The clinical features and management of 27 children with cerebral palsy referred with symptoms of lower urinary tract dysfunction were reviewed. The mean age at referral was 9.9 years. Daytime urinary incontinence was the commonest presenting symptom. Videourodynamic studies were abnormal in 23 patients (85%). Only two children had evidence of upper renal tract damage. Treatment was determined by urodynamic findings, and led to improvement in symptoms in all patients for whom there was follow up information.Urinary incontinence may be improved or cured in children with cerebral palsy. These children would therefore benefit from early referral for assessment and treatment. (Arch Dis Child 1993; 68: 739-742) It is generally perceived that urinary incontinence is commoner in children with cerebral palsy than in normal children. Several (TABLE 2)

Clean intermittent catheterization (CIC) is the mainstay of management in neuropathic vesicourethral dysfunction, both to improve continence and, more importantly, to preserve renal function. We looked at the effects of this procedure on children, adolescents, and their families. In particular, we wished to see if there were any differences between those who successfully catheterized and those who did not. Forty families were enrolled into the study. Ages of children and adolescents (23 females, 17 males) ranged from 1 to 20 years. Most participants (n=31) had spina bifida. Other causes of bladder dysfunction included transverse myelitis, spinal cord injury, and spinal neuroblastoma. Parents were assessed using the Effects of Handicap on Parents semi‐structured interview, the Socioemotional Functioning Interview, and a semi‐structured interview, specifically designed for the study, which looked at family characteristics and experience related to diagnosis and catheterization. In addition, the Rutter Parental‘A’Scale Questionnaire was used to screen for emotional and behavioural disorders in the child. Results showed that CIC by carer or self‐ catheterization itself did not cause major emotional and behavioural problems but the bladder problem may act as a focus that puts considerable strain family relationships. Although most parents disliked CIC they complied with the suggested management. It is important that all those involved understand the aims of management and success can be achieved by combined input from medical, psychological, and specialist nursing staff. The problem is lifelong and continued support from a multidisciplinary team is essential.

This paper describes part of larger study involving 40 families of children and adolescents with neuropathic bladder looking at the psychosocial impact of catheterization on them and their families. This study focuses on their experiences of clean intermittent catheterization (CIC) and self‐catheterization (SC). Twenty‐eight children and adolescents (11 males, 17 females; mean age 9 years, SD 2 years 7 months, range 5 to 20 years) with neuropathic bladder (mostly with spina bifida)participated in a semi‐structured interview to explore their understanding of micturition and catheterization, and their views about the introduction and practical use of this technique. Participants were invited to draw self‐portraits and figure diagrams to depict their understanding of CIC and SC. Age‐appropriate self‐esteem measures (Harter Pictorial Scale of Perceived Competence, the Self‐Perception Profile, and the Culture‐Free Self‐Esteem Inventory) were administered to see if catheterization status affected emotional well‐being. In an extension of this study, children's experiences of SC were explored by a postal questionnaire to all children successfully using SC who were attending the Paediatric Neuropathic Bladder Clinic. Children aged < 5 years, those with learning difficulties, and those using indwelling catheters were excluded. From a total sample of 66 (31 females, 35 males), 52 parents and 42 children and adolescents (28 females and 14 males) responded. No significant difference was observed in self‐esteem for those successfully catheterizing. Specific challenges involved learning SC and practical use of the technique. Concerns were leakage and being wet, and peers finding out about their continence management. Implications for the education, problem solving, and support of families and young people to promote cooperation and optimal benefits from catheterization are discussed.

Although bladder function is thought to be unaffected in Duchenne muscular dystrophy, 46/88 boys interviewed had urinary problems. Nine underwent video urodynamics, showing in eight a small capacity, hyperreflexic bladder, and in the ninth (post spinal surgery) hyperreflexia and detrusor sphincter dyssynergia. Urinary dysfunction is a treatable feature of DMD.T he main clinical phenotype in Duchenne muscular dystrophy (DMD) is of progressive weakness of limb and trunk musculature, a degree of cognitive impairment, and later, cardiomyopathy. There is no recognised association between bladder dysfunction and DMD. As a number of patients admitted to urinary problems when asked, we decided to investigate in detail urinary symptoms in DMD. METHODSEighty eight males with DMD (aged 3-31 years), attending the neuromuscular clinic, were included in the study. A questionnaire was sent to them or their carers and followed up by telephone.Those who reported urinary symptoms were interviewed and examined to exclude other causes of urinary dysfunction.Renal and bladder ultrasound pre and post micturition, and video urodynamics were then offered to define the pattern of lower urinary tract dysfunction. RESULTSEighty four per cent (74/88) replied, of whom 46/74 (62%) were concerned about urinary problems; these are summarised in table 1. All 22 boys with daytime urinary incontinence had been continent at some stage and the problem had become apparent later. Twelve with nocturnal incontinence had been previously dry at night. Twenty used continence aids but only eight had been referred to a continence advisor. Of the 50 who were no longer able to walk independently, only 38 had some adaptation to their bathroom. Although 38 boys had learning difficulties, in only four were they severe enough to affect acquisition of continence.Urinary problems occurred in young, ambulant boys as well as wheelchair dependent patients, with a mean age of 10.8 years (range 3-25years). In all but one patient, who suffered hesitancy post spinal surgery, the problem had not been brought to medical attention previously. Day and night time incontinence, nocturia, urinary frequency, urgency and stress incontinence were found at a mean age of 10.3 years (range 3-25 years). Urinary hesitancy affected an older group with a mean age of 16.7 years (range 11-22 years).

Congenital closed spinal anomalies are associated with distortion of the spinal cord, the spinal nerve roots or both, and can result in neurological abnormalities of the lower limbs and neuropathic bladder dysfunction. This study reports clinical and videourodynamic findings in a group of 51 patients with closed spina bifida. The mean age at presentation to a specialist neurourological clinic was 3.3 years. Twenty five patients presented with urinary tract disturbance and 12 presented with neurological problems. Thirty three had normal neurological examination or only minor objective signs, 21 had normal renal tract ultrasonography but only two patients had normal videourodynamics, with 31 having two or more abnormalities during this assessment. Neither clinical neurological assessment nor the history of voiding behaviour are reliable indicators of bladder dysfunction and subsequent risk of renal damage. Therefore, all patients with a known or suspected diagnosis of closed spina bifida should have videourodynamic assessment.

The underlying risk factors, presenting features, and outcome of 22 children with sacral agenesis and associated neuropathic bladder were studied retrospectively. The age of children at presentation was bimodally distributed, with peaks below 1 year and between 4 and 5 years of age. Ten patients presented after 1 year. The oldest was diagnosed at 12 years of age. In 12 children there was maternal diabetes, orthopaedic anomalies in 14, skin defects in 11, and anorectal/tracheooesophageal anomalies in three. Most children had persistent dribbling of urine on presentation associated with frequency, urgency, recurrent urinary tract infections, failure to respond to medication, and/or constipation. Twenty‐one children had abnormal neurology in the lower limbs. Videourodynamics showed neuropathic vesicourethral dysfunction in all children and vesicoureteric reflux in 10. Nineteen had a history of urinary tract infections. Seven had renal scarring, with renal impairment in three at presentation. Clean intermittent catheterization was recommended for 20 of the children. Bladder or bowel surgery has been carried out in seven and neurosurgery performed in two. Twenty of the 22 children underwent operative procedures. Ten operations were performed before sacral agenesis was diagnosed. Over a third of the children have required psychological support. The combination of urinary symptomatology and any of the above risk factors should give rise to a high level of suspicion and low threshold to perform investigations to exclude sacral agenesis. All these children have abnormal bladder and urethral function which not only causes incontinence but puts the kidneys at risk. Early detection allows effective multidisciplinary input specifically aimed at continence, preservation of renal function, and adequate psychological support.

The underlying risk factors, presenting features, and outcome of 22 children with sacral agenesis and associated neuropathic bladder were studied retrospectively. The age of children at presentation was bimodally distributed, with peaks below 1 year and between 4 and 5 years of age. Ten patients presented after 1 year. The oldest was diagnosed at 12 years of age. In 12 children there was maternal diabetes, orthopaedic anomalies in 14, skin defects in 11, and anorectal/tracheooesophageal anomalies in three. Most children had persistent dribbling of urine on presentation associated with frequency, urgency, recurrent urinary tract infections, failure to respond to medication, and/or constipation. Twenty-one children had abnormal neurology in the lower limbs. Videourodynamics showed neuropathic vesicourethral dysfunction in all children and vesicoureteric reflux in 10. Nineteen had a history of urinary tract infections. Seven had renal scarring, with renal impairment in three at presentation. Clean intermittent catheterization was recommended for 20 of the children. Bladder or bowel surgery has been carried out in seven and neurosurgery performed in two. Twenty of the 22 children underwent operative procedures. Ten operations were performed before sacral agenesis was diagnosed. Over a third of the children have required psychological support. The combination of urinary symptomatology and any of the above risk factors should give rise to a high level of suspicion and low threshold to perform investigations to exclude sacral agenesis. All these children have abnormal bladder and urethral function which not only causes incontinence but puts the kidneys at risk. Early detection allows effective multidisciplinary input specifically aimed at continence, preservation of renal function, and adequate psychological support.

SUMMARY Persistent daytime incontinence is a fairly uncommon but important problem. Videourodynamic studies were carried out in 215 children presenting with this problem in whom there were no neurological signs and who had not responded to simple measures. Over 90% of symptomatic children were shown to have an abnormality, of which over half had detrusor instability and a fifth had the wide bladder neck anomaly. We consider that it is important that these children are fully assessed as many can be helped.Children with diurnal wetting may be referred to a general paediatrician, paediatric neurologist, paediatric nephrologist, urologist, or psychiatrist. Most of these children have never been reliably dry by day, although occasionally the symptom is of recent onset. They are usually treated empirically.The advent of the videourodynamic study has allowed us to assess bladder and urethral function more accurately. This investigation has proved invaluable in the assessment and management of the child with a neuropathic bladder and has enabled us to identify those children at high risk of renal damage. ' The study consists of a filling and voiding cystometrogram combined with a micturating cystourethrogram.2They are recorded simultaneously onto video tape and are viewed side by side using a split screen display so that events occurring in the bladder and urethra can be correlated with pressure changes. As far as the child is concerned measurement of rectal pressure is the only additional feature when compared with a micturating cystourethrogram. A great deal more information, however, is obtained. Patients and methodsWe have reviewed the urodynamic findings in 215 children (with an age range of 3-5 to 16 years) studied at this hospital over the last six years. The children were selected for study because of persistent diurnal wetting that had not responded to simple measures such as star charts and timed voiding. Most wet their pants at school on most days and some had to take changes of clothing to school 128 daily. Children with an ectopic ureter were excluded. All were physically normal and none had neurological signs. Children with nocturnal enuresis alone were not included; indeed, we rarely study these children as it has been found that most have normal bladder function.3 A careful history is important, however, as it may reveal daytime problems that have not been volunteered by the parent or child.The studies were all performed using standard urodynamic techniques and urethral catheters. The children were not sedated and failure to carry out a study because of lack of cooperation occurred in less than 5%.Measurement of urinary flow rate was included as a standard part of the study and provided useful additional information where there was evidence of obstruction to urinary flow-for example, distal urethral stenosis-particularly if high detrusor pressures were being generated in an effort to try and overcome this. If there was a low urinary volume, however, then the flow rate would be reduced. The flow rate co...