Fourth International Consultation On Incontinence (ICI) - Neurogenic Patients Committee Highlights

Main Category: Urology / Nephrology
Article Date: 26 Jul 2008 - 0:00 PDT

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PARIS, FRANCE (UroToday.com) - This committee's task was to evaluate urinary and fecal incontinence (UI, FI) in patients with neurological disease. Dr. Wyndael began by reviewing the common innervation of the lower gastrotintestinal (LGIT) and lower urinary tracts (LUT). Dr. Wyndaele reviewed the prevalence of LUT and LGIT dysfunction in 5 common neurological illnesses including Parkinson's, Multiple Sclerosis, Spinal Cord Injury, Stroke and Diabetes. In general, LUT dysfunction occurs in 50-70% of these patients and is somewhat more prevalent than LGIT dysfunction. The committee made several recommendations in this area. Patients with neurological disease that is known to cause LUT or LGIT dysfunction should be evaluated for dysfunction (Grade A). One should not necessarily wait for symptoms to appear before beginning evaluation if the prevalence of dysfunction is known to be high (Grade A). Finally, the committee recommended investigation for potential neurological disease in patients with "idiopathic" LUT/LGIT dysfunction (Grade A).

Dr. Wyndaele moved on to a discussion of UI in neurogenic patients. The diagnostic approach is similar to that in non-neurogenic patients with the exception that urodynamics is recommended earlier in the evaluation, as symptoms may not be reliable in this group (Level 2 Grade B). He also briefly discussed provocative ice water testing (Level 2), bethanechol testing (Level 3) and neurophysiological testing (Level 2), although recommendation grades were not given.

With respect to treatment, Dr. Wyndaele noted that conservative therapy is the cornerstone of treatment, and that no new treatments have been developed since the last consultation. Several areas were highlighted. Toileting assistance received a Grade C recommendation, CIC a Grade A recommendation, pharmacotherapy a Grade A recommendation and electrical stimulation a Grade C recommendation.

The committee next addressed multiple procedural therapies, which were divided into several different areas. With respect to surgery to decrease vesical pressures and abolish overactivity, botulinum toxin injection was recommended (Grade A) with Level 1 evidence. Enterocystoplasty (Level 2 Grade B) and autoaugmentation (Level 4 Grade C) were also evaluated. Dorsal Rhizotomy received a Grade B recommendation on Level 2 evidence. In patients with sphinceric incontinence, the artificial urinary sphincter and bladder neck sling procedures both received Grade C recommendation on Level 3 evidence while injectable bulking agents were given a Grade D.

To lower outlet resistence to promote continuous emptying, transurethral incision of the sphincter and urethral stents were both given Grade B recommendations on Level 2 evidence, while botulinum toxin injection was given a Grade C recommendation on Level 3 evidence for this purpose.

Dr. Wyndaele next addressed fecal incontinence in the neurogenic patient. The recommended evaluation is similar to that in non-neurogenic patients and may include manometry, transit time testing, transrectal ultrasound and expulsion tests. Needle EMG testing is standard clinically but there is not strong evidence to support its use (Grade C).

A host of conservative treatments were listed, and Dr. Wyndaele stated there was little evidence to support any of them in particular. The same is true for pharmacotherapy, biofeedback and electrical stimulation. Retrograde enemas have been shown to be effective in patients with myelomeningocele and were given a Grade C recommendation. Patient education received a Grade A recommendation, and reflex triggered bowel evacuation was given a Grade B recommendation.

Dr. Wyndaele stated that more data was needed with respect to sacral neuromodulation for this condition. All of the surgical treatments were given Grade C recommendations as the literature is sparse in this area. Antegrade continence enemas are commonly used in myelomenigocele patients and may be useful in some adults. Artificial anal sphincters and dynamic graciloplasty are both fraught with significant rates of treatment failure and need for operative revisions but may be efficacious in select patients. Permanent colostomy may be an option for some patients, especially those with spinal cord injury and refractory FI.

Dr. Wyndaele concluded by outlining other subjects that will be covered in the full committee report but were not included in this presentation.

JJ Wyndaele, MD, Committee Chair

Moderated by Joachim W. Thüroff, MD and Masaru Murai, MD, at the Fourth International Consultation on Incontinence (ICI) - July 5 - 8, 2008. Palais des Congres, Paris, France.

Written by William Jaffe, MD, a Contributing Editor with UroToday.com

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