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Spinal cord injury can either be complete with no neural communication across the injury level or incomplete with limited communication. Similarly, motor neuron injuries above the sacral spinal cord are classified as upper motor neuron injuries, while those inside the sacral cord are classified as lower motor neuron injuries. Specifically, we provide recommendations regarding the urological management of complete upper motor neuron spinal cord injuries; however, we also make limited comments related to other injuries. The individual with a complete upper motor neuron injury may encounter five lower urinary tract conditions: first, neurogenic detrusor overactivity causing urinary incontinence; second, neurogenic detrusor underactivity resulting in high post-void residual volumes; third, detrusor sphincter dyssynergia, which is contraction of striated and/or smooth muscle urethral sphincters during detrusor contractions; fourth, urinary tract infection; and fifth, autonomic dysreflexia during detrusor contractions, which produces high blood pressure as well as smooth muscle detrusor sphincter dyssynergia. Intermittent catheterization is the recommended urinary management method because it addresses the five lower urinary tract conditions and has good long-term outcomes. This method uses periodic catheterizations to drain the bladder, but also needs bladder inhibitory interventions to prevent urinary incontinence between catheterizations. Primary limitations associated with this management method include difficulties with the multiple catheterizations, side effects of bladder inhibitory medications, and urinary tract infections. Three suggestions to address these concerns include the use of low-friction catheters, wireless, genital-nerve neuromodulation for bladder inhibition, and consideration of urine egress into the urethra as a risk factor for UTI as well as egress treatment. The second management method is reflex voiding. This program uses external condoms for urine collection in males and diapers for females. Suprapubic tapping is used to promote bladder contractions. This method is not recommended because it has high rates of medical complications. In particular, it is associated with high detrusor pressure, which can lead to ureteral reflux and kidney pathology. Botulinum toxin injection into the urethral striated sphincter can manage detrusor sphincter dyssynergia, reduce voiding pressures, and risks to the kidney. We suggest a modified method for botulinum toxin injections as well as five additional methods to improve reflex voiding outcomes. Finally, the use of intermittent catheterization and reflex voiding for individuals with incomplete spinal injuries, lower motor neuron injuries and multiple scleroses are briefly discussed.

In 50% of typical (nonneurogenic) women, at least one urinary tract infection (UTI) will occur, with cystitis being the most common UTI, with about 25% of patients experiencing recurrence. A factor not currently included in UTI risk models is egress of urine from the bladder into the urethra during bladder filling and activities of daily living. Urinary egress, if it occurs, would shorten the distance that bacteria need to travel to gain access to the bladder. Video urodynamics with contrast medium can demonstrate urinary egress; however, the observations can be difficult to conduct. Egress can be expected to be more likely in women with lower urinary tract conditions such as urge and stress incontinence. Treatment of the incontinence also reduces UTI rates and the reduction could, in part, be due to reduced urine egress. If UTI risk remains after incontinence management, then further treatment with pelvic floor exercises and pessaries could be considered to reduce the risk from potential residual urine egress. In summary, urine egress as a risk factor for UTI needs further research and clinical consideration.

Individuals with spinal cord injury and multiple sclerosis usually use intermittent catheterization for urinary management; however, many patients will also encounter a condition of neurogenic detrusor overactivity, which causes urinary incontinence. The use of muscarinic receptor antagonists is the first-line treatment to manage this condition. These drugs, however, have significant side effects. Transcutaneous electrical nerve stimulation applied to the genital nerve (GEN) is an alternative noninvasive method that produces detrusor inhibition through neuromodulation. Despite studies demonstrating bladder inhibition with GEN, more outcomes are required regarding decreased use of bladder inhibitory medications and concerns with dangling wires. It is proposed that wireless-GEN can be used in home-use studies in order to address these limitations. If needed, wireless tibial nerve stimulation could be added to improve incontinence management.