Clean intermittent catheterization in the management of the neurogenic bladder in children

Asymptomatic bacteriuria and antibiotic resistance profile in children with neurogenic bladder who require clean intermittent catheterization

STUDY DESIGN

A retrospective cohort study.

OBJECTIVES

To document the prevalence of asymptomatic bacteriuria and to characterize the resistance patterns to antibiotics among children with neurogenic bladder who require clean intermittent catheterization, with an emphasis on multidrug resistance.

SETTING

A national referral pediatric and adolescent rehabilitation facility in Jerusalem, Israel.

METHODS

Routine urine cultures were collected before urodynamic studies in suitable individuals during 2010-2018. None of them had symptoms of urinary tract infection at the time of specimen collection. Cultures were defined as being positive if a single bacterial species was isolated together with a growth of over 10⁵ colony-forming units/ml. Resistance patterns were defined as extended-spectrum beta-lactamase (ESBL) and resistant to 3 antimicrobial groups (multi-drug resistant, MDR).

RESULTS

In total, 281 urine cultures were available for 186 participants (median age 7 years, range 0.5-18). Etiologies for CIC included myelomeningocele (n = 137, 74%), spinal cord injury (n = 16, 9%) and caudal regression syndrome (n = 9, 5%). Vesicoureteral reflux was diagnosed in 36 participants (19%), 14 of whom were treated with prophylactic antibiotics. Asymptomatic bacteriuria was present in 217 specimens (77%, 95%CI [0.72-0.82]). The bacteria species were E. coli (71%), Klebsiella (13%), and Proteus (10%). ESBL was found in 11% of the positive cultures and MDR in 9%, yielding a total of 34 (16% of positive cultures) positive for ESBL and/or MDR bacteria.

CONCLUSIONS

Asymptomatic bacteriuria and resistance to antimicrobials are common in pediatric individuals who require CIC.

Choosing the Right Catheter for Pediatric Procedures: Patient Considerations and Preference

Determining the need for bladder decompression and urinary diversion in the perioperative pediatric surgical patient can cause a clinical conundrum for the surgical team. Add in the several different types of urinary diversion devices possible, and the various materials associated therein and the process can suddenly seem unnecessarily daunting given the lack of concise recommendations and broad consensus. The decision to divert urine, though seemingly trivial, is associated with inherent risks. Managing and mitigating certain risks are best approached through proper education, selection, and technique. We provide a broad overview of pediatric catheter selection, indications, and pitfalls to streamline the process so that energy and attention can best be focused on the planned intervention at hand.

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 outcomes of the Kropp and Salle urethral lengthening bladder neck reconstruction procedures

INTRODUCTION

The Kropp and Salle procedures have shown good short-term outcomes for managing neuropathic urinary incontinence. However, few studies have assessed their long-term results.

OBJECTIVE

This study aimed to evaluate the long-term outcomes of Kropp and Salle procedures, including: dryness, secondary interventions for incontinence or complications, upper urinary tract changes, and use of urethral catheterizations.

STUDY DESIGN

Consecutive patients undergoing Kropp and Salle procedures at the present institution (1983-2012) were retrospectively reviewed. Patients with <1-year follow-up or prior bladder neck (BN) continence procedures were excluded. Data were collected on postoperative dryness per urethra at 4-hourly and 3-hourly intervals, secondary interventions, lab tests, and imaging. Non-parametric tests were used for statistical analysis.

RESULTS

Thirty-eight patients had Kropp (K: 30 boys) and 12 had Salle procedures (S: 8 boys). Patients underwent surgery at similar median ages (K: 7.4 vs S: 8.7 years old, P = 0.51) and had similar median follow-up (6.9 vs 10.3 years, P = 0.10). Most patients had myelomeningocele, a prior/concomitant bladder augmentation (K: 73.7%, S: 58.3%) and catheterizable channel (K: 81.6%, S: 50.0%). Differences in all outcomes between Kropp and Salle procedures were statistically non-significant. The majority of patients did not have additional BN procedures for dryness (K: 84.2%, S: 66.7%). Of this group, K: 81.3% and S: 75.0% were dry for ≥4 h, K: 93.8% and S: 87.5% were dry for ≥3 h between catheterizations (Table). Of the minority of patients who underwent additional BN procedures for dryness (K: 15.8%, S: 33.3%), most achieved dryness for ≥4 h (K: 66.7%, S: 100%) and ≥3 h (100% for both). Among patients without an initial catheterizable channel, 57.1% had one subsequently created after a Kropp procedure, and 33.3% after a Salle. Among patients without bladder augmentation, approximately half underwent delayed augmentation (K: 50.0%, S: 40.0%). Ultimately, most patients required a secondary intervention under anesthesia for incontinence or complications (K: 79.0%, S: 66.7%). Few patients developed worsening hydronephrosis, vesicoureteral reflux or renal function (K: 2.6%, S: 0.0%). At the end of follow-up, few patients catheterized per urethra (K: 10.5%, S: 33.3%).

DISCUSSION

This was a retrospective study without urodynamic data. Originating from a tertiary center, the results may not apply to other clinical settings.

CONCLUSIONS

At the present institution the Kropp and Salle procedures attained similar dryness in 75-81% at 4-hourly intervals and 88-94% at 3-hourly intervals without additional BN procedures. Few patients required subsequent BN procedures to achieve dryness. However, the overall need for secondary procedures during long-term follow-up was high for both procedures.

Therapeutic education and intermittent self-catheterization: recommendations for an educational program and a literature review

PURPOSE

To review the literature and to clarify the recommendations for therapeutic education programs for intermittent self-catheterization.

MATERIALS AND METHODS

The literature on Medline, Pubmed, and Cochrane Library, with specific keywords, as well as the recommendations based on expert consensus.

RESULTS

Clean intermittent self-catheterization (CICS) is the gold standard for managing chronic urinary retention, which allows the patients to improve their quality of life and to reduce the complications of upper urinary tract infections. Patient education needs to have a structured procedure in order to evaluate the ability to understand, accept and perform CISC.

CONCLUSION

Teaching self-catheterization is now well known; nevertheless, the effectiveness of CISC educational therapeutic programs remains to be demonstrated.

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.

Dysfunction of the lower urinary and distal gastrointestinal tracts in pediatric patients with known spinal cord problems

Destruction of the urinary tract in children with elimination, storage, and holding dysfunction of the lower urinary and the distal GI tracts is caused primarily by high intravesical pressure. UTI accelerates this process. The LPP and the status of the urethral control mechanism and its relationship to the detrusor are the primary determinants of intravesical pressure. Intravesical pressures of more than 40 cm H2O are dangerous because they cause a pressure gradient that is transmitted proximally to the renal papillae, which results in the cessation of renal blood flow and a loss of renal function over time. Hydroureteronephrosis, VUR, UTI, urinary incontinence, and calculi formation also may occur. If these dangerously high intravesical pressures remain untreated, renal failure is likely to occur over time. These children then require dialysis or renal transplantation to survive, which is tragic and represents an enormous economic cost to society. Renal failure and upper urinary tract damage is nearly 100% preventable with early and appropriate evaluation and treatment. CIC is a crucial part of the management of these children and has been shown to be safe and effective, even in newborn boys. The use of the Credé maneuver (i.e., manual compression) to empty the bladder is obsolete and should be abandoned. The distal GI tract is inseparable from the lower urinary tract and must be treated simultaneously. Failure to treat the distal GI tract yields poor clinical results and much patient dissatisfaction and makes it difficult or impossible to treat the child's urinary tract problem successfully. Bowel-management programs must include daily high water and fiber intake, together with digital perianal stimulation or fecal extraction. Neuropathic bladder and bowel problems that are intractable to conservative medical and mechanical (i.e., CIC and digital perianal stimulation or fecal extraction, respectively) management almost always can be corrected surgically with high success rates in cooperative patients. Finally, neuropathic bladder and bowel problems can be extremely isolating and debilitating problems. Psychologic counseling and emotional support must be provided as needed. The care that these patients receive must be organized, comprehensive, and correlated with these patients' lifestyles. If these children are evaluated and treated early, they have the potential to live long, healthy, and productive lives.

School-aged children with spina bifida in Western Australia--parental perspectives on functional outcome

A questionnaire mailed to the parent(s) of all 86 school-aged children with spina bifida resident in Western Australia in 1992 who were attending a spinal dysfunction clinic or were members of the Spina Bifida Association was returned by 72 parents. All 72 of these children (55 with myelomeningocele, 17 with meningocele) lived at home with their parent(s). All but two children with meningocele were mobile without aids, whereas only 42% of the children with myelomeningocele were. Twenty one per cent of the children were naturally continent of urine day and night, and 36% were naturally continent of faeces. 76% attended a mainstream school although performance at school was rated below average for 40%. Nine children with meningocele (56%) and 42 with myelomeningocele (76%) were reported to have learning difficulties. This information will be useful in counselling parents of unborn and newborn children with spina bifida, and in allocating resources for children and young adults with spina bifida and their families.

The determinants of successful self-catheterization programs in children with myelomeningoceles

Myelomeningocele is a birth defect that results in lifelong consequences for the child and family. One of the abnormalities that results from the defect is a neurogenic bladder. Most children with myelomeningoceles will require a clean intermittent catheterization (CIC) program for continence. Yet, many children do not have success with these programs. The purpose of this report is to identify in the literature components of a successful self-catheterization program. The importance of proper urinary management in children with myelomeningoceles will be discussed. Physiological, developmental, and motivational qualities that are present in successful self-catheterization programs will be identified. The importance of knowing when the child is ready to learn, how to know when the child is ready to learn, and different styles of teaching self-catheterization will be discussed. Finally, nursing implications for children on CIC programs will be described.

Renal rupture after the Credé maneuver

We report a case of renal rupture with development of a large perinephric urinoma and deterioration of renal function after the Credé maneuver in a girl with neurogenic bladder and detrusor sphincter dyssynergia without vesicoureteral reflux. After percutaneous drainage of the urinoma, management was changed to clean intermittent catheterization, and renal function returned to normal. We recommend that the Credé maneuver not be used in children with neurogenic bladder and nondenervated urethral sphincter.

Adventitious knots in urethral catheters: report of 5 cases

Urethral catheterization with 5 or 8F feeding tubes in 5 boys was complicated by stochastic knotting within the bladder thereby impeding removal. The common factor in these patients was insertion of excessive length within the bladder. Percutaneous endoscopic retrieval was done successfully in 1 child. This technique may avoid urethral trauma associated with catheter removal, particularly in younger boys.

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.

Bowel and bladder control of children with myelomeningocele: a Nordic study

The urinary and bowel control was studied of 527 children with myelomeningocele aged between four and 18 years. Information was obtained from medical records and by parent questionnaire. 44 had normal urinary control, 50 had a urinary diversion and the remaining 433 had neuropathic bladder without urinary diversion, of whom 31 per cent expressed their bladder manually and 40 per cent used clean intermittent catheterisation (CIC). 60 per cent needed assistance emptying their bladder. Children using CIC were more continent and needed less help, but were more often treated with antibiotics. Of the 527 children, 412 had disturbed bowel control. 212 evacuated their bowels manually, of whom 90 per cent needed assistance. Parents judged urinary incontinence to be very stressful for 37 per cent of the children and faecal incontinence for 33 per cent. The authors conclude that social urinary continence should be defined as the ability to keep dry for three hours or more.

Management of urinary incontinence by bladder tube urethral lengthening and submucosal reimplantation

We reviewed the first 25 urethral lengthening and reimplantation procedures done at our institution in 24 patients. All patients had failed to achieve dryness on medical or surgical therapy for total urinary incontinence. A total of 32 patients had neurogenic incontinence. The patients were followed for 1.5 to 7 years. Late complications included catheterization difficulties, vesicoureteral reflux, febrile urinary tract infection, calculi and peritonitis. Reoperations were required in 19 patients primarily because of our initial failure to recognize the necessity of providing a low pressure, high capacity reservoir. The reoperation rate on the continence mechanism was low. Of 24 patients 20 are continent and require no pads or diapers.

Urethral false passage as a complication of intermittent catheterization

Intermittent catheterization is used commonly to treat bladder dysfunction. We treated 10 patients who were experiencing difficulty with intermittent catheterization, 9 of whom had a false urethral passage. Of these patients 6 had previously undergone a bladder neck or urethral operation. Endoscopy was helpful to diagnose the condition. Treatment consisted of stenting in 3 patients, transurethral incision and stenting in 3, and fulguration and stenting in 4. An indwelling catheter was left in place for 2 to 3 weeks, after which intermittent catheterization was resumed with a softer catheter. Two patients again experienced severe difficulty with catheterization and they underwent a continent urinary diversion. When intermittent catheterization becomes difficult or impossible, the presence of a urethral false passage should be suspected as a possible cause.

Disability in children with myelomeningocele. A Nordic study

This study was carried out to evaluate the medical impairments and disability among 527 children with myelomeningocele living in four Nordic countries. The information was extracted form questionnaires and data based on case records. The level of intellectual functioning was fairly high with 76% within normal range (IQ greater than 90). Shunt operations were performed in 68% of the children and 1/3 had had four or more shunt revisions. Twenty-three per cent walked without support. Bladder incontinence was found in 60% of the children whereas 4% were entirely continent. Intermittent catheterisation was used in 36% with higher frequency among girls (48%) than boys (24%). We found a higher incidence of bacteriuria among those who used catheterisation than among those who used manual compression. Bowel control was experienced by 112 (21%) of the children. The overall disability is classified according to Lorbber's 5-graded handicap scale and Lagergren's 3-graded scale. According to Lagergren's scale, 70% suffered form severe overall disability.

The evolving uroradiographic evaluation of the lower urinary tract in neonates with myelomeningocele

Radiographic cystography (VCUG) has been advocated to detect dynamic and anatomic abnormalities of the lower urinary tract in the neonate with myelomeningocele (MM). We reviewed the VCUG in 120 neonates and the radionuclide cystograms (RNC) or cystometrograms (RNCMG) in 30 neonates to reevaluate the role of cystography in this population. Surgery was not required to treat the anatomic abnormalities detected by VCUG. The absence/presence of reflux and a bladder residual volume of greater than 15 cc were the two most important criteria in determining the neonatal voiding regimen. Because RNC provides this information equally well with a much smaller radiation dose and because of the additional functional information available from RNCMG, we now recommend that RNC or RNCMG be used to evaluate the lower urinary tract of neonates with MM.

Management of vesico-ureteric reflux in myelodysplasia neurogenic bladder

During the period 1978-87, 22 patients with myelodysplasia had surgery for vesico-ureteric reflux (VUR) and seven patients with VUR were managed non-operatively. Clean intermittent catheterization was an integral part of the management in both the operated and non-operated cases. The majority of patients had reflux-related upper tract changes pre-operatively, but after operation the urinary tract was stabilized in all but one kidney which was lost. Transverse advancement ureteric reimplantation or the pull-through technique provided satisfactory results, giving a total of 29 refluxing units managed surgically.

Combined bladder augmentation and bladder neck suspension for neuropathic incontinence in girls

We treated five girls with congenital neuropathic bladder, who had genuine stress incontinence combined with reduced detrusor compliance and/or detrusor hyperreflexia, by simultaneous Marshall-Marchetti-Krantz bladder-neck suspension and bladder augmentation using a sigmoid or ileocecal pouch. All are dry on 3 to 4 hourly intermittent self-catheterization and we suggest that this method represents a useful and much cheaper alternative to the artificial urinary sphincter.

Long-term renal risk factors in children with meningomyelocele

We studied renal function and structure in 42 patients with meningomyelocele, 28 treated with intermittent catheterization and 14 with ileal loop diversion. Patients were observed for a minimum of 60 months. Nine of the 28 patients who underwent intermittent catheterization had evidence of unilateral or bilateral reflux, and all patients with ileal loop diversion had free ureteral reflux. Bacteriuria was present in 38% +/- 5% of cultures obtained from patients with catheterization and in 70% +/- 7% of cultures from those with diversion (P less than 0.001). Four (14%) of 28 patients with catheterization had worsening renal function or anatomic appearance by intravenous pyelogram, and required a diversion. Three (28%) of 14 patients with diversion had changes in renal structure or function. Eight of 31 patients from both groups studied with voiding cystourethrography before the onset of therapy had small, noncompliant, trabeculated bladders; all seven patients who had worsening in function or anatomic appearance were from this subset (P less than 0.01). None of the patients with flaccid or distensible bladders demonstrated these changes. Renal disease was unrelated to the level of neurologic function. A small, noncompliant, trabeculated bladder is a risk factor associated with loss of renal function in patients with meningomyelocele.

Management of urinary incontinence in children with myelomeningocele

Several forms of treatment of lower urinary tract functional disorders have been attempted in children with myelomeningocele (MMC). Intravesical electrical stimulation was attempted in 10 patients. Urinary control was achieved in one and in the remaining 9 either the bladder was resistant to stimulation or the children discontinued the treatment due to loss of interest. A combined anticholinergic and calcium blocking agent, terodiline, was tested in 8: symptoms improved in 4, but bladder compliance was unchanged. Clean intermittent catheterization, either alone or in combination with medication, seems to be the most beneficial treatment.

Retained straight catheter: complication of clean intermittent catheterization

Clean intermittent catheterization is a simple and widely used technique with relatively few complications. A child on intermittent catheterization recently was treated for a retained straight catheter. Removal of the catheter was accomplished by urethral dilation. Proper technique of catheter insertion can prevent this complication.

Urethral lengthening and reimplantation for neurogenic incontinence in children

We describe our experience with a urethral lengthening-reimplantation operation for the correction of incontinence in 13 myelomeningocele children, 11 of whom had failed to achieve continence on a program of intermittent clean catheterization. The procedure involves lengthening the urethra by formation of a bladder tube, which is reimplanted back into the bladder through a submucosal tunnel. This procedure allows a catheter to be passed but prevents urine from leaking. All of the operated cases are included. All of the children are out of diapers and socially dry. Followup ranged from 8 to 36 months and the problems encountered are described.