Management of the neurogenic bladder in 413 children

Pediatric Neurogenic Bladder and Bowel Dysfunction: Will My Child Ever Be out of Diapers?

CONTEXT

Managing patient and parent expectations regarding urinary and fecal continence is important with congenital conditions that produce neurogenic bladder and bowel dysfunction. Physicians need to be aware of common treatment algorithms and expected outcomes to best counsel these families.

OBJECTIVE

To systematically evaluate evidence regarding the utilization and success of various modalities in achieving continence, as well as related outcomes, in children with neurogenic bladder and bowel dysfunction.

EVIDENCE ACQUISITION

We performed a systematic review of the literature in PubMed/Medline in August 2019. A total of 114 publications were included in the analysis, including 49 for bladder management and 65 for bowel management.

EVIDENCE SYNTHESIS

Children with neurogenic bladder conditions achieved urinary continence 50% of the time, including 44% of children treated with nonsurgical methods and 64% with surgical interventions. Patients with neurogenic bowel problems achieved fecal continence 75% of the time, including 78% of patients treated with nonsurgical methods and 73% with surgical treatment. Surgical complications and need for revisions were high in both categories.

CONCLUSIONS

Approximately half of children with neurogenic bladder dysfunction will achieve urinary continence and about three-quarters of children with neurogenic bowel dysfunction will become fecally continent. Surgical intervention can be successful in patients refractory to nonsurgical management, but the high complication and revision rates support their use as second-line therapy. This is consistent with guidelines issued by the International Children's Continence Society.

PATIENT SUMMARY

Approximately half of children with neurogenic bladder dysfunction will achieve urinary continence, and about three-quarters of children with neurogenic bowel dysfunction will become fecally continent. Most children can be managed without surgery. Patients who do not achieve continence with nonsurgical methods frequently have success with operative procedures, but complications and requirements for additional procedures must be expected.

Long-term outcome of paediatric spinal cord injury

Background

Spinal cord injuries are relatively uncommon in children and evidence about long-term outcomes is limited. This study was performed to determine the frequency of common long-term complications in patients sustaining spinal injury in childhood (0–18 years) and who were followed up at a single dedicated spinal injuries centre in the UK.

Method

A retrospective review of clinical records of all patients injured at or less than 18 years of age between 1971 and 1999. Complications studied were renal, bowel, musculoskeletal, pressure ulcers and post-traumatic syringomyelia. Long-term social outcomes of independence, employment and driving were also assessed.

Results

Of 69 individuals (47 males, 22 females) the median age at injury was 17 years (range 0–18 y); 68% were older than 13 years at injury and 74% had traumatic injuries. Patients had an average duration of 27 years (12–43 years) of spinal injury – half had a neurological level of T6 and above, 80% had paraplegia and 20% had quadriplegia.

Discussion

Patients with both complete and incomplete spinal cord injury have minimal neurological recovery. Managing medical complications is vital as only 11.5% had normal voiding and 10.6% had normal bowel function. The incidence of skin ulcers increases with duration of spinal cord injury and scoliosis is higher in the non-traumatic injury group. Spasticity is observed in 66.6% and post-traumatic syringomyelia in 11.7%. Long-term social outcomes are good with 75% patients able to do independent care, 46% could drive and 39% managed employment or higher education.

Conclusions

This study documents the long-term outcomes and complications of spinal cord injuries sustained in childhood. With initial active physiological conservative management of the majority of patients, patient education and ongoing support the majority of patients achieved long-term survival and led independent and productive lives.

Study of kidney damage in paediatric patients with neurogenic bladder and its relationship with the pattern of bladder function and treatment received

OBJECTIVES

Kidney failure is the main cause of morbidity and mortality in patients with myelodysplasia. We analysed the presence of renal lesions in these patients using dimercaptosuccinic acid scintigraphy and related their presence with the type of vesical function and the delay in receiving appropriate management.

MATERIAL AND METHODS

We performed a retrospective study of patients with myelodysplasia treated in our hospital since 2004. We analysed the epidemiological and clinical data and the pattern of bladder function according to urodynamic studies. We classified the patients into 4 urodynamic patterns according to detrusor and sphincter behaviour. We linked this behaviour to renal function in the scintigraphy and the care received since birth.

RESULTS

The study included 39 patients with myelodysplasia. The most common bladder pattern was type A (61.5%), with sphincter and detrusor hyperactivity, followed by type D (20.5%), C (7.8%) and B (5.1%). Some 38% of our patients (n=15) had some type of nephropathy. Some 92.9% of the children who were properly treated during the first year of their life had no renal lesions in the scintigraphy. We found some type of nephropathy in 56% of the patients for whom appropriate treatment was delayed for more than a year. The nephropathy was more severe the later the management was started.

CONCLUSIONS

There is a statistically significant relationship between a delay in treatment and impairment in renal scintigraphy in patients with neurogenic bladders. The early study and treatment of patients is essential for decreasing renal impairment, reducing the need for surgery and improving the continence options.

Renal function in children with congenital neurogenic bladder

AIMS

Preservation of renal function in children with congenital neurogenic bladder is an important goal of treatment for the disease. This study analyzed the evolution of renal function in patients with congenital neurogenic bladder.

METHODS

We reviewed the records of 58 pediatric patients with respect to the following attributes: gender, age, etiology of neurogenic bladder, reason for referral, medical/surgical management, episodes of treated urinary tract infections, urodynamics, DMSA scintigraphy, weight, height, blood pressure, glomerular filtration rate, microalbuminuria and metabolic acidosis. Statistical analysis was performed, adopting the 5% significance level.

RESULTS

The mean age at presentation was 4.2 ± 3.5 years. Myelomeningocele was the most frequent etiology (71.4%). Recurrent urinary tract infection was the reason for referral in 82.8% of the patients. Recurrent urinary tract infections were diagnosed in 84.5% of the patients initially; 83.7% of those patients experienced improvement during follow-up. The initial mean glomerular filtration rate was 146.7 ± 70.1 mL/1.73 m²/min, and the final mean was 193.6 ± 93.6 mL/1.73 m²/min, p = 0.0004. Microalbuminuria was diagnosed in 54.1% of the patients initially and in 69% in the final evaluation. Metabolic acidosis was present in 19% of the patients initially and in 32.8% in the final assessment.

CONCLUSIONS

Patient referral to a pediatric nephrologist was late. A reduction in the number of urinary tract infections was observed with adequate treatment, but microalbuminuria and metabolic acidosis occurred frequently despite adequate management.

Neurogenic bladder: etiology and assessment

A review of the various causes of neurologic impairment to the lower urinary tract in children was the aim of this presentation. The emphasis was on diagnosis, pathophysiology, and treatment that strive to maintain as normal a function as possible in order to achieve eventual urinary continence and health of the upper urinary tract. The latest principles based on the most up to date evidence are promulgated but with an eye towards historical prospective. The reader should gain an adequate understanding of various disorders that comprise this condition and feel comfortable with proposing options for management when faced with the responsibility of caring for an affected child.

Selection of the sacral nerve posterior roots to establish skin-CNS-bladder reflex pathway: an experimental study in rats

The purpose of this study was to explore the innervations of different sacral nerve posterior roots to bladder, and to provide evidence for further study of skin-CNS-bladder reflex pathway in the spinal cord injury patient. Spinal cord injury was produced in 10 rats. The bilateral spinal posterior roots of S1-S4 were electrically stimulated, and the bladder plexus action, bladder smooth muscle complex action potential, and intravesical pressure were examined and measured. The results showed that all the sacral nerve posterior roots were involved in innervations of bladder in rats. Among them, the S2 sacral nerve is the dominant nerve in innervations of bladder, followed by S1, S3, and S4 sacral nerve posterior roots. This study has provided valuable information for selection of sacral nerve posterior root for further study of the artificial bladder reflex arc for improving the micturition function in spinal cord injury patients.

Effect of a single-use sterile catheter for each void on the frequency of bacteriuria in children with neurogenic bladder on intermittent catheterization for bladder emptying

OBJECTIVE

The frequency of bacteriuria is high in children with neurogenic bladder on intermittent catheterization for bladder emptying. In an effort to decrease bacteriuria, we examined whether the method of catheter care was responsible for the high rate of bacteriuria. For this, the frequency of bacteriuria was examined in the same patient on single-use sterile catheters and on reused clean catheters.

METHODS

A prospective, randomized, crossover trial was conducted with 10 patients who were randomized to 4 months of a new, sterile catheter for intermittent catheterization and 4 months of reuse of a clean catheter for intermittent catheterization. Each week, a urine sample was collected and symptoms of infection and medication use were recorded.

RESULTS

A total of 158 urine samples were collected during 164 patient-weeks on the new catheter method for each void; 115 (73%) were positive for a pathogen. Of the 161 samples collected during 169 patient-weeks on the standard, reuse method for voiding, 123 (76%) were positive (115 [73%] of 158 vs 123 [76%] of 161). Escherichia coli was the most common pathogen detected during both method periods.

CONCLUSION

A new, sterile catheter for each void did not decrease the high frequency of bacteriuria in patients with neurogenic bladder on intermittent catheterization.

Renal deterioration in myelodysplastic children: urodynamic evaluation and clinical correlates

PURPOSE

We determined which factors portend a higher risk of renal deterioration in the myelodysplastic child, and evaluated the sensitivity and predictive value.

MATERIALS AND METHODS

We retrospectively reviewed the medical history, imaging studies and urodynamics of 90 children with spinal dysraphism. Median patient age at initial evaluation was 3 months and average followup ranged between 2 and 25 years (average 11). We evaluated the relation of urodynamic parameters and sex to upper tract changes and the resolution of these changes.

RESULTS

Statistically significant relationships were identified between the urodynamic parameters of leak point pressure, compliance and detrusor-sphincter dyssynergia, and renal deterioration but not with resolution of deterioration. Boys and girls did not demonstrate a significant difference among urodynamic parameters. Female patients had a higher incidence of reflux and parenchymal loss.

CONCLUSIONS

With knowledge of the inherent sensitivity, specificity and predictive value of urodynamic parameters, selective use of urodynamics will assist in identifying patients at risk of renal deterioration. Female patients with reflux are at greatest risk of parenchymal loss. We advocate early institution of intermittent catheterization in patients identified as high risk for deterioration by urodynamics.

Bacteriuria in children with neurogenic bladder treated with intermittent catheterization: natural history

OBJECTIVE

To determine whether bacteriuria unassociated with symptoms in patients with neurogenic bladder will lead to symptomatic infection and/or deterioration of the upper urinary tract if left untreated, we examined whether bacteriuria persisted in bladder urine of children with neurogenic bladder treated with clean intermittent catheterization (CIC) and whether persistence of bacteria led to symptomatic infection or deterioration of the upper urinary tract.

DESIGN

Weekly home visits were made during 6 months of surveillance of 14 children on the CIC regimen with a normal upper urinary tract and no reflux (as determined by renal ultrasonography, voiding cystourethrography, and serum creatinine measurement). During visits a sample of bladder urine was obtained by CIC, and signs and symptoms of urinary tract infection and all medications were recorded.

RESULTS

Fourteen children were observed for 323 weeks. Cultures of 70% (172/244) of the urine samples collected were positive for organisms (> or = 10(4) colony-forming units per milliliter), 152 (88%) for the usual pathogens and 20 (12%) for commensal organisms. Bacteriuria was associated with pyuria two thirds of the time, regardless of bacterial species. Carriage of the same pathogen for 4 weeks or longer, with associated pyuria, was common during surveillance. Despite frequent episodes of bacteriuria with associated pyuria, there were only five symptomatic infections during the 323 patient-weeks. Children remained clinically well during the study period, and their upper urinary tract did not deteriorate.

CONCLUSION

Bacteriuria persists for weeks in symptom-free children being treated with CIC for neurogenic bladder associated with a normal upper urinary tract. Before attempts are made to eradicate bacteriuria, treatment should be proved to be beneficial to this population.

Use of the fascial sling for neurogenic incontinence: lessons learned

Experience using the fascial sling to manage incontinence in 10 patients with a neurogenic bladder is described. The sling was constructed from rectus abdominus fascia in the first 5 cases. Because of 2 sequential failures attributed to inadequacy of the fascial material fascia lata was used in the last 5 cases. Six patients underwent bladder augmentation concomitant with sling construction. Of the 10 patients 9 were perfectly dry immediately after surgery, although with longer followup several patients became wet. The source of the fascial material used to make the sling did not affect the long-term outcome. Of the 6 patients who underwent augmentation at the time of sling construction 4 remain dry at long-term followup. On the other hand, only 1 of the 4 patients who did not undergo augmentation when the sling was positioned had a good long-term result. Erosion of the fascial sling was suspected in 3 patients who had difficulty with catheterization after surgery. Three patients required bladder augmentation because of changes in detrusor behavior subsequent to sling construction. This series suggests that combining the fascial sling with bladder augmentation appreciably increases the likelihood of achieving dryness and that excessive compression of the urethra by the fascial sling may lead to erosion. The sling, as an isolated procedure for neurogenic incontinence, should only be used in exceptionally capacious compliant bladders.

Sequelae of treatment in 109 patients followed for 5 to 15 years after diagnosis of sarcoma of the bladder and prostate. A report from the Intergroup Rhabdomyosarcoma Study Committee

BACKGROUND

As increasing numbers of young patients with cancer survive, interest in the late effects of therapy is rising.

METHODS

The sequelae of treatment were reviewed after a minimum of 5 years of observation in 109 surviving patients with sarcoma of the bladder or prostate who were enrolled in the Intergroup Rhabdomyosarcoma Studies I and II (1972-1984). The 82 male and 27 female patients were 3 weeks to 19 years of age when the diagnosis was made (median, 2 years) and were 5-29 years of age at last contact (median, 11 years). Treatment consisted of chemotherapy with vincristine, dactinomycin, and cyclophosphamide and bladder irradiation in nearly all patients.

RESULTS

Fifty-four patients underwent total cystectomy, and 10 had a partial cystectomy. Of the 55 patients with bladder preservation, 1 had a urinary conduit with a nonfunctioning bladder. Thus, 54 bladders (50% of the total) remained in place as part of the urinary tract. There was no information regarding bladder function in two patients. Satisfactory bladder function was found in 38 patients (73%), 9 were incontinent, and 5 had urinary frequency with or without nocturia. Posttherapy hematuria was detected in 29% of patients. Nine of the 31 patients (29%) with follow-up renal imaging studies had a structural abnormality, chiefly hydronephrosis, which was more frequent in those with urinary diversion. Positive urine cultures were found mainly among those with enteric urinary conduits, but only two cases of pyelonephritis were documented. Abnormalities of irradiated bone and bowel were observed infrequently. Only one patient had a significantly elevated blood urea nitrogen or serum creatinine value, and only one patient was hypertensive. Most patients were still prepubertal at last follow-up. Of 24 patients who were intrapubertal or postpubertal, 7 (29%) were receiving sex hormone replacement because of delayed pubertal development. Height was decreased by 25% or more in 11 patients, as confirmed by growth chart analysis. Secondary surgical procedures other than repeat biopsy or cystectomy consisted primarily of urinary conduit revisions and repair of bowel adhesions or fistulous tracts. Information about psychosocial status was limited.

CONCLUSIONS

Overall, 50% of the patients retained their bladders, and 73% of them had satisfactory bladder function. Renal function was preserved in nearly every patient.

Follow-up of clean intermittent catheterization for children with neurogenic bladders

Intermittent catheterization remains the primary method of treatment in the management of patients with neurogenic bladders such as those with meningomyelocele. In a follow-up of a previous study, we re-examined the urologic status of patients with neurogenic bladders continuing on a regimen of clean intermittent catheterization five years after the completion of the first study. Thirty-seven of the original 49 patients were available for follow-up, and no significant differences were found between those lost to follow-up and those included in this study. Among the patients re-evaluated, reflux remained unchanged or improved in most patients, renal function was maintained, and the urinary tract infection rate remained low. Additionally, continuation of an intermittent catheterization program does provide independence and social continence in most young adults with meningomyelocele. We conclude that a long-term intermittent catheterization program is associated with stable reflux status, renal function, and infection rate, and that compliance with a catheterization program can result in improved social continence and independence.

Interdisciplinary treatment of spina bifida children

In the Spina Bifida Centre, Niguarda Ca' Granda Hospital (Milan, Italy), from June 1985 to June 1990, 60 spina bifida children have been treated. The results of the rehabilitation programme (including orthopaedic, urological and psychosocial aspects) at the time of the survey were: (a) Neuromotor function: 72% of the patients achieved ambulation, 52% of these being less than 2 years of age, and 20% older than 2 years; 18% were too young for walking. Thus, considering the children's age, about 90% of the subjects achieved the standing position, and 89% achieved ambulation. (b) Bladder function: 83% of the children had a complete urological evaluation; 40% of those with a neuropathic bladder had a hyperreflex type, 54% areflexic, and 6% normoreflexic. Thirty-two percent of the patients had signs of 'high pressure' bladder function. Urinary continence was: 36% > or = 2 hours, 20% < 2 hours, 44% not detectable (age < 2 years). Forty percent of the subjects used intermittent catheterisation. (c) Psychosocial aspect: child adaptation to the disease and to the rehabilitation programme was good in 61% of the patients; family problems were identified in 70% of the patients; enrollment in preschool and school programmes was normal (or with specialist teaching) in about 74%; 33.3% of the subjects had disturbance of affect. The results clearly showed that the interdisciplinary approach favoured the social integration of these children.

Clinical background of patients treated with clean intermittent catheterization in Norway

This study reports on the use of clean intermittent catheterization (CIC) in Norway in 1988/89. A total of 407 adult out-patients was studied. CIC was used in all age-groups and equally in both sex. The patients were divided into five diagnostic groups. There were twice as many patients suffering from neurogenic diseases as non-neurogenic ones. A neurourological index was constructed based on neurological examination and urodynamic data giving a good differentiation and expression of the bladder affection. It appeared that CIC could be performed even by highly disabled persons. A statistically significant correlation was found between the neuro-urological results in patients with decompensated bladder and their over all disability.

Renal scarring and vesicoureteral reflux in children with myelodysplasia

The records of 180 myelodysplasia patients followed from 3 to 18 years were reviewed. Studies included cystography to evaluate vesicoureteral reflux and dimercapto-succinic acid renal scintigraphy to identify acute inflammation and renal scarring. Scarring was noted in 28 of 180 patients (15.5%), of whom 68% were girls. Of the patients with renal scarring 75% had associated reflux and 40% over-all were identified as having reflux. Management of patients with vesicoureteral reflux included clean intermittent catheterization, antibiotic prophylaxis and anticholinergics when indicated. Only 17 of 72 patients (24%) had ureteral reimplantation. Surgical indications included persistent high grade reflux and/or progressive upper tract damage. Reflux resolved in 62% of those on medical management. Resolution was not dependent on grade of reflux (as compared to primary reflux). Twenty-one patients are stable and being followed with persistent reflux. In 7 patients new renal scars developed during aggressive medical management, 5 of whom underwent subsequent surgical correction.

The neuropathic bladder in children with spinal cord injury

The occurrence of spinal cord lesions in children has been reported to be rare. In the literature, there is little information about the management of the neurovesical dysfunction. We report our experience in the treatment of the neuropathic bladder in 18 children with spinal cord injury. The long-term follow-up shows that there is a good recovery and the complication rate is low.

Ureteric re-implantation in the neuropathic bladder

During the last 5 years 174 children with neuropathic bladder were studied, and only 7 required urinary diversions. A total of 31 ureteroneocystostomies were performed in 17 patients, 16 of whom had gross vesico-ureteric reflux. Revisionary surgery was required in four children and two underwent pyeloplasty. Deterioration followed ureteroneocystostomy in two patients, but 13 (76 per cent) of the children were significantly improved.

Vesicoureteral reflux in children with myelodysplasia: natural history and results of treatment

A total of 58 children with myelodysplasia underwent radiographic and cystometric evaluation and were followed periodically for an average of 58 months. Of this group 30 (52 per cent) demonstrated vesicoureteral reflux, including 16 with low grade and 14 with high grade reflux. In 6 children low grade vesicoureteral reflux resolved with prophylactic antibacterials only, while decompressive treatment was required in 6, antireflux surgery was required in 2 and 2 were lost to followup. Despite adequate decompressive treatment 12 of the 14 children with high grade vesicoureteral reflux required an antireflux operation and 2 were lost to followup. Among those who underwent an operation there has been no recurrent reflux but 3 children have shown evidence of upper urinary tract deterioration. We describe our current approach to the treatment of vesicoureteral reflux in children with neurogenic bladder dysfunction and suggest a management protocol based on urodynamic findings.