Clinical decision making in patients with neurogenic bladder: Development of a Neurogenic Bladder Severity Score.
William W. French, BS, Shuvro DE, MD, Abby S. Taylor, MD, Stacy T. Tanaka, MD, John C. Thomas, MD, John C. Pope, IV, MD, Mark C. Adams, MD, John W. Brock, III, MD, Chevis N. Shannon, DrPH, Douglass B. Clayton, MD.
Vanderbilt University Medical Center, Nashville, TN, USA.
Background: Uniformity in urodynamic (UDS) interpretation is challenging and results in significant interrater variability. We seek to investigate the factors driving decision making when concern for renal and bladder health arises during UDS. Thus, we present a Neurogenic Bladder Severity Score (NBSS) that strives to numerically capture the overall clinical picture at the time of individual UDS studies. We hypothesize that increasing NBSS correlates with need for escalation of medical or surgical care in patients with neurogenic bladder.
Methods: We performed an IRB-approved retrospective review of consecutive patients with neurogenic bladder undergoing videourodynamic studies (VUDS) at our institution from 12/2016 to 1/2018. We developed a NBSS by collecting variables from the chart at the time of UDS and dichotomizing the variables for simplicity. Table 1 shows the variables that comprise the NBSS (max score 14). The primary outcome of interest was the clinician’s decision to escalate bladder management after UDS due to concern for renal and bladder health. We did not consider a change in management for continence alone in this study. Thus we identified two groups, a Change group and a No-change group. Escalation of care included initiating CIC with or without anticholinergic therapy, Botox injection, surgery, or maximizing anticholinergic treatment. Statistical tests included non-paired Mann Whitney U test and Fisher’s exact test for examining univariate factors. We also performed binomial logistic regression to assess the combination of factors that contribute to decision making.
|Table 1: Factors Comprising Neurogenic Bladder Severity Score|
|Variable||1 Point each||0 Points|
|Oral and/or Intravesical Antibiotics||Present||Absent|
|Clean Intermittent Catheterization||Present||Absent|
|Use of Anticholinergic medication||Present||Absent|
|Prior Botox therapy||Present||Absent|
|Cystometric Bladder Capacity||< 75% Expected||≥ 75% Expected|
|Slope of the Cystometric Curve||Rising||Flat|
|End Fill Pressure or Detrusor Leak Point Pressure||≥ 40 cm H20||< 40 cmH20|
|Bladder Neck Appearance||Closed||Open|
Results: We reviewed VUDS and the associated clinic note from 96 patients with neurogenic bladder during the study period. 79% had spina bifida with the remainder having other neurologic lesions (cerebral palsy, primary tethered cord, lipomyelomeningocele, spinal cord injury). Median age at the time of the UDS was 4 years (95% CI 3.88 - 5.11). Clinician notes on the day of UDS revealed that concern for renal/bladder health prompted a change in management in 25/96 (26%) patients. The mean NBSS in the entire study population was 3.8 (95% CI 3.4 - 4.35), and we found significantly higher mean NBSS scores in the Change group as compared to the No-change group (6.16 v. 3.35, p < 0.0001, 95% CI -3.69 - -1.92). Univariate analysis revealed multiple significantly different variables between groups (Table 2). Logistic regression revealed that bladder trabeculation, presence of current antibiotic use were statistically significant factors while detrusor overactivity trended toward significance (Table 2).
|Table 2: Factors Associated with Escalation of Care|
|Variable||Univariate Analysis p-value||Multivariable Analysis p-value (OR, 95%CI)|
|Trabeculation||< 0.0001||0.022 (16.73, 2.91-96.06)|
|Oblong Bladder||0.0048||0.857 (0.88, 0.21-3.73)|
|Detrusor Overactivity||0.0160||0.079 (3.39, 0.87-13.18)|
|Rising Slope of UDS Curve||0.0097||0.111 (3.40, 0.75-15.41)|
|Hydronephrosis||0.0322||0.396 (2.12, 0.37-12.09)|
|Pressure > 40 cm||0.0022||0.344 (2.06, 0.46 - 9.20)|
|Antibiotic use||0.0885||0.042 (5.84, 1.07-32)|
|On CIC||0.0363||0.154 (3.32, 0.64-17.26)|
Conclusion: Not surprisingly, a host of clinical and UDS parameters contribute to decision making in patients with neurogenic bladder. In this pilot study, we find that an NBSS scoring system could distinguish patients more likely to require a change in management and that the combination of trabeculation, antibiotic use, and detrusor overactivity seemed to play a greater role in decision making.
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