EUF-860; No. of Pages 30 E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 1 9 ) X X X – X X X ava ilable at www.sciencedirect.com journa l homepage: www.europeanurology.com/eufocus Review – Neuro-urology Pediatric Neurogenic Bladder and Bowel Dysfunction: Will My Child Ever Be out of Diapers? Ashley W. Johnston, John S. Wiener, J. Todd Purves * Department of Surgery, Division of Urology, Duke Medical Center, Durham, NC, USA Article info Abstract Article history: Context: Managing patient and parent expectations regarding urinary and fecal conti- nence is important with congenital conditions that produce neurogenic bladder and Accepted January 13, 2020 bowel dysfunction. Physicians need to be aware of common treatment algorithms and expected outcomes to best counsel these families. Associate Editor: Richard Lee Objective: To systematically evaluate evidence regarding the utilization and success of various modalities in achieving continence, as well as related outcomes, in children with Keywords: neurogenic bladder and bowel dysfunction. Neurogenic bladder 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, Neurogenic bowel including 49 for bladder management and 65 for bowel management. Pediatric Evidence synthesis: Children with neurogenic bladder conditions achieved urinary Urinary continence continence 50% of the time, including 44% of children treated with nonsurgical methods Fecal continence and 64% with surgical interventions. Patients with neurogenic bowel problems achieved fecal continence 75% of the time, including 78% of patients treated with nonsurgical Spina bifida Myelomeningocele 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. © 2020 Published by Elsevier B.V. on behalf of European Association of Urology. * Corresponding author. Department of Surgery, Division of Urology, Duke University Medical Center, P.O. Box 3831, Durham, NC 27710, USA. Tel.: +1-919-584-4655; Fax: +1-919-681-5507. E-mail address: [email protected] (J. Todd Purves). pediatric population [1]. Rarer etiologies include urologic or 1. Introduction anorectal malformations (eg, bladder exstrophy and imper- Congenital spinal dysraphism accounts for the vast majority forate anus), as well as acquired injuries from spinal cord/ of cases of neurogenic bladder and bowel dysfunction in the brain trauma or central nervous system tumors. Disruption https://doi.org/10.1016/j.euf.2020.01.003 2405-4569/© 2020 Published by Elsevier B.V. on behalf of European Association of Urology. Please cite this article in press as: Johnston AW, et al. Pediatric Neurogenic Bladder and Bowel Dysfunction: Will My Child Ever Be out of Diapers?. Eur Urol Focus (2020), https://doi.org/10.1016/j.euf.2020.01.003 EUF-860; No. of Pages 30 2 E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 1 9 ) X X X – X X X of sensory and/or motor input to the bladder, urinary bladder, nonsurgical management included clean intermit- sphincter muscles, rectum, and anal sphincter results in tent catheterization (CIC), anticholinergic medications, and urinary and gastrointestinal dysfunction. botulinum toxin; surgical management included bladder Management of neurogenic bladder is critical to the augmentation, continent catheterizable channels (CCCs), prevention of life-threatening renal failure. The introduc- bladder outlet procedure, and artificial urinary sphincter tion of modern multimodal treatments including both non- (AUS). In evaluating patients with neurogenic bowel, non- surgical and surgical techniques has resulted in increased surgical management included RCEs, biofeedback, diet and life expectancy of patients with spina bifida (SB) [2]. With behavioral therapy, neuromodulation, anal plugs, digital patients living longer, there is increasing focus on urinary stimulation, and oral laxatives. Surgical management continence. As better quality of life (QoL) research instru- included Malone antegrade colonic enema (MACE or ments have become available, it is apparent that patients ACE), and Chait tube. Studies were limited to original arti- enjoy better lives with successful management of urinary cles available in the English language. Review articles, meta- incontinence [3]. Although bowel dysfunction rarely leads analyses, case reports, meeting abstracts, editorials, and to life-threatening complications, constipation and soiling commentaries were excluded. Where multiple studies have similar significant consequences on patient well- reported on the same patient population, only the most being. Therefore, it is incumbent on treating physicians to recent study was included. For the urinary management address both urinary and fecal continence, as well as asso- section, we limited the inclusion of reports with at least ciated issues, such as urinary tract infections (UTIs) and 50 patients and a majority of participants 0–18 yr old. For constipation, to maximize patients’ QoL. the review on neurogenic bowel management, studies had to include at least 20 patients and a majority of participants – 2. Evidence acquisition 0 18 yr old with neurogenic bowel as a diagnosis. There were no criteria regarding the inclusion or type of a control/ 2.1. Search strategy comparator group. The primary outcome of interest was urinary or fecal continence. Secondary outcomes of interest A systematic PubMed/Medline search was conducted in included renal function, UTIs, QoL, or surgical complica- August 2019 using Medical Subject Headings (MeSH) terms tions/revisions. “neurogenic bladder” and “neurogenic bowel.” Using Boo- len techniques, we utilized the following additional MeSH 2.3. Data abstraction terms: “neurogenic bladder AND sling, suburethral”; “neu- rogenic bladder AND artificial urinary sphincter”; “neuro- All authors independently reviewed full-text manuscripts genic bladder AND agents, anticholinergic”; “neurogenic that met the inclusion and study eligibility criteria. bladder AND oxybutynin”; “neurogenic bowel AND fecal Abstracted data included total number of patients, under- incontinence”; “neurogenic bowel AND enema”; “neuro- lying disorder, patient age, study design, treatment inter- genic bowel AND neuromodulator”; “neurogenic bowel vention, definition, and results of primary (continence) and AND electrical stimulation.” To capture additional research secondary (renal function, UTIs, QoL, and surgical compli- beyond MeSH terminology, we also use the following key- cations/revisions) outcomes. If definitions or results of out- words with our main MeSH terms: “neurogenic bladder comes were not included in the text, we noted these missing AND intermittent catheterization”; neurogenic bladder data. AND augmentation”; “neurogenic bladder AND Mitrofan- 2.4. Data synthesis off”; “neurogenic bladder AND bladder neck reconstruc- tion”; “neurogenic bowel management”; “neurogenic bowel Overall urinary and fecal continence rates were calculated AND antegrade enema.” from studies that reported the exact numbers of patients who achieved a strictly defined continence result. The total 2.2. Study selection number of patients studied and the total number of conti- nent patients from each included study were averaged to All authors contributed to the design of the search strategy obtain continence rates. This was performed for nonsurgical and inclusion criteria. All authors reviewed the final list of and surgical management of urinary and fecal incontinence, reviewable publications and ensured that they met the as well as surgical complication and revision rates for inclusion criteria. Study eligibility was defined using patient surgical management of neurogenic bowel. This was not population, intervention, comparator, outcome, and study design. performed for surgical management of neurogenic bladder owing to the great heterogeneity of surgical interventions. There was no temporal restriction for bladder manage- ment. For the bowel management review, included pub- lications dated after 1986, which marked the introduction of 3. Evidence synthesis retrograde colonic enemas (RCEs), an important component in the modern therapy for neurogenic bowel [4]. Publica- 3.1. Management of neurogenic bladder tions were included if they assessed neurogenic bladder or neurogenic bowel in humans. Study interventions included The flow diagram of the neurogenic bladder literature surgical and nonsurgical treatments. Regarding neurogenic search and results is shown in Figure 1. A total of 49 studies Please cite this