REVIEW Surgical and nonsurgical treatment options for pediatric neurogenic bladder The treatment of children with neurogenic bladder has evolved from the simple wearing of diapers and applying abdominal stoma, to better understanding of the bladder pathophysiology, and the introduction into clinical practice of the principles of clean intermittent catheterization, artifi cial sphincter implantation, continent urinary conduits and a wide spectrum of medications that modulate the function of the lower urinary tracts. In this review we discuss the recent developments in the medical therapy of children with neurogenic bladders, examine the surgical options, and briefl y refer to the future perspectives for the management of this group of patients. 1† KEYWORDS: medical treatment neurogenic bladder surgical treatment Boris CherƟ n , Jacob Golomb2 & Yoram Mor2 The most common cause of neurogenic blad- upper urinary tract damage. For these reasons, †Author for correspondence: der dysfunction in children is neurospinal dis- children with neurogenic bladder dysfunction 1Division of Pediatric Urology, ruption, such as primary open back lesion or require close urologic follow-up and evaluation, The Shaare Zedek Medical myelo meningocele (MMC) [1–5] . Other causes and prompt treatment when indicated. Center, P.O.B. 3235, Jerusalem, of neuro genic dysfunction involving the spine 91031, Israel include sacral agenesis, tethered spinal cord Medical therapy Tel.: +972 2655 5560 associated with imperforate anus, cloacal mal- It is well-known that in untreated spina bifi da Fax: +972 2655 5299 formation and spinal cord injuries. CNS abnor- patients, progressive deterioration by the age of bcherƟ [email protected] malities include spastic diplegia (cerebral palsy) 3 years may be observed in up to 58% of the 2Chaim Sheba Medical Center, and learning disabilities (i.e., attention-defi cit patients [1–3] . Several reports have shown this Tel Aviv University, Israel hyperactivity disorder [ADHD]). The main deterioration to be directly related to increased goals of the urologic management of a child intravesical pressures. In 1981, the bladder pres- with neurogenic bladder dysfunction concen- sure at which urethral leakage occurred was trate on maintenance of normal renal function found to be a useful predictor of unsafe blad- and gaining urinary continence. Over 90% of der function. The detrusor leak-point pressure, the children with spina bifi da will have a nor- as it is now commonly referred to, has become mal upper urinary tract (kidney and ureters) at accepted as one of the urodynamic parameters birth. With no follow-up, half of the children that allow clinicians to differentiate between will suffer considerable upper urinary tract patients who are at relatively low and high risk damage due to lower urinary tract (bladder of subsequent upper urinary tract deterioration. and urethra) hostility. With appropriate uro- In 1984, detrusor external sphincter dyssynergia logical management, children at risk for renal (DSD) was identifi ed as an important factor lead- damage can be identifi ed at an early stage and ing to functional obstruction, and intra vesical intervention can be undertaken to prevent the pressure was recognized as the pathophysio- long-term compromise of the kidney function. logical mechanism of subsequent upper urinary During early childhood, the urological focus on tract deterioration. The cornerstone of optimal a child’s health is based on the maintenance of management of neurogenic bladder sphincter normal kidney function [6,7]. As the child begins detrusor dyssenrgia (NBSD) is early identifi ca- to approach school age, interest will be directed tion and characterization, and the institution toward gaining urinary continence. From the of proactive therapy. Crucial for the long-term beginning of the follow-up, no one will be able prognosis of patients with NBSD is the fact that to state which of the children with spinal lesions the management must start before consequences or other nervous system anomalies will be able of bladder dysfunction become apparent. From to preserve the bladder or kidney function, and the outset, the goals of management are to pre- who will be more likely to present with deterio- vent or minimize secondary damage to the upper ration of the bladder function with subsequent urinary tracts and the bladder and to achieve safe 10.2217/14750708.6.2.157 © 2009 Future Medicine Ltd Therapy (2009) 6(2), 157–164 ISSN 1475-0708 157 REVIEW Chertin, Golomb & Mor social continence. Thus, long before continence a higher rate of urinary infections. If symptom- becomes an issue, starting from the fi rst year of atic infections occur, these are mainly caused life, management is directed at creating a low- by incomplete bladder emptying, and the CIC pressure reservoir and ensuring complete and safe technique by the child or the caregiver needs to bladder emptying. Overall, the treatment of chil- be optimized. Nonreusable low-friction catheters dren with neurogenic bladder falls into several are considered valuable in high-risk male patients major categories including behavioral therapy, with urethral false passage, or very tense sphinc- pharmacological therapy (often accompanied ters, but are unnecessary in routine cases. In order by clean intermittent catheterization [CIC] or to maintain therapeutic compliance with CISC self-catheterization [CISC]) and utilization of in adolescents, psycho-social support is often electronic stimulation. required. Neurogenic bowel dysfunction with Behavioral therapy describes a group of treat- constipation and fecal soiling can interfere with ments centered on education, whereby the incon- the institution of a successful CIC treatment. tinent patient can be educated about the condi- Retained stools may mechanically impair bladder tion and can develop strategies to minimize or fi lling, increase detrusor irritability or contribute eliminate the incontinence. There are different to urine retention. Stool incontinence increases components of behavioral therapy, such as timed the risk of bladder contamination and urinary voiding, fl uid dietary management, voiding tract infection. An effective bowel management diary, urge inhibition, reinforcement and pelvic program is therefore needed. muscle training [8]. However, CIS alone is not suffi cient to main- CIC enables complete bladder emptying, tain a low-pressure reservoir and avoid upper and thus avoids bladder residues and the con- renal tract damage. Thus, a combination of CIS sequent risks for infections [1,2,6,8] . In the high- and pharmacological therapy, aiming to decrease risk bladder with DSD, CIC also allows bladder bladder pressure, is considered as the standard empting before the occurrence of high voiding therapy in these children [2,9]. Currently, anti- pressures, which is known to be detrimental for muscarinic agents are the fi rst-line choice for the kidney function and drainage. Which of the wide pharmacologic treatment of overactive bladder variety of available materials and techniques is (OAB) (TABLE 1). Antimuscarinic therapy, such as used for CIC does not seem to affect the effi cacy oxybutynin, tolterodine, trospium chloride, dari- and safety, as long as some basic principles are fenacin and solifenacin, increases bladder capacity applied: proper education and training, clean and delays the initial urge to void, thereby reduc- and atraumatic application and achievement of ing the symptoms of OAB. Pharmacotherapy, good patient compliance on a long-term basis. most often with an anti muscarinic agent, is an For education, training and further guidance established approach to managing neurogenic- during follow-up, a dedicated continence nurse mediated OAB. Antimuscarinic agents, partic- is invaluable. It is benefi cial to begin the cath- ularly oxybutynin, are associated with typical eterization early in life, in order to identify the anticholinergic side effects that may limit treat- small group of children who are at risk for car- ment. These side effects may include dry mouth, rying signifi cant residual urine. In addition, all gastrointestinal effects such as constipation and families become familiar with the technique CNS effects. Only oxybutynin is approved for of catheterization, which can be very helpful if use in children. However, since its introduction this treatment is recommended at a later stage. into the market, tolterodine has been extensively Subsequently, CISC can be successfully taught to used in children as an off-label drug with virtual boys and girls who are motivated and who have absence of side effects [9]. developed the required dexterity, mostly around Since the new generation of the anti muscarinic the age of 6 years. The required frequency of agents may be used in children only as off-label catheterization depends on several factors includ- drugs, and ditropan has a well-known profi le ing fl uid intake, bladder capacity and bladder of side effects, alternative routes of ditropan fi lling/voiding pressures. In practice, it is recom- administration have been explored in order to mended to catheterize six times a day in infants increase the clinical effectiveness and to decrease (linked with feeding time) and fi ve times a day side effects. One of the ways to avoid the afore- in school-aged children. Although the reported mentioned side effects and to increase the clini- incidences of CIC-related infection risks are vari- cal effi cacy of oxybutynin is to deliver the agent able, it is generally agreed that the risk is