A: The level and completeness of injury and the degree of motor ­disturbance; any surgical interventions in acute phase of the spinal injury; and a thorough urologic history including current pattern of voiding, fluid intake, and output, frequency of urinary tract infections, compliance with medications are the other relevant history. If the patient has been performing intermittent self-­catheterization, the frequency of catheterization and timing of any incontinent episodes relative to catheterization are important as well as any difficulties with catheterization such as hematuria or infection. It is also important to ask about bowel function and constipation. Recent changes in medications (including changes in anticholinergic medication and side effects). The functional history should incorporate hand function, dressing skills, sitting balance, ability to ­perform transfers and other medical problems that may affect function, sexuality and living arrangements.

A: Urine microscopy/culture, serum electrolytes and creatinine, and urinary tract ultrasound. CT scan of urinary tract may be indicated if there is suspicion of stone disease or upper urinary tract deterioration. In this patient, the urine and blood evaluation were within normal limits. However, the ultrasound scan showed bilateral hydronephrosis with reasonable renal cortical thickness (Fig. 7.1). Urodynamic evaluation is essential to guide management for patients with neurogenic bladder dysfunction.

A: Based on the level of spinal injury, this patient is likely to have suprasacral neurogenic bladder (see Table 7.1). The urodynamic study showed detrusor overactivity and high pressure filling with incomplete emptying due to detrusor-sphincter dyssynergia (Fig. 7.2). If untreated, this will lead to progressive renal tract decline from the high storage pressures, and this is evident in the development of upper urinary tract dilatation.

A: Anticholinergic therapy to lower bladder storage pressures (see Chap. 4) as well as regular intermittent catheterization to ensure good bladder emptying is the key treatment for patients with DSD. Patients with neurogenic overactive bladders generally require higher doses of anticholinergic agents compared to non-neurogenic OAB.

Patients who have persisting incontinence and more importantly high storage pressures with upper tract dilatation despite adequate anticholinergic therapy should have further treatments such as intravesical botulinum toxin injections (Table 7.2, Fig. 7.3) or augmentation cystoplasty. Other surgical options include long-term catheterization (usually suprapubic catheter) or urinary diversion such as ileal conduit. Sphincterotomy with condom catheter urinary drainage is rarely employed nowadays.

A: Patients with DSD and evidence of high storage pressures are at risk for progressive renal impairment. As such periodic monitoring (e.g., annually for 5 years decreasing to every 2–3 years) of upper urinary tract with ultrasound and annual serum electrolytes/creatinine. Periodic urodynamic evaluation may be necessary especially if there is change in neurologic condition or urological symptoms.

Symptoms such as persisting incontinence, hematuria, and urinary infection should alert clinicians about the possibility of deterioration and prompt early assessment. Patients treated with augmentation cystoplasty to reduce storage pressures should have periodic cystoscopy after 5 years as there is a small risk of cancer development in the augmented bowel segment.