The management of paediatric neurogenic bladder: an approach in a resource-poor setting

Abstract

Background: If untreated, paediatric neurogenic bladder can cause renal failure and urinary incontinence. It is usually caused by neural tube defects such as myelomeningocele. Children with a neurogenic bladder should be monitored from birth and management should aim to preserve renal function and achieve social continence. This article outlines the management options appropriate for these children in resource-poor settings.

Assessment: In most low- and middle-income countries, a general lack of awareness of the neurological effects on the urinary tract results in late presentation, usually with urological complications even when spina bifida is diagnosed early. Physical examination must include neurological examination for spinal deformities and intact sacral reflexes. About 90% of children with occult spinal dysraphisms will have cutaneous sacral lesions. The work-up includes urinalysis, serial ultrasound of the urinary tracts and urodynamics. Urodynamic assessment is essential for the diagnosis and prognosis of the paediatric neurogenic bladder. In poorly resourced settings, simple eyeball urodynamics can be performed in the absence of a conventional urodynamic set-up.

Treatment: Clean intermittent catheterisation (CIC), the mainstay of treatment, is most suitable for resource-poor settings because it is effective and inexpensive. Antimuscarinic drugs such as oxybutynin complement CIC by reducing detrusor overactivity. Intravesical injection of Botox and bladder augmentation surgery is required by a small subset of patients who fail to respond to combined CIC and oxybutynin therapy.

Conclusion: Children with neurogenic bladder in resource-poor settings should have early bladder management to preserve renal function and provide social continence.

Keywords: ACE: antegrade continence enema; CIC: clean intermittent catheterisation; CMG: cystometogram; DSD: detrusor sphincter dyssynergia; EMG: electromyography; MMC: myelomeningocoele; Neurogenic bladder; PVR: post-void residual; Pabd: abdominal pressure; Pdet: detrusor pressure; Pves: intravesical pressure; UDS: urodynamic studies; UTI: urinary tract infection; VUR: vesicoureteric reflux; anticholinergic; augmentation; catheterisation; detrusor; urodynamics.