There is universal agreement that taking a medical history and performing a physical examination should be the first step in the assessment of bladder dysfunction in patients after spinal cord injury (SCI). Thorough history and precise exam are the cornerstones of initial and long-term evaluation in patients with neurological impairment who are suffering from lower urinary tract symptoms.

Medical history should be started with an assessment of the patient’s general condition and should investigate age, sex, ethnicity, cognitive abilities (perception, thinking, reasoning, remembering), behavioral functions (interaction between the person and the environment, social attention), mobility, ability to communicate, cooperation, and psychological status (depression, anxiety, other mood disturbances). The clinician should also assess the influence of SCI on patient’s self-care activities, quality of life, and day-to-day chores.

A more detailed history should document the specific details of time as well as the level and completeness of SCI. It should be conducted with validated methods and standards. The American Spinal Injury Association (ASIA) Impairment Scale (AIS) is a clinician-administered widely used classification to assess the severity (completeness) of injury in individuals with SCI (Table 4.1) [1, 2]. Questions regarding the mechanism of injury may help to identify damaged level. Interview should elicit information regarding extremity weakness, numbness, or paresthesia. Furthermore, patients should be asked about the presence of spine stabilization hardware implanted in the acute phase of injury.

As the first urological consultation of SCI individuals is usually conducted within 2 months of the traumatic accident, the majority of patients are in the stage of spinal shock . This condition appears after suprasacral SCI and usually lasts from 6 to 12 weeks but sometimes can be extended to 1 or 2 years [3]. The duration of spinal shock in patients with incomplete SCI is shorter, sometimes lasting for several days. Muscles are in a flaccid state because of loss of neurological reflexes [4]. Similarly, bladder becomes underactive with disturbed filling sensations and no voluntary control. Therefore, patients present with urine retention managed with intermittent or indwelling catheterization. As spinal shock is not a stable condition and bladder dysfunction will usually evolve to neurogenic detrusor overactivity and/or detrusor-sphincter dyssynergia, only basic urological history should be obtained. Bladder emptying technique and presence of filling sensation should be carefully questioned and documented. The patient should be queried about and then informed regarding the symptoms indicating the end of spinal shock. These include reappearance of bladder sensation, leakage around urethral catheter, or episodes of urinary incontinence between clean intermittent catheterizations, as well as new onset of lower extremity spasms [5]. Patients should be educated about intermittent catheterization (if this has not yet occurred), or catheterization technique should be reassessed. If a urologist presumes terminated spinal shock phase in a patient with suprasacral SCI or consults a patient with sacral/infrasacral injury who presents with urine retention (these patients do not develop spinal shock and usually maintain neurogenic detrusor underactivity), more in-depth evaluation can be conducted at the initial appointment.

Baseline and more in-depth urological investigation is generally performed 3–6 months after the initial injury, by which time spinal shock would have resolved [6, 7]. Questions about urinary symptoms should be subdivided into storage problems (frequency, urgency, nocturia, incontinence), voiding symptoms (hesitancy, straining, poor and intermittent flow), and post-micturition symptoms (sensation of incomplete emptying, post-micturition dribble). The onset and duration of symptoms with severity and degree of bother should also be determined. Patient should be asked about urinary function before SCI, and the information obtained need to be compared with current complaints. In order to maintain professional communication between clinicians, standardized terminology developed by the International Continence Society should be used [8]. Specific urinary history should evaluate bladder sensation and mode of voiding. Interview should elicit information regarding initiation of micturition (normal, precipitate, reflex, strain, Credé) and investigate whether performed by patients themselves or with caretakers. Interruption of micturition (normal, paradoxical, passive) should be revealed. In catheterized patients , the duration of each catheter use before change and the cleaning technique performed (for those using clean rather than sterile intermittent catheterization) should be recorded. Accurate reassessment of catheterization technique is also important. In the presence of urinary incontinence, a thorough history should distinguish stress incontinence, which occurs with increases in intra-abdominal pressure and is usually associated with physical activity, coughing, or straining. Severity of incontinence, both urgency and stress, can be assessed by asking about pad usage, including pad weight, size, number of used pads, and number of urinary incontinence episodes per day. Careful assessment of symptoms indicating possible complications (hematuria, dysuria, fever) should be conducted to rule out comorbid pathology such as malignancy, urolithiasis, or urinary tract infection. It should be noted that SCI individuals may present with other symptoms and signs of urinary tract infection than non-neurogenic patients. In this group, infection within the urinary tract can be manifested by new onset or increase in incontinence; leaking around an indwelling catheter; cloudy urine with increased urine odor; and increased spasticity, malaise, lethargy, anxiety or exacerbation of autonomic dysreflexia [9–11].

Of note, clinicians should be aware that the symptoms of lower urinary tract pathology are subjective and that the perception of their severity is influenced by many factors. Importantly, the severity of symptoms does not always correlate with the magnitude of disease affecting the urinary tract [5, 12, 13]. SCI patients may also lack symptoms because of impaired or altered bladder sensation . Patients might find symptoms difficult to define, such as timing of incontinence and describing whether leakage is associated with urinary urgency or with stress maneuvers like transferring in and out of a wheelchair [5]. Moreover, patients may not be able to reach the toilet in time due to their neurological deficits or poor toilet accessibility. These issues should be investigated.

Patient self-completed and interviewer-administered questionnaires can be a suitable method for assessing the patient’s perspective of bothersome symptoms and their impact on the patients’ quality of life. The utilization of validated questionnaires helps to establish baseline measurements and to quantitate the patient’s response to treatment. Thus, questionnaires should be incorporated in day-to-day clinical practice of SCI individuals. Furthermore, the type of bladder management, considered as the pinpoint of neurourological treatment, has been shown to affect health-related quality of life in patients with SCI [14]. Among a wide variety of questionnaires utilized in patients with neurogenic lower urinary tract dysfunction [15, 16], seven were designed with special attention to SCI individuals (Table 4.2) [17–26] and three instruments (Rick Hansen Spinal Cord Injury Registry Questionnaire, Tetraplegia Hand Activity Questionnaire, Franceschini Questionnaire) are specifically validated in the SCI population [16]. Patients can also be assessed by other generic questionnaires, such as King’s Health Questionnaire (KHQ) or the Short Form 36-item and 12-item Health Survey Questionnaires (SF-36, SF-12) [15]. It is important that the questionnaire of choice should have been validated in the language that it is going to be used. There is no evidence as to which validated questionnaires are the most appropriate for daily practice, therefore each questionnaire can be used alone or in combination with other questionnaires to improve assessment or monitoring of treatment outcomes. Similarly, no evidence was found whether use of these questionnaires has an impact on outcomes from treatment.

Bowel and sexual history is also important because patients with neurourological symptoms may also have related neurogenic bowel and sexual dysfunction [27, 28]. Bowel history should elicit information regarding pattern and frequency of defecation, rectal sensation, desire to defecate and possible episodes of fecal incontinence, constipation, or defecation initiation (digitation, suppository use) [17]. Sexual history should investigate symptoms of genital or sexual dysfunction , presence of sensation in genital area, lack of desire (loss of libido), difficulty in achieving orgasm, possible erectile dysfunction or ejaculation problems (premature, delayed, retrograde, anejaculation) in male or dyspareunia in female.

A wide variety of comorbidities may worsen reported symptoms. Possible related comorbidities include other neurological diseases that may lead to neurogenic bladder (see Chap. 3, “Pathologies Responsible for the Development of the Neurogenic Bladder”), endocrine disorders (i.e., complicated and uncontrolled diabetes, diabetes insipidus), urological conditions (i.e., benign prostatic hyperplasia), respiratory dysfunctions with chronic cough (i.e., chronic obstructive pulmonary disease), fecal motility disorders (i.e., constipation or fecal incontinence), chronic pelvic pain, mobility deficits, prior pelvic surgeries, pelvic cancers, and pelvic radiation. Other details of the medical history should include information of any prior neck or back injuries or surgeries, and history of extensive pelvic procedures (abdominoperineal resection, radical hysterectomy, radical prostatectomy). As SCI-related bladder dysfunction may significantly impair renal function, patients should be carefully asked about previous and present renal disorders, including kidney stones, vesicoureteral reflux, recurrent urinary tract infections, and chronic kidney disease. In women, a thorough obstetric and gynecological history may help to identify concomitant stress urinary incontinence as a consequence of damage of the ligamentous support of the urethra. Patients should be asked about previous surgery for pelvic organ prolapse or incontinence, labor duration, mode of delivery, birth weights of children, year of delivery, intra-partum complications (e.g., obstetric anal sphincter injury, peri-urethral lacerations, wound breakdown), as well as de novo post-partum urinary symptoms.

A carefully conducted medical history is important to ensure that there are no contraindications or risk factors for potential complications with the introduction of future pharmacotherapy (anticholinergics). Conditions to consider include cardiac history, in particular a prolonged QT interval; uncontrolled hypertension; functional gastrointestinal pathology; myasthenia gravis; uncontrolled narrow angle glaucoma; and renal and liver impairment.

The patient should also be asked for the details of current medications, both prescribed and over the counter, as these may worsen reported symptoms. Diuretics and sympathomimetics can cause urgency, frequency, and urgency incontinence [29]. Voiding difficulties can also be caused by drugs with anticholinergic properties (antipsychotics, antidepressants, antihistamines, and anticholinergic respiratory agents), α-adrenoceptor agonists or opiates further described in Chap. 8, “Retention” [30]. Potential allergies, particularly for latex, should be investigated.

The history is completed only when the patient’s social situation has been assessed. SCI individuals can be dependent on caregivers for their basic activities of daily living. Accessibility to care, toileting, and supplies may be limited by financial constraints or other social factors. Home health support systems as well as access to school/work/recreation should be evaluated. Strong concerted efforts with social workers may sometimes be required to improve these patients’ prognosis.