1 Guidance

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

The following recommendations apply to both adults and children and young people unless otherwise stated.

1.1 Assessment of lower urinary tract dysfunction in patients with neurological conditions

Assessment applies to new patients, those with changing symptoms and those requiring periodic reassessment of their urinary tract management. The interval between routine assessments will be dictated by the person's particular circumstances (for example, their age, diagnosis and type of management) but should not exceed 3 years.

These recommendations on assessment apply to people who have a neurological condition. If the assessment shows the incontinence to be non-neurogenic, please refer to Lower urinary tract symptoms (NICE clinical guideline 97) and Urinary incontinence (NICE clinical guideline 40) for guidance on management.

Clinical assessment

1.1.1 When assessing lower urinary tract dysfunction in a person with neurological disease, take a clinical history, including information about:

  • urinary tract symptoms

  • neurological symptoms and diagnosis (if known)

  • clinical course of the neurological disease

  • bowel symptoms

  • sexual function

  • comorbidities

  • use of prescription and other medication and therapies.

1.1.2 Assess the impact of the underlying neurological disease on factors that will affect how lower urinary tract dysfunction can be managed, such as:

  • mobility

  • hand function

  • cognitive function

  • social support

  • lifestyle.

1.1.3 Undertake a general physical examination that includes:

  • measuring blood pressure

  • an abdominal examination

  • an external genitalia examination

  • a vaginal or rectal examination if clinically indicated (for example, to look for evidence of pelvic floor prolapse, faecal loading or alterations in anal tone).

1.1.4 Carry out a focused neurological examination, which may need to include assessment of:

  • cognitive function

  • ambulation and mobility

  • hand function

  • lumbar and sacral spinal segment function.

1.1.5 Undertake a urine dipstick test using an appropriately collected sample to test for the presence of blood, glucose, protein, leukocytes and nitrites. Appropriate urine samples include clean-catch midstream samples, samples taken from a freshly inserted intermittent sterile catheter and samples taken from a catheter port. Do not take samples from leg bags.

1.1.6 If the dipstick test result and person's symptoms suggest an infection, arrange a urine bacterial culture and antibiotic sensitivity test before starting antibiotic treatment. Treatment need not be delayed but may be adapted when results are available.

1.1.7 Be aware that bacterial colonisation will be present in people using a catheter and so urine dipstick testing and bacterial culture may be unreliable for diagnosing active infection.

1.1.8 Ask people and/or their family members and carers to complete a 'fluid input/urine output chart' to record fluid intake, frequency of urination and volume of urine passed for a minimum of 3 days.

1.1.9 Consider measuring the urinary flow rate in people who are able to void voluntarily.

1.1.10 Measure the post-void residual urine volume by ultrasound, preferably using a portable scanner, and consider taking further measurements on different occasions to establish how bladder emptying varies at different times and in different circumstances.

1.1.11 Consider making a referral for a renal ultrasound scan in people who are at high risk of renal complications such as those with spina bifida or spinal cord injury.

1.1.12 Refer people for urgent investigation if they have any of the following 'red flag' signs and symptoms:

  • haematuria

  • recurrent urinary tract infections (for example, three or more infections in the last 6 months)

  • loin pain

  • recurrent catheter blockages (for example, catheters blocking within 6 weeks of being changed)

  • hydronephrosis or kidney stones on imaging

  • biochemical evidence of renal deterioration.

1.1.13 Be aware that unexplained changes in neurological symptoms (for example, confusion or worsening spasticity) can be caused by urinary tract disease, and consider further urinary tract investigation and treatment if this is suspected.

1.1.14 Refer people with changes in urinary function that may be due to new or progressing neurological disease needing specialist investigation (for example, syringomyelia, hydrocephalus, multiple system atrophy or cauda equina syndrome).

1.1.15 Assess the impact of lower urinary tract symptoms on the person's family members and carers and consider ways of reducing any adverse impact. If it is suspected that severe stress is leading to abuse, follow local safeguarding procedures.

Urodynamic investigations

1.1.16 Do not offer urodynamic investigations (such as filling cystometry and pressure-flow studies) routinely to people who are known to have a low risk of renal complications (for example, most people with multiple sclerosis).

1.1.17 Offer video-urodynamic investigations to people who are known to have a high risk of renal complications (for example, people with spina bifida, spinal cord injury or anorectal abnormalities).

1.1.18 Offer urodynamic investigations before performing surgical treatments for neurogenic lower urinary tract dysfunction.

1.2 Information and support

1.2.1 Offer people with neurogenic urinary tract dysfunction, their family members and carers specific information and training. Ensure that people who are starting to use, or are using, a bladder management system that involves the use of catheters, appliances or pads:

  • receive training, support and review from healthcare professionals who are trained to provide support in the relevant bladder management systems and are knowledgeable about the range of products available

  • have access to a range of products that meet their needs

  • have their products reviewed, at a maximum of 2 yearly intervals.

1.2.2 Tailor information and training to the person's physical condition and cognitive function to promote their active participation in care and self-management.

1.2.3 Inform people how to access further support and information from a healthcare professional about their urinary tract management.

1.2.4 NICE has produced guidance on the components of good patient experience in adult NHS services. All healthcare professionals should follow the recommendations in Patient experience in adult NHS services (NICE clinical guideline 138). Recommendations on shared decision making and information enabling people to actively participate in their care can be found in section 1.5 of NICE clinical guideline 138.

1.3 Treatment to improve bladder storage

Behavioural treatments

1.3.1 Consider a behavioural management programme (for example, timed voiding, bladder retraining or habit retraining) for people with neurogenic lower urinary tract dysfunction:

  • only after assessment by a healthcare professional trained in the assessment of people with neurogenic lower urinary tract dysfunction and

  • in conjunction with education about lower urinary tract function for the person and/or their family members and carers.

1.3.2 When choosing a behavioural management programme, take into account that prompted voiding and habit retraining are particularly suitable for people with cognitive impairment.

Antimuscarinics

1.3.3 Offer antimuscarinic[2] drugs to people with:

  • spinal cord disease (for example, spinal cord injury or multiple sclerosis) and

  • symptoms of an overactive bladder such as increased frequency, urgency and incontinence.

1.3.4 Consider antimuscarinic[2] drug treatment in people with:

  • conditions affecting the brain (for example, cerebral palsy, head injury or stroke) and

  • symptoms of an overactive bladder.

1.3.5 Consider antimuscarinic[2] drug treatment in people with urodynamic investigations showing impaired bladder storage.

1.3.6 Monitor residual urine volume in people who are not using intermittent or indwelling catheterisation after starting antimuscarinic treatment.

1.3.7 When prescribing antimuscarinics, take into account that:

  • antimuscarinics known to cross the blood-brain barrier (for example, oxybutynin) have the potential to cause central nervous system-related side effects (such as confusion)

  • antimuscarinic treatment can reduce bladder emptying, which may increase the risk of urinary tract infections

  • antimuscarinic treatment may precipitate or exacerbate constipation.

Botulinum toxin type A

1.3.8 Offer bladder wall injection with botulinum toxin type A[3] to adults:

  • with spinal cord disease (for example, spinal cord injury or multiple sclerosis) and

  • with symptoms of an overactive bladder and

  • in whom antimuscarinic drugs have proved to be ineffective or poorly tolerated.

1.3.9 Consider bladder wall injection with botulinum toxin type A[3] for children and young people:

  • with spinal cord disease and

  • with symptoms of an overactive bladder and

  • in whom antimuscarinic drugs have proved to be ineffective or poorly tolerated.

1.3.10 Offer bladder wall injection with botulinum toxin type A[3] to adults:

  • with spinal cord disease and

  • with urodynamic investigations showing impaired bladder storage and

  • in whom antimuscarinic drugs have proved to be ineffective or poorly tolerated.

1.3.11 Consider bladder wall injection with botulinum toxin type A[3] for children and young people:

  • with spinal cord disease and

  • with urodynamic investigations showing impaired bladder storage and

  • in whom antimuscarinic drugs have proved to be ineffective or poorly tolerated.

1.3.12 Before offering bladder wall injection with botulinum toxin type A:

  • explain to the person and/or their family members and carers that a catheterisation regimen is needed in most people with neurogenic lower urinary tract dysfunction after treatment, and

  • ensure that they are able and willing to manage such a regimen should urinary retention develop after the treatment.

1.3.13 Monitor residual urine volume in people who are not using a catheterisation regimen during treatment with botulinum toxin type A.

1.3.14 Monitor the upper urinary tract in people who are judged to be at risk of renal complications (for example, those with high intravesical pressures on filling cystometry) during treatment with botulinum toxin type A.

1.3.15 Ensure that people who have been offered continuing treatment with repeated botulinum toxin type A injections have prompt access to repeat injections when symptoms return.

Augmentation cystoplasty

1.3.16 Consider augmentation cystoplasty using an intestinal segment for people:

  • with non-progressive neurological disorders and

  • complications of impaired bladder storage (for example, hydronephrosis or incontinence) and

  • only after a thorough clinical and urodynamic assessment and discussion with the patient and/or their family members and carers about complications, risks and alternative treatments.

1.3.17 Offer patients life-long follow-up after augmentation cystoplasty because of the risk of long-term complications. Potential complications include metabolic effects, such as the development of vitamin B12 deficiency and the development of bladder cancer.

1.4 Treatment for stress incontinence

Pelvic floor muscle training

1.4.1 Consider pelvic floor muscle training for people with:

  • lower urinary tract dysfunction due to multiple sclerosis or stroke or

  • other neurological conditions where the potential to voluntarily contract the pelvic floor is preserved.

    Select patients for this training after specialist pelvic floor assessment and consider combining treatment with biofeedback and/or electrical stimulation of the pelvic floor.

Urethral tape and sling surgery

1.4.2 Consider autologous fascial sling surgery for people with neurogenic stress incontinence.

1.4.3 Do not routinely use synthetic tapes and slings in people with neurogenic stress incontinence because of the risk of urethral erosion.

Artificial urinary sphincter

1.4.4 Consider surgery to insert an artificial urinary sphincter for people with neurogenic stress incontinence only if an alternative procedure, such as insertion of an autologous fascial sling, is less likely to control incontinence.

1.4.5 When considering inserting an artificial urinary sphincter:

  • discuss with the person and/or their family members and carers the risks associated with the device, the possible need for repeat operations and alternative procedures

  • ensure that the bladder has adequate low-pressure storage capacity.

1.4.6 Monitor the upper urinary tract after artificial urinary sphincter surgery (for example, using annual ultrasound scans), as bladder storage function can deteriorate in some people after treatment of their neurogenic stress incontinence.

1.5 Treatment to improve bladder emptying

Alpha-blockers

1.5.1 Do not offer alpha-blockers to people as a treatment for bladder emptying problems caused by neurological disease.

1.6 Management with catheter valves

1.6.1 In people for whom it is appropriate a catheter valve may be used as an alternative to a drainage bag.

[This recommendation is from Infection: prevention and control of healthcare-associated infections in primary and community care (NICE clinical guideline 139).]

1.6.2 To ensure that a catheter valve is appropriate, take into consideration the person's preference, family member and carer support, manual dexterity, cognitive ability, and lower urinary tract function when offering a catheter valve as an alternative to continuous drainage into a bag.

1.6.3 Consider the need for continuing upper urinary tract surveillance in people who have impaired bladder storage (for example, due to reduced bladder compliance).

1.7 Management with ileal conduit diversion

1.7.1 For people with neurogenic lower urinary tract dysfunction who have intractable, major problems with urinary tract management, such as incontinence or renal deterioration:

1.8 Treatment to prevent urinary tract infection

1.8.1 Do not routinely use antibiotic prophylaxis for urinary tract infections in people with neurogenic lower urinary tract dysfunction.

1.8.2 Consider antibiotic prophylaxis for people who have a recent history of frequent or severe urinary tract infections.

1.8.3 Before prescribing antibiotic prophylaxis for urinary tract infection:

  • investigate the urinary tract for an underlying treatable cause (such as urinary tract stones or incomplete bladder emptying)

  • take into account and discuss with the person the risks and benefits of prophylaxis

  • refer to local protocols approved by a microbiologist or discuss suitable regimens with a microbiologist.

1.8.4 Ensure that the need for ongoing prophylaxis in all people who are receiving antibiotic prophylaxis is regularly reviewed.

1.8.5 When changing catheters in patients with a long-term indwelling urinary catheter:

  • do not offer antibiotic prophylaxis routinely

  • consider antibiotic prophylaxis[4] for patients who:

    • have a history of symptomatic urinary tract infection after catheter change or

    • experience trauma[5] during catheterisation.

[This recommendation is from Infection: prevention and control of healthcare-associated infections in primary and community care (NICE clinical guideline 139).]

1.9 Monitoring and surveillance protocols

1.9.1 Do not rely on serum creatinine and estimated glomerular filtration rate in isolation for monitoring renal function[6]in people with neurogenic lower urinary tract dysfunction.

1.9.2 Consider using isotopic glomerular filtration rate when an accurate measurement of glomerular filtration rate is required (for example, if imaging of the kidneys suggests that renal function might be compromised)[6].

1.9.3 Offer lifelong ultrasound surveillance of the kidneys to people who are judged to be at high risk of renal complications (for example, consider surveillance ultrasound scanning at annual or 2 yearly intervals). Those at high risk include people with spinal cord injury or spina bifida and those with adverse features on urodynamic investigations such as impaired bladder compliance, detrusor-sphincter dyssynergia or vesico-ureteric reflux.

1.9.4 Do not use plain abdominal radiography for routine surveillance in people with neurogenic lower urinary tract dysfunction.

1.9.5 Consider urodynamic investigations as part of a surveillance regimen for people at high risk of urinary tract complications (for example, people with spina bifida, spinal cord injury or anorectal abnormalities).

1.9.6 Do not use cystoscopy for routine surveillance in people with neurogenic lower urinary tract dysfunction.

1.9.7 Do not use renal scintigraphy for routine surveillance in people with neurogenic lower urinary tract dysfunction.

1.10 Potential complications: providing information and initial management

Renal impairment

1.10.1 Discuss with the person and/or their family members and carers the increased risk of renal complications (such as kidney stones, hydronephrosis and scarring) in people with neurogenic urinary tract dysfunction (in particular those with spina bifida or spinal cord injury). Tell them the symptoms to look out for (such as loin pain, urinary tract infection and haematuria) and when to see a healthcare professional.

1.10.2 When discussing treatment options, tell the person that indwelling urethral catheters may be associated with higher risks of renal complications (such as kidney stones and scarring) than other forms of bladder management (such as intermittent self catheterisation).

1.10.3 Use renal imaging to investigate symptoms that suggest upper urinary tract disease.

Bladder stones

1.10.4 Discuss with the person and/or their family members and carers the increased risk of bladder stones in people with neurogenic lower urinary tract dysfunction. Tell them the symptoms to look out for that mean they should see a healthcare professional (for example, recurrent infection, recurrent catheter blockages or haematuria).

1.10.5 Discuss with the person and/or their family members and carers that indwelling catheters (urethral and suprapubic) are associated with a higher incidence of bladder stones compared with other forms of bladder management. Tell them the symptoms to look out for that mean they should see a healthcare professional (for example, recurrent infection, recurrent catheter blockages or haematuria).

1.10.6 Refer people with symptoms that suggest the presence of bladder stones (for example, recurrent catheter blockages, recurrent urinary tract infection or haematuria) for cystoscopy.

Bladder cancer

1.10.7 Discuss with the person and/or family members and carers that there may be an increased risk of bladder cancer in people with neurogenic lower urinary tract dysfunction, in particular those with a long history of neurogenic lower urinary tract dysfunction and complicating factors, such as recurrent urinary tract infections. Tell them the symptoms to look out for (especially haematuria) that mean they should see a healthcare professional.

1.10.8 Arrange urgent (within 2 weeks) investigation with urinary tract imaging and cystoscopy for people with:

  • visible haematuria or

  • increased frequency of urinary tract infections or

  • other unexplained lower urinary tract symptoms.

1.11 Access to and interaction with services

Access to and interaction with services

1.11.1 Provide contact details for the provision of specialist advice if a person has received care for neurogenic lower urinary tract dysfunction in a specialised setting (for example, in a spinal injury unit or a paediatric urology unit). The contact details should be given to the person and/or their family members and carers and to the non-specialist medical and nursing staff involved in their care.

1.11.2 Provide people with neurogenic lower urinary tract dysfunction, and/or their family members and carers with written information that includes:

  • a list of key healthcare professionals involved in their care, a description of their role and their contact details

  • copies of all clinical correspondence

  • a list of prescribed medications and equipment.

    This information should also be sent to the person's GP.

1.11.3 NICE has produced guidance on the components of good patient experience in adult NHS services. All healthcare professionals should follow the recommendations in Patient experience in adult NHS services (NICE clinical guideline 138). Recommendations on tailoring healthcare services for each patient can be found in section 1.3 and recommendations on continuity of care and relationships can be found in section 1.4 of NICE clinical guideline 138.

Transfer from child to adult services

1.11.4 When managing the transition of a person from paediatric services to adult services for ongoing care of neurogenic lower urinary tract dysfunction:

  • formulate a clear structured care pathway at an early stage and involve the person and/or their parents and carers

  • involve the young person's parents and carers when preparing transfer documentation with the young person's consent

  • provide a full summary of the person's clinical history, investigation results and details of treatments for the person and receiving clinician

  • integrate information from the multidisciplinary health team into the transfer documentation

  • identify and plan the urological services that will need to be continued after the transition of care

  • formally transfer care to a named individual(s).

1.11.5 When receiving a person from paediatric services to adult services for ongoing care of neurogenic lower urinary tract dysfunction:

  • review the transfer documentation and liaise with the other adult services involved in ongoing care (for example, adult neuro-rehabilitation services)

  • provide the person with details of the service to which care is being transferred, including contact details of key personnel, such as the urologist and specialist nurses

  • ensure that urological services are being provided after transition to adult services.

1.11.6 Consider establishing regular multidisciplinary team meetings for paediatric and adult specialists to discuss the management of neurogenic lower urinary tract dysfunction in children and young people during the years leading up to transition and after entering adult services.



[2] At the time of publication (August 2012) not all antimuscarinics had a UK marketing authorisation for this indication or for use in both adults and children. The prescriber should follow relevant professional guidance when prescribing a drug without a marketing authorisation for this indication, taking full responsibility for the decision. Informed consent should be obtained and documented. See the GMC's Good practice in prescribing medicines – guidance for doctors for further information.

[3] At the time of publication (August 2012), botulinum toxin type A did not have UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the GMC's Good practice in prescribing medicines – guidance for doctors for further information.

[4] At the time of publication (August 2012), no antibiotics had a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the GMC's Good practice in prescribing medicines – guidance for doctors for further information.

[5] The GDG for Infection: prevention and control of healthcare-associated infections in primary and community care defined trauma as frank haematuria after catheterisation or two or more attempts of catheterisation.

[6] For more information on the measurement of kidney function, see Chronic kidney disease (NICE clinical guideline 73).

  • National Institute for Health and Care Excellence (NICE)