LUTS in the neuro-urologic patient

It is essential to obtain the neurological history from male lower urinary tract symptoms (LUTS) by asking patients or their partners. Urologists should perform a careful physical exam. Prior to any invasive or irreversible treatment, it is necessary to refer to a neurologist.

Dr Lysanne Campeau (McGill University, Canada) held a state-of-the-art lecture on the basic neurological workup any urologist seeing a male LUTS patient should consider [1]. Key urological symptoms underlying neurological disease may be storage and voiding symptoms, erectile dysfunction, retrograde ejaculation, enuresis, loss of filling sensation, or unexplained stress urinary incontinence.

Common neurological aetiologies for male LUTS can be Parkinson’s disease (PD), multiple system atrophy (MSA), or normal pressure hydrocephalus characterised by dementia, abnormal gait, and urinary incontinence. Concomitant LUTS can also be a sign of multiple sclerosis (MS), several different spinal cord conditions, or cerebral white matter disease.

Dr Campeau obtains relevant history to help make a differential diagnosis, asking the patient and/or partner about memory issues, visual disturbances (MS), anosmia (PD), and speech changes (MSA). The urologist should note if there is a resting tremor indicative of PD, back pain (cauda equina syndrome), saddle anaesthesia, bowel dysfunction and incontinence, weakness or numbness in lower limbs (MS), or gait or balance problems.

The focused physical exam, to determine whether a referral to the neurologist is necessary, uses a top-to-bottom approach. Dr Campeau pointed out that many of these can be observed in the normal course of entry (e.g. gait) and discussion:

• 
  
  • 
    
    • mental status (attention, language, memory);
    • speech (croaky) and masked facies;
    • blood pressure (orthostatic);
    • motor system (speed of movement, Cogwheel rigidity, tremor);
    • coordination (ataxia [finger-nose-finger], repetitive finger tapping);
    • bulbocavernosus reflex (Dr Campeau rarely performs this in practice);
    • sensory system (perineal); and
    • gait assessment (shuffling, wide stance, arm swing).

She recommended that a urinalysis with renal function should be undertaken, and where appropriate, a voiding diary and an ultrasound of the bladder and/or kidney may be indicated. Urodynamic studies can be particularly informative. She cautioned that it is essential to consult with a neurologist prior to any surgery or other irreversible intervention.

1. 
   
   1. Campeau L, et al. EAU20 Virtual Congress, 17-26 July 2020, State-of-the-art-lecture.

Posted on 24 August 202017 May 2024