The evaluation of the neurologic patient includes the normal physical, biochemical and dynamic testing that is important in all patients with lower urinary tract symptoms. The only difference is that special attention must be taken to include the state of the upper tract and neuromuscular evaluation. EMG measurements will give a better understanding of the exact lesion.
History and physical examination
Thorough history and physical examination is necessary with care to evaluate perineal sensation, sphincter tone and lower extremity reflexes and sensation. Abdominal examination will sometimes detect a full bladder.
Remember that the neurogenic patient might have the normal anatomic abnormalities of the urogynae patient and good pelvic floor examination must be carried out.
Knowledge of the dermatomes and reflexes will help to localize the lesion.
Ultrasound of the bladder, urine dipstick and serum creatinine is indicated. If any abnormality is picked up with these screening tests, the necessary workup must be done.
Standard Urodynamic testing gives information on bladder and urethral function. To evaluate co-ordination between bladder contraction and urethral relaxation cystometogram and EMG or video urodynamics will give more information.
In the neurogenic patients, urodynamic studies are very important to evaluate the precise function of the lower urinary tract. Urodynamic studies should be performed in a specialized unit where good studies will be done as well as EMG measurements of the pelvic floor if needed.
Video urodynamics or ultrasound visualization of the bladder and the bladder outlet might enhance the information available on normal urodynamic studies. In a high-pressure bladder system with detrusor pressures reaching more than 40 cm of water, especially in the presence of detrusor sphincter dyssynergia, it might lead to upper tract deterioration. The physician must make sure that proper knowledge of bladder function as well as urethral and pelvic floor activity is known after a full urodynamic evaluation. Specific attention should be given to sensation of the bladder at the time of urodynamic study to plan further treatment. Urodynamic evaluation must always try to mimic the real life symptoms during the study.
- Ice water test might give information on the difference between reflex and areflexic neurologic bladders, but is controversial.
- Betanecol super sensitivity test might also give more information on the difference between neurologic or miogenic a contractile bladders. The current recommendation is that it has to be used with care and only as part of a full evaluation.
- EMG of the sphincter. It is recommended that EMG of the urethral sphincter can be used in the diagnosis of neurologic bladder dysfunction. There is not a good correlation between anal sphincter activity and urethral function.
- The following tests are currently still experimental and there is no clear clinical proof that it will add to the information on the specific patient.
EMG of the detrusor muscle Dynamic bulbocaverneus reflex Nerve conduction studies Somatosensory evoke potentials Electro sensitivity of the low urinary tract Sympathetic skin response.
More research is necessary before these specific tests can prove to be useful as a clinical tool.