. Urodynamic studies should only be employed if the PVR is greater than 50% of total bladder capacity to prove detrusor weakness and/or outflow obstruction.
For overactive bladder (OAB) without obstruction, the treatments include taking anticholinergics*, behavioural therapies (e.g. system voiding programme), or second-line treatments (e.g. tibial nerve stimulation - TNS).
According to Denys, the two challenging cases for urologists are: if the patient has either chronic urinary retention caused by detrusor underactivity or areflexia, because intermittent catheter use is often impossible due to cognitive or prehension disorders; or if the patient has OAB with obstruction, because of the possibility of applying reversible treatment to try to predict the result of surgery. This would involve use of a prostatic stent or pessary, or the use of urodynamic studies to help discriminate between stroke and obstruction in the pathophysiology of their OAB symptoms.
*Denys made a reference to Panicker’s perspective on anticholinergics and finding an alternative.