Pelvic neurophysiology testing uniquely provides an evaluation of the sacral S2, 3 and 4 segmental somatic innervation. Since the tests are involved and some are invasive, a clear clinical question is essential in order to tailor the tests appropriately. Results should always be interpreted in conjunction with the clinical presentation and other investigation findings. The tests provide objective quantitative evidence for nerve injury and there are specific indications where these tests become of paramount importance such as the evaluation of suspected cauda equina syndrome, suspected MSA, chronic urinary retention, pelvic pain, sexual dysfunction and situations where MRI findings are inconclusive. Neurophysiology testing is a useful adjunct to clinical examination, and adds value to the diagnostic workup of patients presenting with neuro-urological disorders.

Aim To present an ICS teaching module on urethral pressure profilometry. This teaching module provides a summary of the evidence base on UPP principles, measurements, and potential clinical applications. Methods This module has been prepared by a Working Group commissioned by the ICS Urodynamics Committee. A comprehensive literature review was performed using modified PRISMA methodology, followed by a review by the members of the Working Group and the ICS Urodynamics Committee core panel. Results The literature review identified 249 publications, of which 81 were accessible, published in English, and involved human subjects. These publications form the evidence base for the preparation of this manuscript. Various UPP technologies have been proposed, each offering distinct advantages and limitations. There is a lack of standardization regarding how UPP is performed and interpreted. Despite these challenges, UPP has demonstrated clinical utility in patients with stress urinary incontinence and dysfunctional voiding. Additionally, UPP has potential research and clinical applications in patients with symptoms that may be secondary to or demonstrate associated “urethral instability” (transient variations to the neural drive to the external sphincter which may result in detrusor overactivity, giggle incontinence, and urethral relaxation incontinence). UPP may also have intra- and peri-operative applications for optimizing urethral closure pressure during or after SUI surgery (e.g. adjustable mid-urethral slings). Conclusions UPP has demonstrable clinical and research utility in pathologies where urethral closure pressure may be transiently or consistently reduced or increased. Technological advances, standardization of data collection and interpretation would increase clinical uptake of UPP as well as potential consideration as an outcome measure for treatments.

Lower urinary tract symptoms (LUTS) may precede or accompany the other symptoms of neurologic disease and may be the presenting clinical manifestations of central, peripheral, or autonomic nervous system dysfunction. In clinical practice, urologists are often the first specialists to evaluate these patients, potentially before underlying neurologic disease has been identified. Early recognition of neurologic contributors to LUTS may help prevent diagnostic delay. This review aims to provide a symptom-based framework that highlights common urologic presentations associated with underlying neurologic disease, along with urodynamic findings of concern, to support earlier recognition of neurological disease in patients presenting with LUTS. Recent work has characterized neurologic diseases associated with LUT dysfunction using disease-based frameworks. Despite this, gaps persist in routine urologic evaluation, including inconsistent screening for neurological symptoms and limited incorporation of focused neurologic history and examination. Certain urodynamic patterns are increasingly recognized as suggestive of neurological pathology but are not consistently interpreted within this context. Barriers to timely neurologic evaluation, including limited specialist availability and prolonged wait times, further contribute to diagnostic delay. As a result, there is growing recognition of the need for urologists to identify clinical features within LUTS presentation that should prompt consideration of neurologic disease, though practical strategies for integrating these insights into routine care remain limited. A symptom-based framework for evaluating LUTS can enhance early detection of neurologic disease in urologic practice. Urologists and pelvic health specialists should have a broad understanding of what clinical characteristics associated with LUTS should trigger concern for underlying neurological disease and should always consider neurological disease in the differential diagnosis. This review provides a practical, clinically oriented overview of neurologic disease in LUTS assessment, including guidance on screening questions, initial testing considerations, urodynamic interpretation, and referral, particularly in the settings with limited neurology access. Algorithms are provided to facilitate early recognition of occult neurological disease within routine urologic practice.

Fowler’s Syndrome is a critically under-researched area of Women’s Urological health. The condition, which causes severe urinary retention in the absence of any obvious obstructive pathology, lacks any non-invasive options for treatment. Transcutaneous Tibial Nerve Stimulation (TTNS) is an established treatment strategy for disorders of incontinence that is non-invasive, safe, and efficacious. Computer based modelling and preliminary animal experimentation indicates that ultra-low frequency TTNS (1–2 Hz) may induce an excitatory effect on bladder function that is of particular therapeutic relevance to Fowler’s Syndrome. Therefore, the present case series describes a three-armed randomised-control (crossover) pilot study conducted from a biomechanical perspective in a population suffering from Fowler’s Syndrome. The study aimed to address the question of if the novel application of low-frequency TTNS could ameliorate the symptoms of Fowler’s Syndrome. Patients (N = 6) were administered either ultra-low frequency TTNS (1 Hz) or placebo. The objective outcome measure of the study was the change in voiding efficiency in response to intervention. 50% (N = 3) participants displayed a positive response to treatment, with a median increase in Voiding Efficiency of 6.3 to 12.6% across test conditions. Two participants displayed a negative response to the intervention, (median −3.6 to −20.9%) which may have been due to placebo effects but should be considered in future. The study indicated that TTNS may be capable of ameliorating the symptoms of Fowler’s Syndrome, to a significant degree in one case. The work provides a foundation for future clinical research. The authors hope that should the results be confirmed by further clinical study they will have considerable impact on patient care.

CONTEXT:Neurological disorders frequently impair the lower urinary tract, sexual, and reproductive function and require lifelong, individualised management. This review summarises the latest update of the European Association of Urology (EAU) Guidelines on Neuro-Urology, highlighting refined terminology, a stronger patient-centred approach, and current diagnostic and therapeutic strategies. OBJECTIVE:To present a summary of the 2026 Neuro-Urology guideline updated using a standardised methodology to provide reproducible evidence for the management of neuro-urology. EVIDENCE ACQUISITION:Recommendations are derived from the updated EAU Neuro-Urology Guidelines following structured evaluation of recent literature and expert panel consensus. Evidence levels, risk-benefit considerations, and patient perspectives informed the formulation of clinically oriented recommendations. EVIDENCE SYNTHESIS:Early risk stratification, urodynamic evaluation, and regular surveillance remain central to preventing complications. Conservative and pharmacological therapies are first-line treatments, whereas minimally invasive and surgical options should be individualised according to neurological status and patient preference. Updated sections reflect refined terminology, integration of patient perspectives, and expanded guidance on urinary tract infection management, neuromodulation, reconstructive strategies, and sexual and reproductive health. Evidence remains heterogeneous, and high-level comparative data are limited for several interventions. CONCLUSIONS:The updated Guidelines emphasise protection of upper urinary tract function, optimisation of bladder dynamics, and shared decision-making within multidisciplinary care. Integration of sexual health and structured long-term follow-up reflects the evolving needs of patients with neurological conditions.

Nature Reviews Neurology is interviewing leading experts who are working at the interface between neurology and other clinical specialties. We spoke with uro-neurologist Jalesh N. Panicker about his work on urogenital dysfunction in people with neurological disease and initiatives to promote collaboration between the neurology and urology fields.

Background and objective: The pudendal nerve (PN) typically arises from sacral roots S2–S4 and gives rise to three main branches: inferior rectal, perineal, and dorsal genital nerves. However, conditions such as pudendal neuralgia and persistent genital arousal disorder exhibit great variability in clinical course and therapeutic responses. Anatomical variation of the PN may contribute to this variability by placing the nerve or its branches in vulnerable positions that lead to compression or traction. This scoping review examined PN anatomical variations to gain a better understanding of their role in pathophysiology and clinical outcomes. Methods: A scoping review was conducted according to the Preferred Reporting of Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews (PRISMA-ScR) guidelines to answer the following research question: What are the anatomical variations of the PN and related structures along its route? Searches were conducted in the MEDLINE and EMBASE databases, with manual screening. Studies on human anatomical investigations of PN variations, regardless of method, were included. Key findings and limitations: The review revealed substantial anatomical diversity in nerve roots, trunk, branches, and related structures, for which detailed schematic illustrations were developed. Limitations include methodological heterogeneity across studies, the predominance of elderly cadaver specimens, and lack of formal quality assessment. Conclusions and clinical implications: Anatomical variation is a key factor in the development and persistence of PN-related conditions. An understanding of this variability is critical for diagnosis, surgical planning, and effective management. This review challenges assumptions of “typical anatomy” and offers context for refinement of decompression techniques and therapeutic strategies. Patient summary: Our study shows that one of the nerves in the pelvis, called the pudendal nerve, varies between individuals. This could explain why standard treatments do not work in some patients and could help doctors to better understand these conditions.

Studies that report an association between anticholinergic medications and dementia often suffer from confounding by indication and rarely consider gender effects. We estimated the association between recurrent prescriptions for anticholinergic overactive bladder (OAB) medications and incident dementia, separately in men and women. We studied patients aged ≥50 years first prescribed an anticholinergic OAB drug (e.g. oxybutynin, solifenacin, tolterodine) during 1998-2019 in England using the Clinical Practice Research Datalink Aurum (CPRD) linked to hospital admissions data. To reduce confounding by indication, we compared patients receiving a second prescription to those only prescribed one during the first year. To reduce protopathic bias, we began follow-up for incident dementia (first diagnosis in CPRD, hospital data or prescription for a cognitive enhancer) first prescription, and censored patients at death, leaving the practice, one month before last data collection, or 31/3/2020. We excluded patients with history of dementia, cognitive impairment, serious central nervous system disorders, severe mental illness, alcohol abuse, or <12 months registration with their GP. We used Cox regression, with age as the time-scale, to estimate hazard ratios (HR) for recurrent OAB prescription and incident dementia adjusted for many socio-demographic and health-related covariates, comorbidities, and concomitant medications, separately in men and women. We also examined risks by drug and cumulative defined daily doses (DDDs). We included 80,874 men and 149,930 women who initiated bladder anticholinergics with ≥3 years of subsequent follow-up. Of these, 83,718 (received only one prescription during the first year. Receiving a second prescription was associated with a greater increased dementia incidence in men (HR = 1.23, 95%CI 1.17-1.29) than women (HR = 1.11, 95%CI 1.08-1.15; p = 0.002 for gender interaction). Associations increased with greater cumulative exposure, with HRs (95%CI) of 1.32 (1.24-1.40) and 1.16 (1.11-1.21) for >6 months of DDDs (vs ≤1 month) for men and women. We observed greater increased rates of dementia for men with recurrent OAB anticholinergic prescriptions than women, and associations were dose-dependent. Prescribers should exercise additional caution in men, and aim for alternative management options or the lowest effective dose and a limited period where possible.

BACKGROUND:People with multiple sclerosis (pwMS) often experience urinary symptoms but may be unaware that they are linked to the disease. The MS Bladder Check self-assessment tool was developed by a multi-disciplinary team of experts to address this issue. OBJECTIVE:To evaluate the usefulness of the MS bladder check tool in raising awareness of urinary symptoms among pwMS and healthcare professionals (HCPs). METHODS:pwMS used the MS bladder check tool prior to HCP consultation and completed a survey to evaluate the tool. HCPs also completed a survey about the tool after their consultations. RESULTS:A total of 503 pwMS and 32 HCPs from France, Italy, Netherlands, Norway, and the United Kingdom completed the MS bladder check tool and the survey. 28.2 % of pwMS recognized current or prior urinary symptoms that were unknown to them; of these, 80.3 % reported that the MS bladder check tool made it easier to discuss urinary symptoms with their HCP. The MS bladder check tool increased awareness of urinary symptoms amongst pwMS and made discussions with their HCP easier. HCPs reported that they would use the MS bladder check tool in their clinical practice and that they would share it amongst their colleagues. CONCLUSION:The MS bladder check tool is of value in clinical practice, empowering pwMS and HCPs to engage in discussions about urinary symptoms with a view to early identification, specialist referral, and optimal intervention.

Aims: Dysfunctional voiding (DV) is characterised by fluctuating or intermittent urinary flow during voiding in neurologically normal individuals. Given the different definitions used and heterogeneous pathophysiologies, outcomes following sacral neuromodulation/sacral nerve stimulation (SNM/SNS) are variably reported. The aim was to identify the areas of research required to be able to accurately predict response to SNM/SNS in adults with DV. Methods The relevant literature was reviewed by a multidisciplinary panel and the findings were discussed at the ICI-RS meeting held in 2025 in the UK. The outcomes of this discussion are presented. Results DV has unique diagnostic features, typically requiring pressure-flow studies and uroflowmetry to establish the diagnosis. Further investigations such as electromyography and urethral pressure profilometry help to better understand the pathophysiology. Phenotyping the lower urinary tract dysfunction helps to identify patterns of abnormalities, and it is likely that certain groups show a better response to SNM/SNS than others, such as in Fowler's syndrome. Older age and change in body weight following implantation are associated with a worse outcome, though not specifically in DV. Studies evaluating the impact of neuropsychiatric co-morbidities on SNM/SNS outcomes show mixed results. Central dysregulation of micturition networks possibly contribute to DV and could represent an additional therapeutic target of SNM. Conclusion Precise phenotyping of individuals with DV integrating clinical, urodynamic, neurophysiological, and neuropsychiatric factors is essential to predict which adults respond best to SNM/SNS. Future research should focus on establishing criteria for patient selection and designing comprehensive prospective interventional studies to assess efficacy and complications.

PURPOSE:The existing literature on the sacral dermatomal evoked potentials (dSEPs) is limited. This study aims to develop stimulating parameters and establish normative values for S2, S3, and S4 sacral dermatomes in healthy adult populations. METHODS:Twenty healthy adult volunteers were enrolled in the study. The study was ethically approved, and written consent for participation was provided. All participants underwent tibial, pudendal, S2, S3, and S4 dSEPs. Stimulating and recorded parameters were established for all evoked potentials. P40 latency, amplitude, and interpeak parameters were calculated for each waveform. A comparison was made between tibial, pudendal somatosensory evoked potentials, and all sacral dSEPs. Normative values were generated for sacral dSEPs based on various height, age, and Body Mass Index (BMI) parameters. RESULTS:The sacral dSEPs were well tolerated and recorded in all participants. S2 latency was mildly influenced by age and height, while S3 and S4 latencies were unaffected by age or height. BMI does not affect the S2 and S3 latencies but mildly affects the S4 latency. Sacral dSEP latencies were comparable with pudendal SEPS but not with the tibial somatosensory evoked potential. CONCLUSIONS:The S2, S3, and S4 sacral dSEPs can be used as diagnostic tools to evaluate sacral nerve lesions such as cauda equina syndrome and Tarlov cysts, complementary to pudendal and tibial somatosensory evoked potentials.

Neurogenic urogenital dysfunction encompasses various urinary and sexual issues resulting from neurological disorders, which significantly impact patients' quality of life. To address these challenges, the European Academy of Neurology (EAN), in collaboration with the European Federation of Autonomic Societies (EFAS) and the International Neuro-Urology Society (INUS), developed the NEUROGED guidelines. These guidelines aim to provide neurologists with evidence-based recommendations for managing neurogenic bladder and sexual dysfunctions. The task force comprised 37 members from 17 countries across four continents, highlighting a comprehensive and collaborative effort. The committee has established evidence-based recommendations for 11 key questions, consensus-based recommendations for eight questions, and good practice statements for 19, addressing the complexities of managing neurogenic urogenital dysfunction. This review seeks to enhance understanding of the NEUROGED guidelines through two sections. The first section examines the neuroanatomy, pathophysiology, and clinical presentation of lower urinary tract symptoms (LUTS) and sexual dysfunction (SD), establishing a basis for the guidelines. The second section explores the impact of the NEUROGED guidelines on the investigation and management of urogenital symptoms, addressing their implementation and potential barriers in clinical practice.

ABSTRACT Aims To explore the boundary of clinical use of sacral nerve stimulation (SNS) in neurogenic lower urinary tract dysfunction (NLUTD), identifying barriers to approval and early‐impact research questions. Methods This review is derived from a proposal discussion at the International Consultation on Incontinence‐Research Society in Bristol in June 2025. Results Current evidence for predicting NLUTD symptom improvement or functional recovery after SNS remains mainly from small retrospective cohorts. Definitive trials are a research priority, accordingly. The influence of SNS on urodynamic parameters is uncertain due to the lack of studies with urodynamics as the primary endpoint. Additionally, there is no core outcome set for NLUTD treated with SNS. Use of closed‐loop SNS in NLUTD to adjust stimulation parameters may improve outcome and device longevity. Hence, we need to elucidate how SNS modulates LUT control network over time and across disease stages. Optimal stimulation parameters need to be defined for patient populations, but also for individuals, with dynamic strategies for adjustment. Use of SNS in NLUTD needs to enable ongoing use of MRI scanning for neurological evaluation, especially in progressive conditions. An MR Conditional SNS device means it can be safely scanned in specific MR environments. Use of such a device needs to factor in the range of further electronic implants that might be used in complex medical conditions. Conclusions The application of SNS to NLUTD is likely to increase. A key aspiration is nuanced patient selection, using functional assessment and urodynamic findings. To translate SNS into standard clinical practice, interdisciplinary collaboration and robust clinical trials are essential.

BackgroundUrinary and sexual symptoms are common following neurological disease, and we aimed to develop multidisciplinary inter-society evidence-based management guidelines.MethodsThe ADAPTE framework was used, and a systematic search of guidelines published in different languages was performed. Guidelines, consensus statements, and systematic reviews were included, and guideline quality was appraised using AGREE II. Patient representatives reviewed the relevance and suitability of recommendations. A modified Delphi process integrating the Evidence to Decision framework adapted from GRADE and the Oxford Centre for Evidence Based Medicine system was used to reach consensus on recommendation wording and strength.ResultsRecommendations were drafted, using guidelines/consensus statements (59 urinary, 50 sexual), systematic reviews (8 urinary, 2 sexual) and others (7 urinary,13 sexual), and wordings/strengths achieved at least 80% consensus through 2 Delphi rounds. Eleven evidence-based recommendations, 19 good practice statements, and 8 consensus-based recommendations were made. Individuals with neurological diseases should be asked about urogenital symptoms and undergo targeted physical examination when appropriate. Urinary symptom assessments include urinalysis, bladder diary completion, and post-void residual volume measurement. Treatments include fluid intake optimization, pelvic physiotherapy, tibial nerve stimulation, and oral medications. Urinary retention is managed by intermittent catheterization. Antibiotics should not be recommended to treat asymptomatic bacteriuria. Suprapubic catheterization is preferred for long-term catheterization. A comprehensive sexual history should be taken, focusing on multidimensional factors affecting sexual health. Treatments include lubricants, vibrators, and phosphodiesterase-5 inhibitors. Red flag symptoms warrant a shared-care approach with specialist colleagues.ConclusionsThe 38 NEUROGED recommendations will guide neurologists to comprehensively manage urogenital symptoms reported by individuals with neurological diseases.

Objectives Hypersexuality involves an inability to control intense, recurring sexual impulses, resulting in repetitive sexual behaviours. It frequently manifests in patients with neurodegenerative disorders such as Parkinson’s disease (PD) and dementia. Using a qualitative approach, this study aims to explore the impact of hypersexuality on spousal carers of patients with PD and dementia.Design Qualitative study using semistructured interviews and thematic analysis.Setting This study was conducted in secondary care settings, including movement disorder and dementia clinics, as well as through patient support organisations. Participants were recruited from multiple centres across the UK. Interviews were conducted in a clinical research setting.Participants Eight spousal carers (five caring for patients with PD, three for patients with dementia) participated in the study. Participants were selected based on their role as primary carers and their experience managing hypersexuality in their partners.Results The thematic analysis identified 12 themes: manifestations, sexual practices, impact, control, emotional formulations, beliefs in causes of hypersexuality and attributions, relationship with the partner, dealing with hypersexuality, coping with hypersexuality, self-image, stigma and professional help-seeking. Hypersexuality altered patients’ sexual cognitions and behaviours, causing distress and strain on carers’ mental health and marital life. Carers struggled to cope with their partners’ hypersexuality, facing emotional burden and barriers to seeking professional help.Conclusions Hypersexuality significantly impacts spousal carers of patients with PD and dementia, affecting their emotional well-being and relationships. Healthcare professionals should recognise and address hypersexuality’s psychological and relational consequences. Psychoeducation, support groups and tailored interventions for patients and carers are recommended to alleviate emotional distress. Future research should explore the broader familial impact of hypersexuality and develop effective management strategies.

Spinal cord injury causes a cascade of physiological responses, which may trigger a subsequent neurotoxic increase in intracellular sodium. This can lead to neurodegeneration, both at and beyond the site of injury, causing clinical symptoms and loss of function. However, in vivo measurements of tissue sodium remain challenging. Here we utilise sodium magnetic resonance spectroscopy (23Na-MRS) at 3T to measure tissue sodium concentration (TSC) and its association with microstructural measures and macromolecular MRI metrics in the cervical spinal cord, distal to the site of injury. Twenty people with cervical myelopathy and twenty healthy controls, were studied. Associations with motor and sensory impairments were explored using ASIA and jOAMEQ scores. No significant difference in TSC in the cervical myelopathy group (39 ± 10 mM) relative to healthy controls (35 ± 13 mM) was found. However, patients had a significantly lower cord-cross-sectional area than controls (70 ± 9 mm2 vs. 82 ± 9 mm2, p < 0.001). Lower-extremity function positively correlated with intracellular volume fraction (p = 0.031). In conclusion, using 23Na-MRS, TSC in cervical myelopathy patients was successfully measured. Differences in TSC relative to healthy controls did not reach significance, despite a significant reduction in cord-cross-sectional area. However, lower intracellular volume fraction, indicating reduced neurite density distal to the site of injury, was associated with physical impairment.

AIMS:After presentation with urinary symptoms, an underlying neurological mechanism sometimes emerges subsequently. Increased awareness may bring earlier diagnosis, improving prognosis and outcomes. METHODS:A 2024 International Consultation on Incontinence Research Society think-tank considered the clinical pathway for identification of an undiagnosed neurological or autonomic contribution precipitating urinary symptoms, and the implications for prognosis. RESULTS:Alongside adult-onset neurogenic conditions, potential for missed diagnosis includes congenital and pediatric-acquired neurogenic conditions, which may become symptomatic during a growth spurt due to spinal cord tethering. Detailed assessment is needed, also considering bowel and sexual dysfunction, with timely referral to neurology to reduce preventable progression of disease. In neurological assessment, control of micturition is often poorly characterized compared with other aspects of spinal cord function and the cranial nerves. Screening tools may be used to identify people who have increased likelihood of particular conditions, but currently available tools are either single-system or population specific. In addition to the general pelvic examination, the assessment of sacral reflexes and pelvic sensations can suggest a neurological mechanism, though the sensitivity and specificity of the neuro-urological examination is unknown. Including the results of the neuro-perineal examination in the urodynamic report may improve the interpretation of the results and potentially support a neurological aetiology. CONCLUSION:Future research should consider the value of neuro-urological examination in diagnosis of occult neurological disease, the development of an occult neurology screening tool/risk scoring based on pelvic organ symptoms, and appropriateness of non-neurologist practitioners requesting neurological investigations such as MRI scanning. CLINICAL TRIAL REGISTRATION:Does not apply.