A recent international consensus review emphasized that health care professionals should maintain a high index of suspicion for underlying neurologic conditions in patients presenting with lower urinary tract symptoms.
The findings were presented at a 2024 International Consultation on Incontinence Research Society (ICI-RS) think tank that considered the clinical pathway for identifying undiagnosed neurologic or autonomic contributions precipitating urinary symptoms.
In the study, published in Neurourology and Urodynamics, an expert panel identified several neurologic conditions in which lower urinary tract symptoms (LUTS) can be an early feature, including multiple sclerosis (MS), multiple system atrophy (MSA), Parkinson's disease, normal pressure hydrocephalus, dementia, and structural spinal cord conditions. These disorders are predisposed to affect characteristic parts of the nervous system, which may initially manifest as urinary symptoms prior to other neurologic signs become apparent.
"After presentation with urinary symptoms, an underlying neurologic mechanism sometimes emerges subsequently. Increased awareness may bring earlier diagnosis, improving prognosis and outcomes," the study authors stated.
Of particular concern is the potential for missed diagnosis of congenital and pediatric-acquired neurogenic conditions. The review noted that spinal dysraphism (SD) included "a heterogeneous group of neural tube defects, related to a large spectrum of clinical entities. The range covers severe forms, diagnosed in childhood, to silent forms discovered incidentally during and after puberty, or even in adulthood," the study authors emphasized.
They noted that SD may become evident only with the emergence of symptoms from cord tethering, which they described as "a stretch-induced disorder of function of the lumbosacral spinal cord [resultant from] excessive tension." This can manifest as LUTS, scoliosis, clubfoot, back pain, constipation, and gait disturbances. The symptoms are "often precipitated by rapid growth in height and exacerbated by puberty, in association with prostate enlargement or urethral oestrogenization."
The panel pointed out that comprehensive assessment should include consideration of bowel and sexual dysfunction alongside LUTS. They indicated that "a 'full house' of pelvic organ involvement may be suggestive of a neurologic disorder affecting their common pathways.
In neurologic assessment, the review stated that "control of micturition is often poorly characterized compared with other aspects of spinal cord function and the cranial nerves." Physical examination was deemed crucial, with testing necessary for "all urogenital sensations and reflexes [and] comprehensive testing of the pelvic floor and anal sphincter," they added.
While screening tools may help identify those with increased likelihood of particular conditions, the study authors observed that "currently available tools are either single-system or population specific." The sensitivity and specificity of the neuro-urological examination remains unknown, though the absence of touch or prick sensations, or an asymmetry between sides, should be considered abnormal.
The investigators recommended that including the results of the neuro-perineal examination in the urodynamic report may improve interpretation of results and potentially support identification of a neurologic etiology.
"The physical examination can support or go against a primary neurologic hypothesis, but it is not primarily diagnostic," the study authors cautioned.
The review also addressed autonomic disorders, which were not considered in previous International Continence Society consensus statements. Given the dominant role of the parasympathetic and sympathetic nervous systems in lower urinary tract function, such disorders "have a high chance of eliciting LUTS and LUTD," the study authors underscored.
The think tank concluded by identifying several priority research needs, including evaluating the value of neuro-urological examination in diagnosing occult neurologic disease, developing screening tools based on pelvic organ symptoms, and determining the appropriateness of non-neurologist practitioners requesting neurologic investigations such as MRI scanning.
"Timely referral to neurology might reduce preventable progression of disease," the study authors concluded, emphasizing that "research is needed to evaluate neuro-urological examination for diagnosis of occult neurologic disease and nonspecialist requesting of neurologic investigations, and to develop a screening tool or risk scoring."
Full disclosures can be found in the review.
