Neurourology and Urodynamics
Core concepts
Understand neurogenic bladder patterns by lesion level: suprasacral (spastic, detrusor overactivity, risk of dyssynergia), sacral/peripheral (flaccid, areflexic), and mixed. Know urodynamic parameters: capacity, compliance, detrusor pressure, leak point pressure, and detrusor-sphincter dyssynergia. Management includes clean intermittent catheterization, antimuscarinics/beta-3 agonists, botulinum toxin, and sacral neuromodulation for non-neurogenic urgency/frequency. Protect the upper tracts: high storage pressure and poor compliance are the enemies.
Traps
Do not rely on symptoms alone in spinal cord injury - urodynamics guide risk. Detrusor-sphincter dyssynergia raises storage pressure and can cause reflux and renal injury. In areflexic bladder, retention requires catheterization; do not give anticholinergics. Check compliance: low compliance with high pressure needs intervention even if the patient is asymptomatic.
Worked example
A T6 spinal cord injury patient with recurrent UTIs and hydronephrosis: urodynamics show high detrusor pressure and dyssynergia - treat with antimuscarinic/botulinum and consider sphincter management to lower pressure.
Exam strategy
Link lesion level to bladder pattern, then protect kidneys.