First consultation of patients with spinal cord injury (SCI) should include bladder management counselling and follow-up planning. Both activities depend on the time of consultation and the previous clinical findings.

Urological care is an important part of the holistic care of SCI patients, as urological complications of SCI can be devastating and develop silently. Counselling in terms of bladder management is of utmost importance for these patients’ prognosis and future quality of life. However, there is a paucity of high-quality evidence in this area [1]. To overcome this serious issue, the Spinal Cord Injury Think Tank Group from the United Kingdom developed a specific SCI management guideline to support clinicians in their day-to-day clinical practice. Table 6.1 summarizes these recommendations [1]. Due to a lack of reliable data, the recommendations presented have been mainly based on expert opinion and divided into four stages.

Patients after SCI should be educated regarding bladder management at the time of discharge. This helps to avoid complications and results in improvement of long-term care. Unfortunately, available data suggest that less than 50% of these patients have proper knowledge regarding bladder management after being discharged [2]. Therefore, it seems to be necessary to adequately inform and educate clinicians and other community health professionals in terms of the impact of bladder management on these patients’ prognosis and future quality of life [3]. It has been shown that systematic teaching and learning strategy based on educational booklets directed to caregivers can be a substantial support in reaching the goals of treatment [4]. Patient education has been further described in Chap. 17, “Patient Education.”

Proper follow-up monitoring of SCI patients suffering from neurogenic lower urinary tract dysfunction has multiple goals. This helps to prevent irreversible changes within the urinary tract and includes, but is not limited to [5, 6]:

The outcomes of SCI patients with neurogenic bladder (NB) dysfunction have improved in the past decades. During that time urological complications, in particular renal failure and urosepsis, were the leading cause of death in SCI [7, 8]. Improvements in follow-up monitoring, bladder management strategies, and treatment of complications have virtually eliminated neurogenic bladder-related mortality in developed countries and significantly contributed to increasing the lifespan of these patients [9]. Nowadays, leading causes of death in a group of SCI patients have been reported as pneumonia and influenza, septicemia, cancer, ischemic heart disease, and suicide [10].

Nonetheless, no consensus exists on the optimum frequency of follow-up evaluation in SCI patients with NB [11]. Furthermore, there is no agreement on the specific type of tests that should be performed [9]. Currently available recommendations vary and they are mainly based on expert opinion. There is a paucity of high-quality evidence to support an optimal long-term follow-up protocol. Additionally, there is a lack of evidence on clinical outcomes when different guidelines had been strictly followed [12].

The Spinal Cord Injury Think Tank Group proposed yearly ultrasound assessment of upper and lower urinary tract with measurement of post-void residual volume when possible [1]. Kidney function should be assessed with creatinine clearance and serum creatinine levels at about 12 months, when body muscle mass has been stabilized. Then, renal evaluation should be performed annually based on the serum creatinine level as a single test. Urodynamic study should be repeated as clinically indicated. These include jeopardy of upper urinary tract, recent occurrence of incontinence, previous diagnosis of detrusor-sphincter dyssynergia with sustained raised vesical pressure or low compliance (signifying a rise in pressure with ongoing bladder filling), change in bladder management (before and after introduction of the treatment modification), onset of urinary tract infections (UTIs) or stones, and presence of vesicoureteral reflux or high post-void residual. The Group did not support regular urine testing, as the results are confusing and lead to overtreatment of clinically unimportant bacteriuria. Authors also stressed that urologists who take care of SCI patients should be aware of all responsibilities related to the patient’s overall care, including bowel and sexual dysfunctions, pressure sores, pain, muscle spasms, and deteriorating neurological status.

The Veterans Health Administration Group [13] proposed that the annual evaluation of the genitourinary system needs to include urinalysis, culture with sensitivity, serum creatinine, blood urea nitrogen, assessment of upper tract function with an anatomical test (e.g., abdominal ultrasound) and/or an evaluation of function (e.g., creatinine clearance, renal scan). Diagnostic tests such as computed tomography and intravenous pyelogram should be ordered only when clinically indicated. Surveillance using cystoscopy, cytology, and random bladder biopsy should be performed on a regular basis at the SCI center. Indications for urodynamics during follow-up include deterioration in renal function, anatomical changes in the upper tract (e.g., hydronephrosis), recurrent autonomic dysreflexia of unknown etiology, and urinary incontinence in the absence of UTI. Authors emphasized that standard medical history and physical examination (evaluating symptoms and signs) are not sensitive in screening for high intravesical pressures, thus showing the importance of urodynamic surveillance, when indicated.

The National Institute for Health and Care Excellence Guidelines recommended that lifelong ultrasound surveillance of the kidneys should be offered to people who are judged to be at high risk of renal complications (at annual or 2-year follow-up) [14]. High-risk groups have been defined as patients with SCI or spina bifida and those with worrisome findings on urodynamics (impaired bladder compliance, detrusor-sphincter dyssynergia, vesicoureteral reflux). Moreover, urodynamic investigation as part of a surveillance regimen should be considered in these groups of patients. Of note, authors did not recommend plain abdominal radiography, cystoscopy, and renal scintigraphy for routine surveillance. If an accurate measurement of glomerular filtration rate is required, it should be supported with isotopic techniques. Physicians were advised not to rely on serum creatinine and estimated glomerular filtration rate in isolation for monitoring renal function.

The expert panel of the first International Neuro-Urology Meeting concluded that non-invasive urodynamics must be part of a routine follow-up of SCI patients, as only the results of these investigations allow the timely detection of risk factors before irreversible damage has occurred [12]. Silent deterioration in bladder dysfunction is not uncommon. Retrospective data on patients with incomplete SCI have shown that more than two-thirds of ambulatory patients experienced silent deterioration of bladder function on urodynamics during long-term follow-up [15]. Changes in bladder dysfunction may also occur even though there may be no change in overall symptoms [16]. This emphasizes the importance of regular urodynamic follow-up.

Guidelines on neurourology developed by the European Association of Urology recommended regular follow-up with time intervals based on the type of neurogenic lesion and dysfunctional pattern [17]. The timespan should not be longer than 1–2 years. Special consideration of high-risk patients, particularly those with SCI, stressed that the proposed interval should be much shorter in this specific group of patients. Renal ultrasound should be performed every 6 months, whereas physical examination and urine laboratory should be conducted every year. Urodynamic investigation was recommended at regular intervals but authors did not specify precise time spans. Any significant clinical changes should be further investigated with adequate methods and recommendations.

Other proposals include 6-month follow-up monitoring during the first 2 years with the full range of clinical tests, in particular with urodynamics and ultrasound [18]. Over the subsequent 5 years, 1-year follow-up monitoring should be conducted. After that, in the following 8 years , 2-year follow-up monitoring should be employed. The utilization of specific tests depends on the current clinical situation, previous findings, and presented risk factors. Regular urodynamic checkup of SCI patients can detect changes in compliance and pressures resulting from increase in detrusor-sphincter dyssynergia before symptoms occur. Therefore, presented abnormalities can be diagnosed in time before possibly irreversible changes in the urinary tract have occurred. After 15 years, clinical and ultrasound-based assessment should be conducted every 2–5 years.

When discussing urological surveillance of SCI patients suffering from NB, special attention should be given for cystoscopic evaluation . As the exact mechanisms of increased risk of bladder cancer in SCI patients have not been well analyzed, strong recommendations cannot be provided. One proposal includes follow-up monitoring every year in patients who have one or more of the following risk factors: smoking and age >50 years, enterocystoplasty or any augmentation cystoplasty over 10 years, any neurogenic bladder over 15 years [18]. Evaluation should be performed with urethrocystoscopy and biopsy, if required. Another proposal stated that urethrocystoscopic monitoring in high-risk patients with indwelling catheter is essential to diagnose and manage complications at an early stage [19]. Importantly, this study has shown that endoscopic findings do not significantly differ between symptomatic and asymptomatic groups. This reinforces the hypothesis that patients with indwelling urethral catheters or suprapubic tube require regular cystourethroscopic surveillance in order to diagnose and manage complications at an early stage. Interestingly, similar findings between symptomatic and asymptomatic patients have been reported with regard to ultrasound surveillance [20].

Readers should be aware that proposed schedules can be modified by presentation of other risk factors, emerging complications, or the patient’s compliance with treatment.

A recently published systematic review, analyzing long-term urological follow-up strategies for patients with NB, reported 13 studies related to individuals after SCI [12]. Apart from their recommendations, the review mentions other methods of investigation that may be included in urological surveillance of SCI patients: urography, computed tomography, magnetic resonance imaging, 24 h endogenous creatinine clearance, and 99 mTc-DTPA clearance of creatinine (renal scintigraphy). The utilization of these tests depends on clinical indications. However, the majority of included studies were retrospective, without a control group, and with different time intervals and primary/secondary outcomes. To make matters worse, some of the included studies described interventions that were performed only once, and thus did not form an established surveillance program. As a result, reliable conclusions and recommendations have not been made due to the low quality of the evidence.