Neuro-urology addresses neurogenic lower urinary tract dysfunction (NLUTD) resulting from conditions such as spinal cord injury, multiple sclerosis, Parkinson’s disease, and Spina Bifida. NLUTD affects storage and voiding phases, with significant impact on  quality of life (QoL)(1,2). In Belgium, approximately 450 urologists are in practice, of whom an estimated 50 regularly manage patients with NLUTD. Despite international recommendations (3), national guidelines are lacking. This study aimed to evaluate current neuro-urological practices in Belgium, focusing on management of storage and emptying disorders, and to describe practitioner demographics.

A structured questionnaire was developped based on clinical practice and reimbursement criteria and distributed using SurveyMonkey ®. It was sent to all 450 practicing urologists in Belgium via national urology societies and a national neuro-urology discussion group. The questionnaire was disseminated three times over two months to optimize the response rate. Responses were anonymized. The survey explored demographic characteristics and first-line treatment strategies for NLUTD during both storage and voiding phases. Descriptive statistics were used for analysis.

Out of 61 participants, 59 started responding, 42 responded to most questions, and 36 (59%) completed the full questionnaire and actively managed patients with neurogenic bladders. Median age was 42.5 years (IQR: 32.0–64.0); median post-residency experience was 12 years (IQR: 0–33.0).

Geographically, 25 (59.5%) were from Flanders, 13 (31.0%) from Wallonia, and 4 (9.5%) from Brussels. In Flanders, 19 (76.0%) reported seeing more than 10 patients/month, compared to 4 (30.8%) in Wallonia; in Brussels, 3 (75.0%) saw fewer than 10/month. Regarding expertise, 30 (71.4%) gained knowledge during specialization, 24 (57.1%) completed a fellowship, and 20 (47.6%) pursued additional university training. Most attended conferences.

The most common pathologies were suprapontine/pontine lesions (33 [78.6%]), peripheral lesions (34 [81.0%]), spinal cord lesions (27 [64.3%]), and disseminated central lesions (25 [59.5%]). Six (14.3%) treated spina bifida patients.

Concerning urodynamic studies (UDS), 36 (85.7%) urologists had UDS in their centers: 20 (57.1%) used continuous urethral pressure monitoring, 18 (50.0%) EMG patches, 10 (28.0%) provocative tests, and 9 (25.0%) video UDS.

For overactive bladder, Solifenacin was preferred over Oxybutynin (23 [59.0%] vs. 11 [28.2%]). Over 80% considered failure after two anticholinergics and a beta-3 agonist. Then, 35 (90.0%) chose botulinum toxin, and 19 (48.7%) opted for sacral neuromodulation (SNM). Regarding the toxin used, 32 (91.4%) chose Botox® and 3 (8.6%) Dysport®. We noted various management approaches when botulinum toxin treatment fails (see Table 2). Only 10 (25.6%) performed UDS after botulinum toxin injections.

Ultrasound was the preferred imaging for diagnosis and follow-up in 35 (89.7%). Renal function was assessed using creatinine in 22 (56.4%) and cystatin C in 6 (15.3%). Cystoscopic follow-up for indwelling catheters was rare (8 [20.5%]).

While 36 (92.3%) used bladder diaries, only 18 (46.1%) used questionnaires. The International Prostate Symptom Score (IPSS ) was most common (13 [33.3%]), and 3 (7.6%) used the Quality of Life with Urinary Problems for Patients with Neurological Conditions questionnaire (QUALIVEEN).

This study highlights variabilities in the management of NLUTD among Belgian urologists. Key gaps include underuse of advanced diagnostic tools, inconsistent follow-up, and limited use of validated questionnaires. The preference for Solifenacin as first-line therapy, despite reimbursement restrictions in Belgium (limited to second-line use), raises questions about optimal care and cost-effectiveness. The higher number of patients followed up in Flanders compared to Wallonia may point to disparities in healthcare access across regions.

This study reveals heterogeneous practices for neurogenic bladder dysfunction in Belgium, with variations between regions. To ensure optimal outcomes, stricter national recommendations and adherence to evidence-based practices are needed. Encouraging interdisciplinary collaboration and continuous education for urologists could bridge these gaps and improve care for this vulnerable patient population.

Amarenco G, et al. Impact of neurogenic LUT dysfunction on quality of life: A systematic review. Ann Phys Rehabil Med. 2022;65(3):101592
Bonniaud V, et al. QUALIVEEN-30: Validation and clinical utility in neurogenic bladder. Neurourol Urodyn. 2021;40(1):448-456
Blok BFM, et al. EAU Guidelines on Neuro-Urology 2023. Eur Urol. 2023;83(4):387-400